Postpartum psychosis is receiving renewed public attention because of the high-profile criminal trial involving Lindsay Clancy in the United States. Much of the current discussion focuses on what the condition is, what it can look like, and what can happen when severe mental illness goes unrecognised.
For those working with women and families during pregnancy, birth and the postnatal period, there’s another important conversation. Postpartum psychosis is usually discussed in the context of a live birth, yet serious mental illness can also occur following pregnancy loss.
Postpartum psychosis is rare, serious and can develop very quickly. As practitioners whose work brings us into contact with women experiencing pregnancy loss, we have a professional responsibility to understand the condition well enough to recognise significant changes in mental state, take concerns seriously and know when prompt specialist assessment is needed. It’s also worth knowing what the relevant referral pathways are in your area, how concerns should be communicated and documented, and how you can follow up to ensure the appropriate steps have been taken.
Understanding Postpartum Psychosis
This condition is a rare but serious severe psychiatric emergency that can develop suddenly, most often in the days or weeks following childbirth. Similar psychotic illness has also been reported following pregnancy loss. It most often begins within the first two weeks, and symptoms can develop very quickly.
Symptoms can include severe confusion, marked changes in mood or behaviour, agitation, racing thoughts, unusual beliefs, paranoia, hallucinations and significant disruption to sleep. A person may also have limited insight into what’s happening, meaning they may not recognise that they’re becoming unwell.
Postpartum psychosis is a psychiatric and medical emergency and requires prompt assessment and treatment.
Also read: How to Support Bereaved Parents Who Blame Themselves after Pregnancy Loss
Postpartum Psychosis after Stillbirth and Pregnancy Loss
This condition is usually discussed in the context of having a live baby. But a live baby isn’t a prerequisite for serious psychiatric illness to occur in the period following pregnancy and birth.
Research has specifically examined postpartum psychosis following stillbirth. Findings are mixed, although some population-based research has found a higher rate of diagnosis following stillbirth than following live birth. Other studies haven’t found the same association.
There’s less research examining psychotic illness following miscarriage or abortion. This doesn’t mean that psychotic illness can’t occur after these experiences, rather, the evidence is more limited than it is following live birth and stillbirth.
What we can say with confidence is that the absence of a live baby doesn’t, by itself, rule out serious psychiatric illness in the postpartum period. For practitioners working across perinatal and reproductive loss, this distinction is important.
Also read: Anger after Pregnancy Loss: What It May Be Communicating and How We Can Respond
Understanding the Risk Factors for Postpartum Psychosis
The exact causes aren’t fully understood. What we do know is that childbirth appears to be a potent trigger for severe mood and psychotic illness in people with particular vulnerabilities. Research suggests that biological changes around pregnancy and reproductive transitions may be important, with hormonal shifts, disruption to sleep and circadian rhythms, immune factors and genetic vulnerability all being investigated.
The strongest established risk factors are a previous episode of postpartum psychosis and a history of bipolar disorder. A family history of bipolar disorder or severe mental illness can also increase risk. However, it can occur as a first episode of severe mental illness, so the absence of a known psychiatric history doesn’t rule it out.
Sleep disruption may also contribute, particularly in people who are already vulnerable to mania or psychosis. However, the relationship isn’t straightforward. Reduced sleep can be a contributing factor, but it can also be an early sign that an episode is developing.
The reproductive transition itself matters, not simply the demands of caring for an infant. This helps explain why a live baby isn’t necessary for serious psychiatric illness to occur. However, the biological changes associated with pregnancy and its ending vary depending on the circumstances, and the mechanisms underlying the condition aren’t fully understood.
Also read: How We Can Strengthen Support for Families Experiencing Pregnancy Loss
Recognising the Signs of Postpartum Psychosis
Postpartum psychosis can develop rapidly, and the early signs aren’t always immediately recognisable. Someone may seem unusually energised, elated, agitated or irritable, talk much more than usual, have racing thoughts or become unable to sleep. They may also become confused, unusually suspicious or fearful, or behave in ways that are markedly different from usual.
As the illness develops, psychotic symptoms may become more apparent. These can include hallucinations, delusions or significant confusion and disorientation. A person may have beliefs that seem very real to them but aren’t shared by those around them, or may hear or see things that others don’t.
One of the challenges is that some early changes can be mistaken for understandable responses to the postnatal period or bereavement/loss. Not sleeping, feeling highly energised or behaving differently may initially seem less concerning, particularly when there are many changes happening at once.
For practitioners working with perinatal loss, recognising the condition doesn’t need to begin with suspecting psychosis. Someone may simply seem unusually unwell or different, the woman herself may describe changes in her thoughts or perceptions, or a partner, family member or another professional may express concern. This can be particularly important when you’re meeting someone for the first time and don’t know what’s usual for them. Confusion, markedly reduced need for sleep, unusual beliefs, hallucinations, or rapidly changing mood or behaviour may all be signs that something more serious is happening.
You don’t need to be certain about what’s happening before taking a concern seriously. Your role isn’t to diagnose the condition, but to recognise when something seems unusual, and promptly and efficiently reach out for relevant support.
Also read: Why Bereaved Parents Stay Connected to Their Baby: Understanding Continuing Bonds Theory
When Grief and Psychosis Coexist
Grief after pregnancy loss can be intense, unpredictable and highly individual. Someone may experience profound sadness, anger, numbness, difficulty concentrating, disrupted sleep or a sense of unreality. These experiences can be deeply distressing without indicating psychosis.
Psychosis is different. It involves a significant disturbance in a person’s perception of reality and may include hallucinations, delusions, severe confusion or markedly disorganised thinking or behaviour.
The distinction isn’t always straightforward, particularly when someone is acutely bereaved. Sleep disruption, intense emotion and changes in behaviour can occur in grief as well as in serious mental illness. The question isn’t whether someone’s response to a pregnancy loss or stillbirth looks unusual, but whether there are signs that their perception of reality or mental state has changed in a way that needs urgent specialist attention.
Grief and serious mental illness can coexist. When we work with women who are experiencing profound grief, significant changes in their mental health still warrant our attention.
Also read: Signs of Unresolved Grief and How It Affects Us Over Time
What Practitioners Can Do
When something doesn’t seem right, the first step is to take the concern seriously and communicate it clearly.
Depending on your role, this might mean speaking directly with the woman about what she’s experiencing, listening to concerns raised by a partner or family member, or passing your observations to the appropriate healthcare professional or service.
Sharing your own concerns honestly and openly with the woman and her family is important. Where appropriate, let them know what you’ve noticed, why you’re concerned, and what you’re going to do next. Explain who will be involved and why, as far as you’re able to. Clear communication can help people understand what is happening at a time that may already feel confusing and overwhelming.
Concerns, observations and actions should also be documented accurately so that important information isn’t lost as care moves between professionals or services.
It’s also important not to assume that someone experiencing pregnancy loss will recognise that they’re becoming unwell. Psychosis can affect insight, and a person may not see their experiences as unusual or concerning.
Where there are signs of possible postpartum psychosis, prompt specialist assessment is important. Depending on your role and local systems, this may mean contacting the relevant local mental health or medical service. Where you have made a referral or raised a concern, consider how you will follow up to ensure that the appropriate steps have been taken.
You might also like to keep information about this condition alongside your pregnancy loss resources, together with your own local referral pathways and contact numbers, so they’re easy to find if you ever need them.
Also read: Men and Miscarriage: Understanding Fathers’ Grief after Pregnancy Loss
Why This Matters in Perinatal Bereavement Care
Postpartum psychosis is rare, and most practitioners working with pregnancy loss are unlikely to encounter it. However, for all of us whose work brings us into contact with women experiencing pregnancy loss, we have a professional responsibility to educate ourselves. Recognising that something isn’t right and knowing what to do next can make a significant difference.
Practitioners working across pregnancy, birth, postnatal and pregnancy loss care will meet women and families at very different points in their experience. We may be supporting someone immediately after a stillbirth, during care following an abortion or miscarriage, or alongside a family weeks or months after a loss. We may also be one of several professionals involved in their care, each seeing a different part of what’s happening.
This makes awareness of postpartum psychosis relevant across disciplines. We don’t need to be mental health specialists to recognise significant changes in someone’s mental state, take concerns seriously, communicate clearly with the woman, her family and the professionals involved, and know how to access appropriate support.
For practitioners working with pregnancy loss, understanding postpartum psychosis is also part of recognising the limits of our own professional scope of practice and when someone may need support beyond our role.
Also read: Compassion Fatigue in Reproductive & Perinatal Loss: Recognising the Signs, Finding Support
Continuing Professional Development
Being aware of the signs and symptoms of postpartum psychosis, and understanding that serious mental illness can occur in the context of pregnancy loss, gives practitioners an important foundation for responding when concerns arise. Knowing how to communicate those concerns, access appropriate support and navigate the next steps is part of developing confident practice.
Notes for the Journey is a monthly professional development resource for practitioners whose work brings them into contact with pregnancy loss, stillbirth, neonatal death, and other forms of reproductive loss. Each edition includes a reflection, a research insight, a practical takeaway, and a question to carry into your work.
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People Also Ask
Can postpartum psychosis happen after a stillbirth?
Yes. It has been reported and studied following stillbirth, although research findings are mixed. The absence of a live baby doesn’t rule out serious psychiatric illness in the postpartum period.
Can postpartum psychosis happen after a miscarriage?
Psychotic illness has been reported following miscarriage, but research specifically examining this is limited. The evidence isn’t as well established as it is for diagnosis following live birth.
Can postpartum psychosis happen after an abortion?
Psychotic illness has been reported following abortion, but it appears to be rare and the evidence base is limited. Research in this area is much less extensive than research into postpartum psychosis following live birth.
What are the early signs of postpartum psychosis?
Early signs can include marked changes in mood or behaviour, unusually high energy or agitation, racing thoughts, very little need for sleep, confusion, unusual beliefs, suspiciousness or changes in perception. Symptoms can develop rapidly.
Does postpartum psychosis only happen to people with a history of mental illness?
No. Although a previous episode and bipolar disorder are important risk factors, postpartum psychosis can occur as a first episode of severe mental illness. A lack of previous psychiatric history doesn’t rule it out.
References
Albers, S., et. al. (2023). Postpartum psychosis during delivery hospitalizations and postpartum readmissions, 2016–2019. American Journal of Obstetrics & Gynecology MFM, 5(5), 100905. https://doi.org/10.1016/j.ajogmf.2023.100905
Carr, C., et. al. (2023). Sleep and postpartum psychosis: A narrative review of the existing literature. Journal of Clinical Medicine, 12(24), 7550. https://doi.org/10.3390/jcm12247550
Jones, I., et. al. (2014). Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. The Lancet, 384(9956), 1789 – 1799. https://doi.org/10.1016/S0140-6736(14)61278-2
National Institute for Health and Care Excellence (NICE). (2014, updated 2020). Antenatal and postnatal mental health: Clinical management and service guidance (CG192). NICE.
Perry, A., et. al. (2021). Phenomenology, epidemiology and aetiology of postpartum psychosis: A review. Brain Sciences, 11(1), 47. https://doi.org/10.3390/brainsci11010047
Reilly, T. J., et. al. (2023). Systematic review of the association between adverse life events and the onset and relapse of postpartum psychosis. Frontiers in Psychiatry, 14, 1154557. https://doi.org/10.3389/fpsyt.2023.1154557
Royal College of Psychiatrists. (n. d.). Postpartum psychosis. Royal College of Psychiatrists.
Toor, R., et. al. (2024). Postpartum psychosis: A preventable psychiatric emergency. FOCUS, 22(1), 44 – 52. https://doi.org/10.1176/appi.focus.20230025
