Puerperal Psychosis

Frequently Asked Questions About Puerperal Psychosis

What is Puerperal Psychosis?

We define Puerperal psychosis as any manic or other psychotic illness sufferer by a woman, which begins in the first 6 weeks after she has given birth to a child. (Some authorities would include any such illness beginning within 3 or 6 months of childbirth.)

If a woman sufferer manic symptoms, she will seem very excited and elated. She will often talk very fast, not completing sentences and jumping from 1 topic to another. She may be overactive, not sleeping and rushing from one task to another. She may be bossy and demanding and becoming angry and aggressive if crossed.

Some sufferers become severely depressed or have both manic and depressive phases. Other psychotic symptoms include hallucinations, that is seeing or hearing things which are not there and delusions such as believing their baby is the Messiah or that people are trying to harm her.

Puerperal psychosis is not included as a category within the official symptoms of classification used by psychiatrists and there is uncertainty and debate as to whether it can be considered a separate psychiatric disorder in its own right. (Many now believe it is related to manic depressive (bipolar) disorder).

Puerperal psychosis is also referred to as postpartum psychosis or postnatal psychosis.

What is the treatment for puerperal psychosis?

It is very hard to generalise about treatment, as this will depend on the nature and severity of particular symptoms. Also some people respond to particular treatments better than others.

Mothers with puerperal psychosis need to be treated by a psychiatrist. It is sometimes possible for mothers to be treated at home, but admission to hospital is often necessary. In some areas there are specialist mother and baby psychiatric units where mothers can be admitted with their babies and treated by staff with specialist knowledge of postnatal mental illness.

Treatment is usually with antipsychotic drugs (especially drugs like Olanzipine, which have fewer side effects than Haloperidol - there are to many different drugs available to name them all here) which help to control symptoms of mania, delusions or hallucinations. In addition to this, anti-depressants or a mood stabiliser such as Lithium may be given. Response to Lithium and antipsychotics is usually fast, but anti-depressants can take a few weeks to work.

All drugs sometimes cause unwanted side effects and sometimes these can be unpleasant. It is important to let your psychiatrist know of any symptoms you are suffering as adjusting or changing your medication can often alleviate these.

ECT Electro-convulsive therapy is sometimes used, particularly in cases where a patient does not seem to be improving with drug therapy.
We regret that we cannot give advice about treatment in specific cases.

How long does the illness last?

This varies a great deal from case to case. Most are better within a few weeks, others may take months to recover. Even after being discharged from psychiatric care it can take time to get back your self confidence, come to terms with what has happened and feel fully back to normal.

Additional therapies such as relaxation classes or individual or group therapies may help with this.

If I have already had an episode of puerperal psychosis, how likely is it that I will have another episode following another pregnancy?

It is important to say that we have a great deal to learn about puerperal psychosis and it is difficult to be very precise in answering questions, particularly about the exact percentage of risks of illness. That being said, the studies which have been undertaken show that if a woman has one episode of puerperal psychosis, the risk of her having a further episode in a subsequent pregnancy is in the region of 20-25%. This figure is an average across studies and the true risk for an individual woman is likely to vary depending upon other factors. For example, the risk of puerperal psychosis in a subsequent pregnancy seems to be increased if the first episode of puerperal psychosis was puerperal mania and the risk also seems to be higher if the woman has already suffered two previous episodes of puerperal psychosis. The risk is known to be particularly high if the woman has suffered an episode and has also experienced at least one episode of mania unrelated to childbirth (i.e. a non-puerperal episode) in which case, one American study suggests the risk may be close to 100%. Most studies have looked at the risk of puerperal psychosis following a full term pregnancy, but there is also evidence that risk of illness is elevated following a termination.

Although some of these risks seem high, it is worth emphasising that for a woman who has had a single episode of puerperal psychosis the risk is in the region of 20-25% which means that the likelihood is 75-80% that in a subsequent pregnancy the woman will not suffer with puerperal psychosis. Furthermore, if the mother and her family are aware of the potential risk, it is possible to recognise symptoms early and nip subsequent episodes of illness in the bud. There is also some evidence that taking lithium immediately following delivery, may lead to reduced risk of puerperal psychosis and Professor Brockington is currently undertaking an important study of Lithium in this situation to obtain better evidence about its effectiveness.

What can I do to prevent puerperal psychosis recurring after a subsequent pregnancy?

As stated above, there is some evidence that taking Lithium immediately following delivery may reduce the risk of puerperal psychosis recurring. This evidence is not strong enough for us to be able to make firm recommendations and that is why we are involved in a clinical trial of the effectiveness of Lithium as a prophylactic. Researchers based in London are looking at the effectiveness of Oestrogen in preventing recurrences.

Progesterone injections have been advocated as a preventative measure. There is no convincing scientific evidence to support this.

If you have suffered puerperal psychosis and are pregnant or thinking about having another baby, it is important to liaise with your psychiatrist so that you can agree how best to monitor your mental state. It would also make sense to rope in as much practical support as you can get from your family, friends, social services or hired help around the time of birth so that you and your family can be looked after and supported.

Are Puerperal psychosis sufferers at risk of further illness unrelated to childbirth?

It's important to begin by pointing out there is much to be learned about puerperal psychosis and that it is impossible to be precise about risks. It is also important to remember that every individual is different and that there are many factors which will influence the risk factor of further episodes that will be specific to that person.

The illness we call puerperal psychosis encompasses a wide variety of symptoms but there are good reasons to believe that the majority of episodes are closely related to manic depressive illness (often called bipolar disorder). The nature of manic depression is that, although people get better between episodes, they are at risk of further periods of illness at some point in their lives. The same is true for women who have had puerperal psychosis - although many women will only have illness following childbirth others will have further episodes at other times. To put a figure on this risk is difficult but studies would suggest that there is about a 50% risk (i.e. a one in two chance) of further episodes of illness.

As for the nature of the episodes of illness that may occur, the close relationship between puerperal psychosis and manic depressive illness is again reflected in that episodes tend to be either depression or mania (highs). These episodes may be severe with psychotic symptoms (such as delusions or hallucinations) needing treatment in hospital. Alternatively they may be much less severe and respond quickly to treatment at home.

The important point to remember is that recognising an episode of illness quickly and getting treatment can nip it in the bud. Recognising that there is a risk of further episodes of illness can therefore be used positively by women and their families to get the help they need quickly.

Action on Puerperal Psychosis
Dept of Psychiatry
Division of Neuroscience
University of Birmingham
Queen Elizabeth Hospital
Mindelsohn Way
Birmingham B15 2QZ
Tel: 0121 678 2354
Email: j.f.benjamin@bham.ac.uk
Web: www.bham.ac.uk/app