While the onset of postpartum psychosis (PP) is rapid and often occurs in the week following delivery, a study by Heron and colleagues shows that there are identifiable symptoms in the early postpartum period prior to onset of a full-blown psychotic episode. This study provides a loose timeline for the onset of PP and notably describes subclinical behavior changes experienced by some women prior to the onset of PP. In other women, more clinically significant symptoms were seen in the first three days following delivery. In all women where risk factors for PP are present, close monitoring of mood and behavior changes in the immediate postpartum is vital to ensure early identification and treatment of PP.
The study was conducted using a sample of 127 women who met the criteria of at least one episode of PP within 4 weeks of delivery. These women were interviewed using a semi-structured psychiatric interview to assess symptoms of mania, depression, and psychosis. Additionally, lifetime psychiatric history was taken. During the interview women were asked about the earliest symptoms they could remember that they believed to be related to PP. They were asked to describe their symptoms and how the symptoms impacted their functioning. Both clinical and subclinical symptoms were noted. Clinically significant symptoms are those that cause distress, impairment, and interference with mental functions or affect others. Subclinical symptoms are described as the presence of a symptom but to a lesser degree with little to no impairment in functioning or distress associated with the symptom.
In terms of a timeline for the onset of symptoms, this study showed that by day 3 postpartum, 73% of women interviewed reported experiencing symptoms. 40% of women reported onset of symptoms on the day of delivery, and 8% reported experiencing mild subclinical symptoms prior to delivery that increased in intensity throughout the third trimester. The most commonly reported symptoms were hypomania, confusion, perplexity, sleep disturbance, irritability, anxiety, detachment, and lability (experiencing emotions that are irregular or not proportional to the situation). Many of these symptoms are similar to those flagged as early warning signs for bipolar disorder outside of pregnancy; however, there were some symptoms that were more specific to pregnancy-related episodes including confusion, disorientation, and detachment from surroundings.
Interestingly, while women could retroactively identify hypomanic symptoms as abnormal and related to PP, many women reported feeling at the time of onset as though they were coping particularly well. The nature of hypomanic symptoms makes them harder to distinguish than depressive symptoms from normal feelings in the postpartum period. When women experience feelings of excitement or elation and find that they need much less sleep than usual, as is the case with many women who experience hypomanic symptoms proximal to the onset of an episode of PP, they may attribute it to normal feelings about motherhood. However, hypomanic symptoms are serious and should always be noted and carefully monitored, as they may be warning signs for an episode of PP. Not all women who experienced PP had hypomanic or other symptoms prior to onset of the episode, and not all hypomanic symptoms in the immediate postpartum preclude an episode of PP, but even so, care providers should continue to observe and track these symptoms.
Careful monitoring of symptoms in the immediate postpartum is essential for early detection and treatment of PP. As such, it is crucial that all members of a woman’s postpartum care team including obstetricians, midwives, nurses, general practitioners, and mental health professionals are informed about the early symptoms and behavior nor mood changes associated with the onset of PP. Early detection and intervention lead to better management of symptoms and improved psychiatric outcomes, which is an important step towards improving the individual experiences of women with PP and understanding how to most effectively treat the disorder.
Research summary compiled by Nicola Roux.
Heron, J., McGuinness, M., Blackmore, E., Craddock, N., & Jones, I. (2008). Early postpartum symptoms in puerperal psychosis. BJOG: An International Journal
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