Postpartum Psychosis Doesn’t Look Like Other Psychosis

Before Lindsay Clancy, Andrea Yates was tried for infantacide in 2002

Nearly a third of women developed psychosis more than 4 weeks after delivery, well past the window most clinicians watch.

STUDY: Cohen LS et al, Molecular Psychiatry 2025;30:2537–2544

STUDY TYPE: Retrospective cohort study

FUNDING: Jeanne and Gerhard Andlinger Research Fund for Innovative Science at Massachusetts General Hospital; Rosalie Katz Family Foundation

Background

Postpartum psychosis affects 1 to 2 of every 1,000 new mothers. The Massachusetts General Hospital Postpartum Psychosis Project set out to describe the full range of the illness in the largest study to date.

The Study

• 248 women with at least one psychotic episode within 6 months of delivery, recruited mainly online and through referrals from 41 states and 7 countries.
• Researchers used a structured phone interview (MINI-PDS) and a study questionnaire; episodes occurred an average of 3.2 years before the interview.
• Outcomes included diagnosis, symptoms, timing of onset, time to recovery, and treatment received.
• The sample was mostly white (88%), married (88%), and college educated.

Results

Postpartum psychosis lacks a category of its own, so women are diagnosed with either bipolar (in this case, 72%) or major depression (15%) with psychotic features. A few were diagnosed with brief psychotic disorder or a schizophrenia-spectrum illness.

Over a third (38%) had no prior psychiatric diagnosis. 13% had psychotic symptoms before the postpartum onset (not clear how long before), often connected to a preexisting bipolar illness.

The psychosis began 10 days after delivery, on average, but the range stretched from the day of birth to six months later. About 31% began after 4 weeks.

The most common symptoms were:

• Odd beliefs or delusions (88%)
• Persecutory delusions (75%)
• Ideas of reference (56%)
• Visual hallucinations (52%)
• Auditory hallucinations (48%)

Paranoia often centered on the partner or the baby’s safety. Nearly half of women (46%) said their symptoms waxed and waned. Women took a median of 25 weeks to feel back to baseline, though those with recurrent episodes recovered faster, at about 10 weeks.

Their Treatment

Almost all (93%) received medication, and 74% were hospitalized. Atypical antipsychotics were most common (81%), followed by SSRIs (50%, which are not recommended in guidelines and can worsen the condition, but may be appropriate for rare unipolar cases) and benzodiazepines (47%). Only 29% received lithium, a first-line intervention, and 9% received valproate.

Limitations

They relied on a structured interview (Module K of the MINI-PDS) which captures traditional psychotic symptoms but misses other features of postpartum psychosis like dissociation and derealization, described in our Carlat interview with Amritha Bhat.

This was based on delayed recall (up to 10 years later), and psychosis can distort memory. The authors couldn’t tell whether reported medications treated the psychosis or preceded it. Online recruitment likely favored well-resourced women, and there was no comparison group.

Practice Implications

1. Despite the psychosis, many women with postpartum psychosis are self-aware and socially appropriate.
2. That may cause us to miss the diagnosis, as they rationalize their paranoia or hide it out of fear that their children will be taken away.
3. The delirium-like, waxing and waning symptoms can also cause us to miss it.
4. Learn more about how to diagnose and treat postpartum psychosis.

—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report

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