POSTPARTUM PSYCHOSIS: RECOGNISE THE EMERGENCY, SAVE A LIFE

Dr Weriwoyingipre Silver Yeibake

The period after childbirth is often filled with joy, relief and new responsibilities. It can also be physically exhausting, emotionally demanding and overwhelming. Many mothers become tearful, irritable, anxious or unusually sensitive in the first few days after delivery. This is often called the "baby blues" and usually improves with rest, reassurance and family support.

However, some mothers develop a much more serious condition called postpartum psychosis. This is a rare but severe mental-health emergency that may begin suddenly after childbirth. It can affect a mother’s thinking, mood, behaviour and sense of reality. If it is not recognised quickly, both mother and baby may be at risk. The encouraging news is that postpartum psychosis is treatable, and many women recover well when they receive urgent medical care and sustained family support.

EBIWENIMO’S STORY

Ebiwenimo is a fictional 29-year-old Izon woman who lives in Ogbia Local Government Area of Bayelsa State. She sells smoked fish and other food items in her community market. After the birth of her first child, she was initially happy and excited. Her delivery had gone well, and family members visited frequently to celebrate the baby’s arrival.

A few days later, her husband noticed that she was barely sleeping. Even when her mother took over care of the baby at night, Ebiwenimo remained awake. At first, the family thought she was simply excited about motherhood or worried about breastfeeding. Over the next two days, however, she began talking rapidly and moving restlessly around the house. She said she had received a special message about the baby and became frightened that people wanted to harm the child.

Soon, Ebiwenimo began hearing voices that others could not hear. She became suspicious of relatives who brought food into the house and insisted that someone was trying to poison her. At times she was tearful and confused; at other times, she seemed unusually energetic. One evening, she attempted to leave the house with the baby because she believed she had been instructed to take the child to a "safe place."

Her family took the right steps. They did not mock her, beat her, accuse her of pretending or leave her alone with the baby. They stayed calm, ensured that the baby was safe and took her urgently to hospital. She was assessed, admitted and treated by a mental-health team. With treatment, supervision and family support, her symptoms improved.

Ebiwenimo’s story is fictional, but situations like this can occur in real life. It illustrates why sudden and severe changes in a mother’s behaviour after childbirth should always be taken seriously.

WHAT POSTPARTUM PSYCHOSIS MEANS

Postpartum psychosis, also called puerperal psychosis or postnatal psychosis, is the most severe mental-health condition associated with childbirth. It is uncommon, with studies reporting incidence estimates ranging from approximately 0.89 to 2.6 cases per 1,000 births. Although rare, it has potentially serious consequences and requires immediate assessment.

The illness often begins rapidly within days after delivery and commonly during the first two weeks after childbirth. It may start with severe sleeplessness, anxiety, excitement or unusual irritability. Within a short time, the mother may become confused, overly energetic, paranoid, depressed, agitated or detached from reality.

Postpartum psychosis is not a sign of poor character, weak faith, spiritual failure or lack of love for a baby. It is a medical and psychiatric condition. Current evidence suggests that it results from a combination of individual biological vulnerability, rapid hormonal changes after childbirth, circadian disruption and severe sleep loss. In many women, it is closely related to bipolar-spectrum illness.

BABY BLUES AND POSTPARTUM PSYCHOSIS

The baby blues are common and usually mild. They often begin two to three days after delivery, may peak around the third to fifth day and generally settle within days or by about two weeks. A mother may cry easily, feel anxious, become irritable, feel emotionally overwhelmed or worry more than usual.

Although a mother with the baby blues may be distressed, tired or emotionally overwhelmed, she remains in touch with reality. She recognises her baby and surroundings, understands what is happening and can usually be comforted with rest, reassurance and practical support.

Postpartum psychosis is different because it involves a major disturbance in mood, thinking, behaviour or contact with reality. The mother may be unable to sleep for several nights, even when someone else is caring for the baby. She may talk unusually fast, become overactive, appear excessively excited, become severely fearful or suspicious, or experience intense and rapidly changing moods.

She may hear voices, see things that are not present or hold beliefs that are clearly untrue. For example, she may believe that relatives are plotting against her, that someone is trying to poison her, that her baby has been replaced, or that the baby has special powers or a special mission. These are not ordinary worries of new motherhood. They are danger signs requiring urgent medical assessment.

A useful way to remember the difference is that the baby blues are emotional but reality-based. Postpartum psychosis involves a severe change in judgement, behaviour or sense of reality. A mother who is tearful and overwhelmed may need rest and support. A mother who hears voices, holds bizarre beliefs, becomes severely confused, remains awake for days or behaves in a dangerously unusual way needs emergency help.

WARNING SIGNS FAMILIES SHOULD NOTICE

Postpartum psychosis can develop rapidly over hours or days. A mother may not recognise that she is unwell, which is why the observations of relatives, friends and healthcare workers are so important.

Warning signs include severe sleeplessness, increasing restlessness, excessive energy, rapid speech, unusual excitement, marked irritability, agitation, panic, extreme anxiety, suspiciousness, confusion, poor concentration, disorganised speech, hallucinations, delusions, severe depression, suicidal thoughts and thoughts of harming the baby.

The mother may appear very different from her usual self. She may withdraw from others, become unusually talkative, stop eating, become fearful of people she normally trusts, or behave in ways that are impulsive, unsafe or difficult to understand. Any sudden and severe change in mental state after childbirth should be treated seriously.

WHY IT IS AN EMERGENCY?

Postpartum psychosis can impair insight, judgement and awareness of danger. A mother may not realise that she is ill, may refuse help or may become too confused to care safely for herself or the baby. The condition is associated with a risk of suicide and possible harm to the infant, particularly when disturbing voices, severe delusions or confusion are present. It is therefore regarded as a psychiatric emergency that often requires urgent inpatient assessment and care.

If postpartum psychosis is suspected, the mother should not be left alone with the baby until she has been assessed by health professionals. A trusted adult should remain with her and arrange urgent transport to the nearest emergency department, Federal Medical Centre, teaching hospital or another facility where emergency and psychiatric care can be provided.

Relatives should stay calm and avoid forcefully arguing about hallucinations or delusions. It is usually more helpful to reassure the mother, speak gently and focus on obtaining medical help. Medicines, sharp objects, poisons, weapons and other possible means of self-harm should be kept away from her where possible until professional help is available.

When taking her to hospital, tell the healthcare team that she recently gave birth and has developed severe sleeplessness, unusual behaviour, confusion, hallucinations, suspiciousness or bizarre beliefs. This information can help the team recognise the urgency of the situation.

WHO MAY BE AT HIGHER RISK?

Postpartum psychosis can occur in women with no previous mental-health diagnosis. However, the risk is higher in women with bipolar disorder, a previous episode of postpartum psychosis, schizophrenia, schizoaffective disorder or another psychotic illness. A family history of bipolar disorder, psychosis or severe mental illness may also increase risk.

The risk may increase when prescribed psychiatric medicines are stopped suddenly during pregnancy or around delivery without a specialist plan. Severe sleep deprivation after childbirth may also contribute to relapse or worsening symptoms in women who are vulnerable.

Women who have previously experienced postpartum psychosis should be supported, not discouraged, if they plan another pregnancy. They need early pre-pregnancy, antenatal and postnatal planning involving obstetric and mental-health professionals. A good plan may include medication review, early follow-up after delivery, protection of sleep, family support and a clear emergency pathway if symptoms return.

TREATMENT AND RECOVERY

Postpartum psychosis is treatable, but urgent professional assessment is necessary. Many mothers require admission to hospital during the acute phase so that their safety can be monitored, treatment can begin quickly and the baby can be adequately protected.

Treatment may include antipsychotic medication, mood stabilisers and short-term medication for severe agitation or insomnia. In selected severe cases, electroconvulsive therapy may be considered because it can produce a rapid response, especially where there is severe depression, catatonia, high suicide risk or an urgent need for clinical improvement.

Healthcare workers should also assess for physical conditions that may cause or worsen confusion after delivery. These include infection, severe anaemia, hypertensive complications, thyroid disease, metabolic disturbances, substance use, medication effects and delirium.

Decisions about breastfeeding should be individualised. Breastfeeding is important, but the immediate safety and recovery of the mother must come first. Families should support the mother to attend follow-up appointments, obtain adequate rest, reduce stress and avoid isolation after discharge.

A MESSAGE FOR FAMILIES AND COMMUNITIES

Postpartum psychosis should never be hidden because of shame. It should not be dismissed as stubbornness, a spiritual attack, bad behaviour or a lack of faith. Faith leaders, family members and community members can provide valuable support, but prayer and social support must not delay urgent medical and psychiatric assessment and treatment.

A new mother who develops severe confusion, hallucinations, delusions, paranoia, extreme mood changes, persistent inability to sleep or behaviour that is markedly different from her usual self may have postpartum psychosis. The safest response is simple: protect the mother and baby, seek urgent medical care and respond with compassion rather than stigma.

REFERENCES

VanderKruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS, et al. The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry. 2017;17:272. doi:10.1186/s12888-017-1427-7.
Bergink V, Rasgon N, Wisner KL. Postpartum psychosis: madness, mania, and melancholia in motherhood. Am J Psychiatry. 2016;173(12):1179-1188. doi:10.1176/appi.ajp.2016.16040454.
Perry A, Gordon-Smith K, Jones L, Jones I. Phenomenology, epidemiology and aetiology of postpartum psychosis: a review. Brain Sci. 2021;11(1):47. doi:10.3390/brainsci11010047.
Perry A, Gordon-Smith K, Jones L, Jones I. Postpartum psychosis: a proposed treatment algorithm. J Psychopharmacol. 2023;37(10):960-970. doi:10.1177/02698811231181573.
Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014;384(9956):1789-1799. doi:10.1016/S0140-6736(14)61278-2.
National Health Service. Postpartum psychosis. Available from: https://www.nhs.uk/mental-health/conditions/post-partum-psychosis/