Summary: New review finds that pregnant women with bipolar disorder face a substantially increased risk of developing postpartum psychosis.
Source: Northwestern University
Disorder often overlooked; clinicians sometimes hesitant to prescribe the most effective medication for new mothers.
Women with bipolar disorder, their families, and clinicians should be aware of a markedly higher risk of postpartum psychosis after childbirth, according to a comprehensive review led by Northwestern Medicine researchers in collaboration with colleagues at Stanford University and Erasmus Medical Center. The review synthesizes the limited but critical literature on this rare and serious psychiatric emergency.
Postpartum psychosis is distinct from postpartum depression: it is acute, dramatic in onset, and most often arises in the context of bipolar disorder. Because it affects only a small number of mothers—typically one or two per 1,000 births—it can be missed by clinicians and misunderstood by patients and families. Raising awareness and improving diagnosis are essential steps to prevent potentially tragic outcomes.
One of the central clinical concerns highlighted by the review is reluctance to use lithium during breastfeeding. Despite clinician hesitancy, lithium remains the most effective and fastest-acting evidence-based medication for treating and preventing postpartum psychosis. Published studies of breastfed infants whose mothers received lithium have been limited, but careful monitoring in those studies has not shown adverse infant outcomes. The review emphasizes that, in many cases, the risks of untreated severe psychiatric illness outweigh the risks associated with appropriate lithium use under clinical supervision.
Postpartum psychosis carries real risks, including an elevated likelihood that a mother may harm herself or her infant. “More often than not, the risk of the medication is less than the risk of the uncontrolled disorder,” said senior author Dr. Katherine Wisner, Norman and Helen Asher Professor of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine.
Clinicians must distinguish between two clinical presentations: women who experience psychosis only in the postpartum period, and women with bipolar disorder who have mood episodes throughout pregnancy and beyond. For women with documented postpartum-only episodes, the review supports an immediate postpartum strategy—beginning lithium at delivery to prevent a recurrent psychotic episode. Women with chronic bipolar disorder typically require continuous medication across pregnancy, with careful dose adjustments as maternal metabolism changes.
Postpartum depression and postpartum psychosis present very differently. Postpartum depression can include extreme anxiety, obsessive thoughts (for example, intrusive worries about harming the baby), and compulsive checking behaviors; while these symptoms are distressing, they do not involve hallucinations or delusions. By contrast, acute postpartum psychosis often appears suddenly: mothers may become disorganized, confused, or delirious and may experience frank psychotic symptoms such as hallucinations or delusional beliefs, including false impressions that a harmful force compels them to act against their baby.
The review also notes that some cases of postpartum psychosis have treatable medical or neurological underpinnings, including autoimmune thyroiditis, infections, or rare conditions such as anti-NMDA receptor encephalitis or metabolic disorders that can first present after childbirth. A careful diagnostic evaluation during hospitalization is often required to ensure safety, identify potential medical contributors, and start appropriate treatment. Electroconvulsive therapy (ECT) is an effective option in some cases, and inpatient care allows clinicians to manage acute risk while initiating therapy.
Prevention strategies emphasized by the review include prophylactic lithium immediately after delivery for women at high risk and proactive safety monitoring for mother and infant. Population-based studies summarized in the review report that first-lifetime onset postpartum psychosis or mania occurs in roughly 0.25 to 0.6 per 1,000 births. After a first episode, approximately 20–50 percent of women will have psychosis limited to the postpartum period, while the remainder have mood episodes outside the perinatal window, usually within the bipolar spectrum. The estimated relapse risk after a subsequent pregnancy for women with isolated postpartum psychosis is around 31 percent.
Another significant gap identified by the review is limited availability of mother-baby psychiatric units in the United States. In many other countries, dedicated mother-and-infant admission units enable joint care so mothers can remain with their infants while receiving treatment, which supports breastfeeding and family involvement. In contrast, U.S. psychiatric hospitals often restrict newborn visitation, creating barriers to breastfeeding and family-centered recovery.
Source: Jeff Hansen – Northwestern University
Image source: This image is provided for illustrative purposes and is in the public domain.
Original research: Veerle Bergink, M.D., Ph.D., Natalie Rasgon, M.D., Ph.D., and Katherine L. Wisner, M.D., M.S., “Postpartum Psychosis: Madness, Mania, and Melancholia in Motherhood,” American Journal of Psychiatry, published online September 9, 2016; DOI: 10.1176/appi.ajp.2016.16040454.
Northwestern University. (2016, September 9). Postpartum Psychosis Big Risk for Mothers With Bipolar Disorder. NeuroscienceNews. Citation access date: September 9, 2016.
Abstract (review summary)
Objective:
Postpartum psychosis and mania after childbirth are psychiatric emergencies that carry elevated risks of suicide and infanticide. This review examined epidemiologic, genetic, and physiological triggers (endocrine, immune, and circadian factors) and summarized clinical evidence for diagnosis, treatment, and prevention.
Method:
The authors reviewed population-based and clinical studies, analyzed proposed biological mechanisms that may precipitate psychosis after birth in genetically vulnerable women, and synthesized the limited treatment literature to provide clinical recommendations.
Results:
Incidence estimates of first-lifetime postpartum psychosis range from approximately 0.25 to 0.6 per 1,000 births in register-based studies. After an initial episode, 20–50 percent of women have psychosis confined to the postpartum period; the remainder have mood episodes outside the perinatal window, often within the bipolar spectrum. Potential postpartum triggers include rapid hormonal shifts, immune changes, and circadian disruption, and some cases are associated with treatable medical conditions. Fewer than 30 publications have focused on treatment; the largest available study supports the efficacy of lithium for acute and maintenance treatment, and other reports document successful use of ECT. Inpatient care is frequently required to stabilize patients, complete diagnostic evaluation, and initiate therapy. Preventive strategies include immediate postpartum lithium prophylaxis for high-risk women and close safety monitoring.
Conclusions:
Postpartum psychosis is a distinctive and treatable form of affective psychosis that provides an important model for studying the neurobiology of mood-related psychosis. Improved awareness, careful diagnosis, and evidence-based treatment—including consideration of lithium when clinically appropriate—can reduce risk and improve outcomes for mothers and infants.