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Postpartum psychosis (PPP) occurs in one to three out of every 1,000 pregnancies. However, its diagnosis is difficult because it is not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), and because the name is a misnomer. Symptoms include not only psychosis but also mania, depression, and delirium.
Dr. Susan Hatters-Friedman returned to the International Forensic Psychiatry Lecture Series on December 12, 2024, this time with Meghan Cliffel to discuss Personal, Clinical, and Forensic Perspectives on Postpartum Psychosis.
Dr. Hatters-Friedman covered the clinical and forensic perspectives before Ms. Cliffel shared her perspective, vividly bringing PPP to life by sharing her story in the present tense.
Although a recording of this lecture is not available, you can read their co-authored journal article online.
Effects of Postpartum Psychosis
“To me, as a reproductive and forensic psychiatrist, [PPP] is the most concerning mental health difficulty that a woman may experience because of its rapid onset, its rapid changes, and the risks,” Dr. Hatters-Friedman said.
PPP often develops quickly in the first two weeks after delivery but can also emerge months later, for example, triggered by changes in breastfeeding. It is a mental health emergency because of the risks of suicide (the leading cause of death in the first year postpartum), infant neglect (because of cognitive disorganization), and infanticide.
Diagnosis Difficulties
PPP symptoms include grandiose bizarre delusions; paranoia; mood swings; audio, visual, tactile, olfactory, and gustatory hallucinations; confusion; and disorganized behaviour. It occurs suddenly in previously healthy individuals, differing from other forms of psychosis.
Doctors may misdiagnose these symptoms as postpartum depression, postpartum obsessive-compulsive disorder, or schizophrenia. Doctors should also consider whether symptoms are substance-induced, such as from prescribed corticosteroids or other substance use.
Because PPP is not in the DSM, it isn’t included in psychiatry training. Forensic mental health professionals who do not fully understand PPP may misdiagnose it as malingering, which is exaggerating or faking symptoms to escape an obligation.
Complicating diagnosis further is that patients might hide their symptoms if they have some insight into what’s happening and fear losing custody of their infants.
The Survivor’s Experience
Ms. Cliffel suffered PPP in December 2015, eight months after her second baby was born. She shared her story in the first person and present tense as if it was happening during the lecture. It provided a vivid picture of her fear and desperation. She believed a cult was out to kill her and her children, and she didn’t know which side her husband was on.
The onset was so sudden that she said it was a matter of hours between “firing on all cylinders” to being a threat to herself and her family.
Patient Care
Her break with reality was so sudden and severe that involuntary commitment was life-saving for her. However, at the time, it fit into her delusion. She thought people were coming to capture her, and they did. “It was only when people started to express empathy and communicate the goals really clearly to me that it kind of poked holes in the plot that I had cooked up,” she said.
When she returned home from the hospital, her body remembered it as a battlefield where she fought for her and her children’s safety. She encouraged doctors to recognize the traumatic effect of their patients’ experiences and provide support to help patients re-enter their lives thoughtfully, including support for posttraumatic stress disorder (PTSD).
In addition to mood and sleep medication, therapy and knowledgeable psychiatric care were critical to her healing after her acute period. Eye movement desensitization and reprocessing (EMDR) therapy then became particularly helpful for PTSD once Ms. Cliffel was ready to work with resultant triggers. She also uses writing, meditation, and yoga to help her cultivate self-compassion and find meaning in her experience.
Dr. Hatters-Friedman stressed the importance of creating a treatment alliance with the new parent and their family and support network, with sleep being essential. Medication often includes mood stabilizers and atypical antipsychotics.
Prevention
Ms. Cliffel encouraged doctors to learn more about the vulnerable nature of the perinatal period and PPP, so they can better inform their pregnant patients about them and their risks. One in five females suffer from a maternal mental health issue.
When she had her third child, knowing there was a one-in-three chance of experiencing PPP again, her approach and supports were very different. Attention was also on her, ensuring sleep, support, lithium immediately after the delivery, and enjoyable activities.
Dr. Hatters-Friedman said expectant parents with a personal or family history of bipolar disorder are at higher risk of PPP, so they should be monitored more closely.
Ongoing Work
Advocacy efforts focus on improving training about PPP, so medical and mental health professionals better understand the condition. This would allow these professionals to better share information with expectant parents and help plan family supports holistically.
Including PPP in the DSM would support not only training but also interactions between maternal, mental health, and emergency doctors, and court explanations of unusual behaviour.
Research in 2024 included studies on prevention, recovery, and the impact on the family; medications; genetics; and the neurological, endocrine, and immune systems.
You can find more information in the American Academy of Psychiatry and the Law’s Practice Resource for Reproductive Psychiatry/Women’s Mental Health in Forensic Psychiatry Practice.
Written by Virginia St-Denis and approved by Dr. Susan Hatters-Friedman and Meghan Cliffel.
