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Remember that postpartum psychosis can come on rapidly and fluctuate – more so than other psychotic disorders. Risk assessment is crucial, and there is a lower threshold to admit/intervene due to the risks involved.
Key Knowledge
● Postpartum psychosis affects approximately 1-2 in 1000 women soon after giving birth
● Its onset is typically within the first 2 weeks postpartum, most commonly days 3-5
● The strongest risk factor is a personal or family history of bipolar affective disorder or previous postpartum psychosis
● It presents as a rapidly evolving, fluctuating illness—often manic or mixed in quality, with psychotic features
● Delusions frequently involve the baby (special powers, being in danger, not being the real baby)
● It is crucial to risk assess for suicide and infanticide
● It requires urgent inpatient admission, usually to a Mother and Baby Unit (MBU)
● Women with bipolar affective disorder have approximately a 25-50% risk of postpartum psychosis after delivery
● While a history of bipolar I disorder is the strongest risk factor, Other factors like advanced maternal age and low birth weight of the baby are also thought to be contributing factors
● Prognosis is generally good with prompt treatment, though recurrence risk with subsequent pregnancies is high
What is Postpartum Psychosis?
ICD-11 does not classify postpartum psychosis as a distinct diagnostic entity. It is coded using a cluster approach: 6E21 (Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, with psychotic symptoms) is assigned as the primary code, alongside an additional diagnosis — either bipolar disorder (6A60), a depressive episode with psychotic features (6A71), or a mixed episode — when full diagnostic criteria are met. ICD-11 defines the puerperium as commencing within approximately 6 weeks after delivery. In clinical practice, postpartum psychosis is recognised as a distinct syndrome due to its rapid onset, severity, and unique relationship to childbirth.
Core Clinical Features
Core clinical features:
● Rapid onset: Hours to days, typically within 2 weeks of delivery
● Fluctuating course: Mental state can shift dramatically within hours—lucid one moment, severely disturbed the next
● Mood disturbance: Most commonly manic or mixed; elevated, irritable, or rapidly cycling mood. Pure depressive presentations occur but are less typical of the acute onset form.
● Psychotic symptoms:
○ Delusions—often involving the baby (belief the baby is special, chosen, or in danger; belief the baby has been replaced or is not the real baby). Other delusions may include delusions of reference, grandiose delusions and persecutory delusions
○ Hallucinations—auditory or visual
○ Confusion and disorientation: A distinctive feature of postpartum psychosis. The person may be perplexed, disorganised, and unable to follow conversation.
○ Behavioural disorganisation: Agitation, restlessness, severely disrupted sleep (beyond normal newborn demands), bizarre or erratic behaviour
○ Thought disorder: Disorganised thinking, loosening of associations
Early warning signs (often reported by family before full psychosis develops):
● Insomnia—not sleeping even when baby sleeps, not appearing tired despite no sleep
● Elation or unusual happiness, irritability, or rapid mood shifts
● Overactivity, excessive talking, pressured speech
● Confusion, perplexity, disorientation
● Expressing unusual ideas or concerns about the baby
Differential Diagnosis for Postpartum Psychosis
1. Postnatal depression (PND) with psychotic features
Key distinctions: PND with psychotic features has a more gradual onset (weeks rather than days) and the dominant mood is depressive. In postpartum psychosis, the onset is rapid and mood is typically manic or mixed, with prominent confusion. However, the boundary can be blurred, particularly in mixed presentations.
2. Bipolar disorder (manic episode, non-puerperal)
Key distinctions: Postpartum psychosis is considered by many to be a manifestation of bipolar disorder triggered by childbirth. In clinical practice, the distinction lies in the perinatal context and the prominent confusion, which is more characteristic of postpartum psychosis. A previous non-puerperal manic episode in the history supports a broader bipolar diagnosis.
3. Brief psychotic disorder
Key distinctions: Brief psychotic disorder involves sudden onset psychosis lasting less than one month. Postpartum psychosis is distinguished by its perinatal context and typically manic or mixed quality. The two can overlap diagnostically.
4. Schizophrenia or schizoaffective disorder
Key distinctions: Schizophrenia has a more insidious onset, lacks the rapid fluctuation and confusion of postpartum psychosis, and is not specifically linked to childbirth. A previous diagnosis of schizophrenia or schizoaffective disorder would be important context.
5. Delirium (organic cause)
Key distinctions: Postpartum delirium from organic causes (sepsis, haemorrhage, eclampsia, thyroid disease, Wernicke’s encephalopathy) can mimic postpartum psychosis. Always exclude organic causes. Investigations: FBC, U&E, LFTs, TFTs, blood cultures, urine MC&S, glucose, and neuroimaging if indicated.
6. “Baby blues”
Key distinctions: “Baby blues” involve tearfulness, emotional lability, and low mood on days 2-5, resolving spontaneously within two weeks. There are no psychotic features, no confusion, and no behavioural disorganisation.
7. Substance-induced psychosis
Key distinctions: Ask about substance use. Stimulant use or withdrawal can precipitate psychosis in the postnatal period. Urine drug screen should form part of initial assessment.
Risk Assessment in Postpartum Psychosis
As with every risk assessment, you must consider risk to self, to others and from others.
To self:
● Suicide — Leading cause of maternal death in the first postnatal year. Risk is highest in the first few weeks.
● Self-harm — May occur in context of psychotic symptoms (command hallucinations, delusional thinking) or severe mood disturbance
● Self-neglect — Severe disorganisation may impair ability to eat, drink, maintain basic self-care
● Accidents/Misadventure — Due to confusion, disorientation, or agitation
To others (the infant and other children):
● Infanticide — Rare but real risk. Delusions directly involving the infant (e.g., belief the baby must be “saved,” is suffering, or is not human) are particularly concerning. This must be assessed directly. Altruistic infanticide may occur in the context of nihilistic delusions or delusional beliefs about protecting the baby from a worse fate
● Neglect — Disorganisation and psychosis may impair basic infant care even without intent to harm
● Other children — Supervision and safety of older children must be assessed
From others:
● Domestic abuse — High-risk period; ask sensitively
● Exploitation — Vulnerability due to psychosis and impaired judgment
Communication Tips
Key skills include systematic assessment; clear risk communication; sensitive but direct questioning. In general the skills you need are the same as in other history taking stations, and in terms of eliciting psychopathology. It is important to be especially sensitive when enquiring about risk to the baby or other children; explaining why you are asking and normalising this part of the assessment can reduce alarm.
Exploring Symptoms:
● “How have you been feeling since the baby arrived?”
● “How much are you sleeping? What happens when you try?”
● “How is your mood – are you feeling particularly high or low?”
● “How are you feeling about your baby?” (Probe for unusual beliefs)
● “Has anything felt strange or unusual recently – anything you’ve seen, heard, or experienced that others don’t?”
● “Do you have any worries about the baby – their safety, who they are?”
● “Have you heard voices or seen things that other people don’t?”
● “Do you feel like messages are being sent to you—through the TV, the radio, or from other people?”
Assessing risk:
● “Have you had any thoughts of harming yourself?”
● “Have you had any thoughts of ending your life?”
● “Have you had any thoughts about the baby being harmed, or any thoughts of harming the baby yourself?”
● “What stops you from acting on those thoughts?”
Explaining the diagnosis (explanation station):
● “What your wife has experienced is called postpartum psychosis. It’s a serious but treatable illness that can develop very quickly after childbirth.”
● “The most important thing right now is that she gets specialist treatment, which usually means admission to a Mother and Baby Unit where she and the baby can be cared for together.”
● “With the right treatment, most women make a full recovery.”
● “We do need to make sure both she and the baby are safe while she’s unwell.”
CASC Station: Postpartum Psychosis — Collateral History and Risk Assessment
Setting: Acute psychiatric ward
Candidate Instructions:
You are the SpR on the acute psychiatric ward. Ms Aisha Okafor, a 29-year-old accounts administrator, was admitted last night under Section 2 of the Mental Health Act. She is 11 days postpartum following the birth of her first child, a daughter named Imogen. She was admitted after her husband, Dami, called 999 following a period of increasingly unusual behaviour over the past four days. Aisha is currently too distressed to give a reliable history.
Dami Okafor, 32, is waiting to speak to a doctor. He is a secondary school PE teacher. He has Imogen with him; Imogen is currently being cared for by a nurse at the ward reception.
Your tasks are to:
● Take a collateral history from Dami
● Perform a risk assessment
Scenario Summary:
Aisha Okafor is a 29-year-old woman with postpartum psychosis, admitted eleven days after the birth of her first child. Over the past four days, her behaviour has escalated from insomnia and elation to frank psychosis with prominent delusions involving her baby (belief that Imogen is “chosen” and has a divine mission), auditory hallucinations (voices confirming this), disorganisation, and confusion. Last night, she attempted to take Imogen out of the house at 2am, saying she needed to “present her.” Dami intervened and called 999. Aisha has a previously undiagnosed bipolar disorder—her mother had bipolar affective disorder and was hospitalised twice. Dami is frightened, exhausted, and has significant concerns about both Aisha’s and Imogen’s safety. He is cooperative and desperate to help.
Actor Brief:
You are Dami Okafor, a 32-year-old PE teacher. You live with your wife Aisha in a three-bedroom house. Your daughter Imogen was born eleven days ago after an uncomplicated vaginal delivery. You are exhausted, frightened, and relieved to be speaking to someone.
The first few days after the birth felt normal – Aisha was tired, a bit emotional, but you both were. She was breastfeeding and seemed to be getting the hang of it. Then, about four days ago, something changed. She stopped sleeping. She’d be awake all night, moving around the house, tidying obsessively, reorganising the nursery. When you tried to get her to come to bed, she said she wasn’t tired, that she felt “electric.” You thought maybe it was adrenaline from having a new baby.
Then she started talking about Imogen differently. She became convinced that Imogen was special—not in the normal new parent way, but in an intense, strange way. She told you that Imogen had been “sent” for a reason, that she had a mission to fulfil, and that she and Aisha had been “chosen together.” At first, you thought it was sleep deprivation talking. But over the next two days, it escalated. She started quoting religious texts—neither of you is particularly religious—and speaking very rapidly about signs and meanings she was receiving. She seemed confused at times, not recognising where she was in the house, asking you where the old kitchen was (you haven’t moved house—the kitchen has always been in the same place).
Last night was the worst. At around 2am, you woke to find Aisha dressed and about to leave the house with Imogen wrapped in a blanket. She said she needed to “present” Imogen and that she’d been told it had to happen before sunrise. You blocked the door and took Imogen from her. Aisha became upset, started crying, and said you were stopping her from completing something important. You called 999. The paramedics came and she was brought here.
In terms of the voices—she mentioned a few times over the past couple of days that she could hear someone “confirming things” to her. She said it felt like thoughts but from outside. You weren’t sure if she meant a voice or just strong feelings.
You’re terrified about Imogen’s safety. You’ve been awake for most of the past four days. Imogen is fine physically—you’ve been feeding her formula since Aisha stopped breastfeeding two days ago when she became too disorganised to manage it.
Aisha has no previous psychiatric history that you know of. She’s never been on psychiatric medication, never seen a psychiatrist, never been admitted to hospital for mental health reasons. She’s always been lively and energetic—her friends would describe her as the most enthusiastic person in the room—but never like this.
Her mother, Grace, who lives in Lagos, was hospitalised twice when Aisha was a child for something Aisha described as a “breakdown.” Aisha said it happened after each of her younger siblings was born—after the first and third. Grace was on lithium for several years. Aisha has mentioned this, so it’s something you know about. You think this might be relevant but you’re not sure.
Aisha has no medical problems. She was taking pregnancy vitamins and iron tablets during pregnancy. No allergies. No drugs. She drinks occasionally—maybe a glass of wine at the weekend pre-pregnancy—nothing since she found out she was pregnant.
You are cooperative, frightened, and want to understand what’s happening.
Feedback for Scenario:
Knowledge & Clinical Skills
A good candidate will:
● Elicit the characteristic clinical features of postpartum psychosis from the collateral history, covering the rapid onset and escalating course over four days, prominent insomnia without fatigue, elevated or manic mood quality, psychotic symptoms (delusions involving the infant, possible hallucinations), disorganisation, and confusion with disorientation
● Identify the key risk incident—the attempt to leave the house with Imogen at 2am with a delusional explanation—and assess this in detail, including the patient’s mental state at the time, intent, what prevented escalation, and what it reveals about ongoing risk to the infant
● Elicit the family history of bipolar disorder in the maternal line (mother hospitalised twice postnatally, on lithium), recognising this as the strongest risk factor for postpartum psychosis and supporting the likely diagnostic formulation of bipolar disorder presenting in the puerperal period
● Conduct a thorough risk assessment addressing both maternal risk (suicide, self-harm, self-neglect) and infant risk (neglect, harm related to delusional beliefs, the specific risk of an altruistic or mission-driven attempt to take or harm the infant), and assess current safeguarding arrangements (who is caring for Imogen, is she safe)
Demonstrate knowledge of appropriate management if asked.
Communication
A good candidate will:
● Establish rapport quickly with a distressed collateral informant, acknowledging his fear and exhaustion before moving into systematic history-taking, recognising that some moments of validation at the start can be helpful and effective as a communication strategy.
● Demonstrate awareness of the broader family system, and how Imogen’s needs are currently being met.
Authors / Reviewers
Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Sarah Barber is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.
Dr Grace Crowley is a Psychiatry Registrar, currently completing an PhD in global mental health.
References and Resources
● World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
● National Institute for Health and Care Excellence. (2020). Antenatal and postnatal mental health: Clinical management and service guidance (CG192). https://www.nice.org.uk/guidance/cg192
● Royal College of Psychiatrists. (2018). Perinatal mental health services: Recommendations for provision of services for childbearing women (CR232). https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr232.pdf
● Jones, I., & Craddock, N. (2001). Familiality of the puerperal trigger in bipolar disorder: Results of a family study. American Journal of Psychiatry, 158(6), 913–917. https://doi.org/10.1176/appi.ajp.158.6.913
● MBRRACE-UK. (2023). Saving lives, improving mothers’ care. University of Oxford. https://www.npeu.ox.ac.uk/mbrrace-uk
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.