Postpartum psychosis: what has the research told us so far?
9 November 2022
In November this year we hosted a webinar discussing postpartum psychosis which was sponsored by the Section of Women’s Mental Health of the European Psychiatric Association and was in collaboration with Action on Postpartum Psychosis (APP).
Trigger warning: this blog contains references to suicide.
NCMH Director Professor Ian Jones introduced the webinar and research taking place at Cardiff University into postpartum psychosis; “a condition that classification systems do not treat adequately.”
A lived experience voice: Dr Sally Wilson
Dr Sally Wilson, who works with APP, first experienced symptoms of postpartum psychosis after the difficult birth of her daughter Ella.
Sally used her medical notes to detail the development of her symptoms which began as ‘feeling funny and agitated’ and gradually worsened to hallucinations and delusions where she was paranoid that had harmed her baby.
“On the outside it looked like exhaustion, but internally I really felt as though I really had done something to my daughter. My whole reality and perception of the world had shifted. I was living in an afterlife and being punished for what I had done.”
After Sally’s episode, she was admitted to a general psychiatric ward. However, her symptoms were treated in relation to stress, and no mention of postpartum psychosis was made.
“I was prescribed various anti-psychotic medications and monitored at home. But I still believed I was living in a parallel universe.
“I couldn’t understand it as I didn’t feel depressed throughout my pregnancy. […] I would flit between desperately wanting to get better and not knowing how that may happen.”
It wasn’t until Sally’s husband had researched her symptoms that they discovered postpartum psychosis and were able to use this to advocate for the right treatment.
Since receiving a diagnosis of postpartum psychosis, Sally received electroconvulsive therapy and the guidance of a clinical psychologist who allowed her to work through her experience of postpartum psychosis, including feelings of trauma and guilt.
“Without clinicians, researchers, and organisations like APP working together, I probably wouldn’t be sitting here today.”
Working hard to determine the risk
Professor Arianna Di Florio who leads the reproductive mental health programme at Cardiff University discussed the team’s research into the risk of developing postpartum psychosis.
“In the general population,” Professor Di Florio noted, “the risk of experiencing postpartum psychosis is about 1-2 in 1,000.”
However, researchers at Cardiff University want to know if this number is all women and people who have given birth or if there is a group who are more at risk than others.
This research in collaboration with the University of Worcester, with help from Bipolar UK and APP, has created the largest research network of people with lived experience of bipolar disorder and/or postpartum psychosis in the world.
Using data from this network, researchers have calculated how many women with a diagnosis of bipolar do suffer from postpartum psychosis.
"Whilst for the general population the rates are 1-2 in 1000, for people with bipolar 1 disorder who give birth the rates are 1 in 5, or 20%."
“People with a diagnosis of bipolar are at 100 times more risk of developing postpartum psychosis than people in the general population.”
Researchers have continued to use this data to develop personalised ways of identifying risk, such as evidence-based questions to use in clinics.
“Our studies are necessary milestones toward the official acknowledgement of postpartum psychosis by diagnostic systems with important implications for research and clinical practise.”
Postpartum psychosis and the developing world
Professor Di Florio acknowledged the disparity of healthcare systems across the globe, especially within the lower socio-economic countries.
An international consortium with bases in India and Malawi has been developed which involves women and organisations from different geographical, linguistic, and socio-demographic background in order to help develop more culturally sensitive approaches toward reproductive mental health.
“For the first this time has given an active role to women with postpartum psychosis living in non-western countries.”
Professor Di Florio also cited the Motherhood and Mental Health survey which aims to tailor and manage prognosis even further.
This survey is currently open and you can take part on the NCMH website.
Out of the hospital and into the clinic – diagnosis, treatment, management
The final segment of the webinar was led by Dr Marisa Casanova Dias who emphasised the importance of translating the discoveries made by this research into clinical practise.
“Every health professional who comes across a woman and her family in the perinatal period needs to know about postpartum psychosis and be able to recognise the signs, symptoms and what to do.”
Dr Dias used the clinical criteria for identifying postpartum psychosis and the analogy of a kaleidoscope to highlight how important it is for clinicians to not only be able to recognise symptom onset and progression, but how these fluctuate from individual to individual.
Urgent action is needed
Dr Dias also outlined how an episode should be managed through various assessment methods and treatments such as medication, admission to a mother and baby unit, psychological therapies, and electro-convulsive therapy (ECT).
“Postpartum psychosis is a medical emergency and needs to be treated quickly and with appropriate specialist care if available.”
Prevention is key
Discussion at general psychiatry appointments should involve conversations about pregnancy, so that if the patient does want to become pregnant than a tailored care plan can be developed, Dr Dias concluded.
“There are no certainties about what works for each person; therefore discussion needs to be had. Whilst the prognosis for an acute episode is good if identified and treated early, longer term support also needs to be provided.”