Image by Andrea Paterson. www.andreapaterson.com
Article by Dr. Deirdre Ryan
In this article, Dr. Ryan provides a clinical exploration of the differences between postpartum depression and postpartum psychosis. It’s important to be able to distinguish between the two illnesses and to remember that postpartum psychosis is extremely rare. The Pacific Post Partum Support Society does not have resources to provide support or treatment to those with postpartum psychosis. If you suspect that you, or someone you love, is suffering from postpartum psychosis please contact your family doctor right away to discuss treatment options. If you don’t have a family doctor, visiting a hospital emergency department is a legitimate option especially if you suspect that harm may come to mother or child.
Newspaper headlines outlining the details of moms who have drowned their babies or thrown themselves and their babies off bridges are horrifying and dismaying. They often hint at ‘Post-partum psychosis’ or ‘postpartum depression’. If you are pregnant or a new mom, these headlines can be frightening too. Although incidents like these appear to occur often, they are, in fact, very rare and usually the result of untreated postpartum psychosis. Postpartum psychosis is the most severe psychiatric condition that can occur after childbirth and requires immediate treatment, including hospitalization for the new mom. Only 1-2 new moms for every 1000 births will experience it however.
The postpartum period is a vulnerable time for all woman because of physiological changes occurring in her body, especially drops in hormone levels and immunological changes. Some women have a higher risk of postpartum psychosis than others. For those with a prior history of a serious depressive or bipolar disorder or those with a family history of bipolar disorder, the postpartum period, with all its changes, is a particularly vulnerable time, especially for first-time moms.
In the majority of cases, the onset is rapid (within hours) and symptoms usually occur within 4 weeks of delivery. Typically, the new mom may experience insomnia and mood swings, in addition to psychotic symptoms, which might include rambling speech, disorganized behaviour, hallucinations (seeing and hearing things that are not present) and delusions ( false beliefs that are not based in reality). If the mom is hallucinating, she may hear voices telling her to hurt herself or her baby. Often her delusions relate to her infant, typically that the infant is possessed, has special powers or is dead. When a mom is psychotic, she has lost contact with reality. Usually, she has little insight into the fact that she is ill and needs treatment. This creates risks for herself and her infant as untreated postpartum psychosis is associated with an elevated risk of both suicide and infanticide. A woman with postpartum psychosis needs immediate hospitalization for her own safety and the safety of her infant. Often moms with postpartum psychosis will need certification to ensure that they remain in hospital and get the treatment that they need. The woman will require a full medical workup, including a physical examination and blood tests. This is to make sure that she does not have any infection or medical condition that may be contributing to her symptoms.
Treatment for postpartum psychosis always requires medications, and may include sleep medications, anti-psychotic medications, antidepressants and mood stabilizers. Treatment will also include education and psychotherapy. Rarely, ECT (electroconvulsive therapy) is needed. Ideally, mothers should maintain contact with their babies while they are in hospital to facilitate bonding and attachment. Although postpartum psychosis is a potentially life- threatening condition in the acute phase, most women do very well with treatment and will be able return to their normal activities, including childcare. It is important that their partners understand their illness and ensure that they get the emotional and practical childcare support that they need.
Women who have been diagnosed with a postpartum psychosis need to be aware that they have a greater than 50% risk of developing another postpartum psychotic episode after a subsequent delivery. In all subsequent pregnancies, an integrated treatment plan should be in place which involves the woman, her family supports and her healthcare providers.
Postpartum depression is a more common condition than postpartum psychosis and affects 1 in 8 new moms. Women with a previous history of depression or anxiety or a family history of psychiatric illness are most at risk of developing a postpartum depression. Postpartum depression is often associated with anxiety symptoms, including excessive worry and panic attacks. New moms will complain about feeling sad and anxious with changes in their sleep, appetite and energy levels. They may have difficulty focusing or remembering things. They may also complain of feeling overwhelmed, guilty, worthless or hopeless. Some women may be distressed by thoughts or images of harming their children. In severe cases they may experience thoughts of suicide or may even have plans to harm themselves.
The vast majority of patients with postpartum depression will not experience psychotic symptoms. In particular, they will not experience delusions or hallucinations. Moms with postpartum depression have insight into their illness. They know that they are sad and not functioning as they would like and they are distressed by their symptoms. They don’t want to be sad and they don’t want their sadness to affect their families, especially their infants. In particular, they don’t want to hurt their children. Whereas moms with postpartum psychosis have lost touch with reality, moms with postpartum depression have insight into the fact that they need help.
There are different treatments available for moms with postpartum depression. Unless they are experiencing thoughts of suicide, most moms with postpartum depression will not require hospitalization. Most can be successfully treated by their health care providers in the community. Treatment options may include education, self- care strategies (with an emphasis on nutrition, sleep, exercise, getting time for oneself and mobilizing supports) and psychotherapy, either individually or in groups. For moms with moderate to severe symptoms, medications may be necessary. Medications may include antidepressants or anti-anxiety medications. The most commonly used antidepressants are the SSRIs or Selective Serotonin Reuptake Inhibitors, like Zoloft or Cipralex. When moms are breastfeeding and taking antidepressants, a small amount of the antidepressant is excreted into the breast milk but usually does not cause any side effects in the baby.
Most women will do very well with a combination of self- help strategies, therapy and medications. Unfortunately, women who do not get treatment may develop chronic depressive disorders and their children are at risk of developing learning difficulties, behavioural problems and depressive and anxiety disorders in childhood. Early treatment and support ensures optimal outcome for the mom and ensures that her baby does well in the first year and into toddlerhood and childhood.
Dr. Ryan did her medical training in Ireland and her psychiatry training at U.B.C. She has been working in the area of Reproductive Mental Health for the past 20 years. In 2012 she was made Medical Director of the Reproductive Mental Health Program at British Columbia’s Children’s and Women’s Hospital in Vancouver. She has been involved in expanding the Group Therapy Program and updating the Best Practices Guidelines related to Mental Health Disorders in the Perinatal Period. Her areas of interest include treating women with psychiatric illnesses associated with infertility and pregnancy loss. She is a Clinical Assistant Professor at U.B.C. and is actively involved in teaching medical students and residents.