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OpinionLindsay Clancy
Postpartum psychosis What expectant parents and families should know
As the Lindsay Clancy trial brings postpartum psychosis into the spotlight, two Irish psychiatrists explain the symptoms, causes and treatment of the condition.
THERE HAS BEEN a lot of media coverage in recent weeks about postpartum psychosis, on the back of the Lindsay Clancy murder trial in the US. It is a difficult topic to discuss because it plays into fears people may have about its potential consequences – even those which are newsworthy partly because they are so rare.
The months around childbirth are already a time of significant biological and psychological change. Stories about mental illness in this context can be stigmatising and deeply worrying for new mothers, pregnant women and those of childbearing age, along with their partners and families. Our intention here is to look compassionately beyond the media drama and provide accurate, useful information on postpartum psychosis itself. We have provided helpful resources at the end.
No new mother should ever be afraid to say that she is not feeling well, and this is no less true when it comes to her mental health. But it is especially the case with postpartum psychosis because it represents an uncommon psychiatric emergency that requires assessment, care and treatment very quickly. This treatment is usually very effective and full recovery is the norm.
What is this condition?
So, what exactly is postpartum psychosis? Sometimes referred to as “puerperal psychosis”, it is a severe psychotic illness that begins suddenly in the days or weeks following childbirth.
It affects approximately 1-2 women per 1,000 births. But to understand it properly, we must first say what “psychosis” itself is. Here, we have a collection of symptoms in which a person becomes detached from reality. These symptoms include hallucinations (seeing or hearing things that are not there, for example, hearing voices), delusions (fervently believing things you do not normally believe, for example, marked paranoia) and thought disorder (in which your thoughts become jumbled up, making communication very difficult).
Women with acute psychosis shortly after childbirth may also experience confusion, disorientation, agitation, impaired judgment, disorganised or unusual behaviours, a reduced need for sleep, and extreme mood changes ranging from severe depression to mania.
A specialist clinician will usually be able to distinguish postpartum psychosis from the much more common (albeit still serious) postpartum depression without psychosis, which affects around 10% of women in the months following childbirth. Postpartum depression is characterised by persistent low mood, loss of interest or pleasure, feelings of hopelessness and profound guilt, marked insomnia and other mood-related symptoms that significantly affect functioning. Baby blues involve a few days to a few weeks of much milder mood swings, anxiety, tearfulness and irritability. It occurs in up to 80% of women postpartum.
Importantly, a mother experiencing postpartum psychosis may not actually realise that she is unwell. This lack of insight can make the illness particularly challenging and can contribute to it becoming a genuine psychiatric emergency. Aside from the obvious distress felt by any woman in this situation, there can be a risk of suicide or of harm to the baby, although these are rare outcomes that are preventable by timely access to good quality assessment and treatment. This is why recognition by partners, relatives, midwives, GPs and other professionals is particularly important. No mother should ever feel afraid to confide in others about their symptoms. She will typically make a full recovery with the appropriate support.
Diagnosis and treatment
So, what causes it? The answer to this is complex. As we have said, the months around childbirth are already a time of significant biological and psychological change. There is the physical and psychological recovery from childbirth, along with changes in levels of hormones like oestrogen, progesterone and prolactin, immune system changes, and a profound disruption in sleep, diet and overall lifestyle.
The risk of postpartum psychosis is higher if someone in your family has had it. There is also a strong association between postpartum psychosis and some other psychiatric illnesses such as bipolar disorder. Specialist perinatal psychiatric care and planning during and after pregnancy can help to reduce the risk of postpartum psychosis going unrecognised or untreated.
This is important because postpartum psychosis undoubtedly requires an urgent psychiatric assessment, ideally within hours. In Ireland, this might be accessed via the midwife, obstetrician, public health nurse, perinatal psychiatrist, a GP, the emergency department or a mental health crisis team. A definitive diagnosis is typically made in the hospital setting following a comprehensive assessment by a psychiatrist. Treatment should begin without delay, and can include medications such as antipsychotics, antidepressants and mood stabilisers, taking into account breastfeeding, medication safety and the mother’s and baby’s needs. Other more complex interventions are available if needed, followed in due course by multidisciplinary team involvement such as psychology and social work support.
Services will do their best to facilitate regular contact between mother and baby during recovery. At present, care typically involves admission to a psychiatric hospital, but psychiatrists, midwives and other specialist clinicians have been lobbying for years for a specialised mother and baby unit (MBU) that would allow the mother and baby to be cared for together in a supportive inpatient setting.
The plan for an MBU is outlined in the HSE’s 2017 document, Specialist Perinatal Mental Health Services Model of Care for Ireland, but is unfortunately yet to be built. But even while we wait, a high standard of quality care is available for women experiencing postpartum psychosis. Where appropriate, partners and other family members are involved and supported, bearing in mind how traumatic the experience can be for them. Afterwards, ongoing psychiatric follow up is important.
In the end, while postpartum psychosis is a psychiatric emergency, it is also an entirely treatable illness from which recovery is the norm. Women who have experienced postpartum psychosis may find themselves frightened and confused by what has happened to them.
But compassion, support and timely medical treatment mean that life soon returns to normal – or better than normal with the patter of tiny feet about the house.
Dr Niall Iósaef Ó Gallchobhair is a registrar in psychiatry with the Psychosis Team at St John of God University Hospital, Stillorgan, Co Dublin. Dr Stephen McWilliams is a consultant psychiatrist with the Psychosis Team at St John of God University Hospital, Stillorgan, Co Dublin, a Clinical Associate Professor at the School of Medicine, University College Dublin, and an Honorary Clinical Senior Lecturer at RCSI University of Medicine and Health Sciences.
If you have been affected by any of the issues mentioned in this article, you can reach out for support through the following helplines. These organisations also put people in touch with long-term supports:
- Samaritans 116 123 or email jo@samaritans.org
- Text About It – text HELLO to 50808 (mental health issues)
- Aware 1800 80 48 48 (depression, anxiety)
- Pieta House 1800 247 247 or text HELP to 51444 – (suicide, self-harm)
- Teen-Line Ireland 1800 833 634 (for ages 13 to 19)
- Childline 1800 66 66 66 (for under 18s)
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