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Postpartum Psychosis, Psychotic Disorders and Bipolar Disorder during the Perinatal Period

Updated July 2025

Postpartum (puerperal or postnatal) psychosis is a condition with a long history. For as long as people have written about childbirth there have been accounts of severe mood or psychotic episodes occurring following childbirth (1).   

The Diagnostic and Statistical Manual of Mental Disorders (DSM-) (2),does not recognize postpartum (puerperal or postnatal) psychosis as a distinct clinical diagnostic entity, but postpartum psychosis can be categorized as a “short psychotic ” (3). However, it does allow for a ‘peripartum specifier’ if the condition has arisen in pregnancy or within 4 weeks of delivery. The International Classification of Diseases 11th Revision (ICD-11) classifies postpartum psychosis as one of the syndromes associated with pregnancy or the puerperium (beginning within about 6 weeks of delivery) that involves significant mental and behavioural characteristics, such as delusions, hallucinations, or other psychotic (3) . Mood symptoms, including depression and/or mania, are almost always present as well. If the patient's symptoms are consistent with the diagnostic criteria for a certain mental condition, then that disorder must also be ascribed as a ‘causing condition’ (ICD-) (3) .

Qualitative research has revealed that a label of a postpartum psychosis is favoured by women themselves, and this is the preferred term used by the key third sector organisation in the United Kingdom for women who have experienced a psychotic episode or symptoms during the perinatal period (4,5). Additionally, we use the terms woman/women in these documents, within this we acknowledge that not all birthing people identify as women.

Psychosis may occur for the first time in the postpartum period or as the continuation of a pre-existing psychotic presentation that began in or prior to pregnancy. Postpartum-onset presentations, traditionally labelled as ‘postpartum’ or ‘puerperal’ psychosis, most commonly take the form of mania, severe psychotic depression, or a mixed episode with features of both high and low mood (6). The core features of psychosis such as delusions and hallucinations are common, and women may also be markedly confused or perplexed (1,6,7). However, the term ‘postpartum psychosis’ can also be used for recurrences of pre-existing enduring conditions such bipolar disorder or schizophrenia.

The majority of episodes of postpartum psychosis have their onset within 2 weeks of birth, with over 50% of symptoms beginning between days 1–3 postpartum (8). Sudden onset and rapid deterioration are typical, and the clinical picture often changes quickly, with wide fluctuations in the intensity of symptoms and severe swings of mood (1,6,7). Postpartum psychosis can result in significant distress, may disrupt the developing bond between mother and child, and can have long-term implications for the well-being of the woman, the baby, her family and wider society. In rare but tragic cases, the condition can lead to suicide, a leading cause of maternal death, and even more rarely infanticide (7). With treatment, a good outcome is usual for the specific episode, but there is a very high risk of recurrence, both in future postpartum and non-postpartum periods.

There is a very close association between postpartum psychosis and bipolar disorder and women with that diagnosis have a significantly elevated risk of recurrence in the postnatal (9). There is evidence that women with an existing diagnosis of non-affective psychotic disorder have a specific risk profile regarding their mental health in (10)and in the postnatal period (9).

For those with bipolar disorder or previous postpartum psychosis, there is good evidence for preventative interventions to reduce the risk of postpartum recurrence with clear recommendations on risk screening and treatment (11,12). In addition, although more research is needed, evidence suggests that provision of consistent mental health care during pregnancy is associated with lower risk of post-partum psychiatric admission in the group of women with non-affective psychosis (13) and that risk factors for adverse outcomes in pregnancy may be modifiable (14) Parent-infant psychological interventions delivered postnatally in this group may also improve child developmental outcomes (15)

The global incidence of perinatal psychosis (includes pregnancy and the post-partum period – studies vary in the length of time post-partum from weeks to months) ranged from 0.89 to 2.6 in 1,000 women throughout the investigations (16).

The period after childbirth confers the highest risk of admission to psychiatric hospital for women than at any other time in their lives, although the absolute risk remains low. Episodes of postpartum psychosis occur in around 1 in 500 to 1 in 1000 births (7,16) . Women with previous bipolar episodes are at much higher risk —at least 1 in 5 births (7,16,17), and significantly higher when there is additional family history and when relapses not requiring admission are also included, and women who experience postpartum psychosis are at high risk of subsequent episodes of bipolar disorder not related to childbirth (18).

Information within this page will be relevant to healthcare professionals who care for women with mental health disorders in the perinatal period, social services and other non-NHS services, commissioners, and women in the perinatal period or those of childbearing potential with previous or existing mental health disorders and their families.

This topic page covers approaches to Postpartum Psychosis, Psychotic Disorders and Bipolar Disorder in the perinatal period. The Matrix addresses Common Mental Health Problems in the Perinatal Period, mainly anxiety and depression, and sets out guidance on Delivering effective psychological therapies and interventions to people in the perinatal period. Full guidance on identifying, assessing, and managing mental health disorders in the perinatal period can be found in the NICE guidance (2)(12) and SIGN (169) (11). The use of psychotropic medicines for the treatment of perinatal mental health disorders is not covered, nor is the wider impact of these disorders on family interactions [NES - Early Intervention Framework].

 

 

 

 

To inform the generation of the current document, a protocol for a Systematic Review in line with best practice guidance was developed and published on the PROSPERO registry: ‘A systematic review of psychosocial interventions for women with a diagnosis of bipolar disorder, puerperal psychosis, and psychotic disorder during the perinatal period’ (CRD42022295798)[1] by the NHS Wales advisory group. The results of the literature search found that no studies met the inclusion criteria.

SIGN (11) makes the following recommendations for treatment adapted from NICE guidance:-  ‘Consider psychological interventions for women/birthing parents with bipolar disorder including;- CBT, IPT and behavioural couples therapy for bipolar depression. Structured individual, group and family interventions designed for bipolar disorder to reduce the risk of relapse, particularly when medication is changed or stopped. For women/birthing parents with a diagnosis of psychosis or schizophrenia, who become pregnant and are at risk of relapse (e.g. arising from stress associated with pregnancy or the postnatal period or a change in medication including stopping medication), consider a psychological intervention, such as CBT or family intervention’, delivered as described in the section on how to deliver psychological interventions in the NICE guideline on psychosis and schizophrenia in adults.

In the absence of any guidance on specific psychological interventions for women with postpartum psychosis the types of psychological interventions to consider include interventions that target the psychotic (see Matrix Psychosis tables, NICE guidance, SIGN 131) and trauma related symptoms (see Matrix PTSD tables) and interventions that target difficulties in the parent-infant relationship [see NES - Early Intervention Framework] and difficulties in the couple relationship (e.g. Behavioural or Systemic Couples Therapy).

This evidence is supplemented by several empirical studies (the majority using qualitative methodologies) and systematic reviews investigating women’s and family members’ experiences of, and recovery from, postpartum psychosis, as well as their preferences for psychological intervention, (4,19-21) to inform the following practice points:-

  • psychological assessment and formulation should draw on a range of psychological theories and models relevant to psychotic and bipolar presentations inside and outside of the perinatal period, and the evidence base from developmental psychology on infant development and parent-infant relationships.

  • psychological assessment and formulation should consider the mother’s mental health needs, the couple relationship, the parent-infant relationship, and the perinatal and family context (e.g., whether pregnant or postpartum, the impact of changes in life roles such as employment, education, caring for a new infant and participation in social activities).

  • See Delivering Effective Interventions in the Perinatal Period for further practice guidance.

Recommendation

Who for?

Intervention

Type of psychological intervention

Evidence

Efficacy

First line recommendations

Symptoms of PTSD in the perinatal period

CBT with a trauma focus

EMDR

(see PTSD evidence summary for full details)

Enhanced/Specialist

 

N/A

 

N/A

 

 

Bipolar depression

Bipolar relapse prevention

CBT, IPT, Behavioural Couples Therapy (SIGN 169)

 

Structured group and family interventions (SIGN 169)

Enhanced/Specialist

 

 

 

 

 

 

N/A

 

 

 

 

N/A

 

Diagnosis of psychosis or schizophrenia – relapse prevention

CBT

Family intervention

(see Matrix Psychosis tables, NICE guidance, SIGN 131)

Enhanced/Specialist

N/A

N/A

We would like to thank the Matrix Cymru team for sharing their work with us:- Dr Laura Coote (Cardiff and Vale UHB), Dr Matthew Lewis, Co-Chair (Swansea Bay, UHB), Dr Sarah Douglass (Aneurin Bevan UHB and Cardiff and Vale UHB), Dr Cerith Waters, Chair, (Cardiff University and Cardiff and Vale UHB), Dr Dwynwen Myers (Betsi Cadwalder), Judith Cutter (Cardiff and Vale UHB), Prof. Ian Jones (Cardiff University), Dr Jessica Heron (Action for Postpartum Psychosis), Dr Sally Wilson (Action for Postpartum Psychosis), Dr Molly Tong (Cardiff and Vale UHB), Dr Rebecca Forde (Aneurin Bevan UHB).

Technical group:- Dr Angus McBeth, Marie Claire Shankland

Advisory Group:- Dr Fiona Fraser, Dr Roch Cantwell, Susan McConachie, Dr Leeanne Nicklas, Dr Suzy Clark.

1.Brockington I. Motherhood and Mental Health Chapter 4 - Puerperal Psychosis. 1996; .

2.American Psychiatric Association. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION, DSM-5™. 2013.

3.Baldaçara L, Leite VdS, Teles ALS, da Silva AG. Puerperal psychosis: an update. Rev Assoc Med Bras (1992) 2023;69(Suppl 1):e2023S125.

4.Dolman C., Jones I., Howard LM. Pre-conception to parenting: A systematic review and meta-synthesis of the qualitative literature on motherhood for women with severe mental illness. Archives of Women's Mental Health 2013;16(3):173–196.

5.Action on Postpartum Psychosis. Action on Postpartum Psychosis | The national charity for mums and families affected by postpartum psychosis.

6.Jones I, Heron J, Roberston Blackmore E. Puerperal Psychosis. In: The Oxford Text Book of Womens Mental Health. 2010; .

7.Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. The Lancet 2014;384(9956):1789–1799.

8.Heron J., McGuinness M., Blackmore E.R., Craddock N., Jones I. Early postpartum symptoms in puerperal psychosis. BJOG: An International Journal of Obstetrics and Gynaecology 2008;115(3):348–353.

9.MunkOlsen T., Laursen T.M., Mendelson T., Pedersen C.B., Mors O., Mortensen PB. Risks and predictors of readmission for a mental disorder during the postpartum period. Arch Gen Psychiatry 2009;66(2):189–195.

10.MacBeth A., McSkimming P., Bhattacharya S., Park J., Gumley A., St Clair D., et al. General and age-specific fertility rates in non-affective psychosis: population-based analysis of Scottish women. Soc Psychiatry Psychiatr Epidemiol 2023;58(1):105–112.

11.Healthcare Improvement Scotland. SIGN 169 Perinatal mental health conditions.

12.National Institute for Health and Care Excellence. Overview | Antenatal and postnatal mental health: clinical management and service guidance | Guidance | NICE. 2014; . Accessed Jun 12, 2025.

13.Vigod S.N., RochonTerry G., Fung K., Gruneir A., Dennis C.L., Grigoriadis S., et al. Factors associated with postpartum psychiatric admission in a population-based cohort of women with schizophrenia. Acta Psychiatr Scand 2016;134(4):305–313.

14.Taylor C.L., Stewart R., Ogden J., Broadbent M., Pasupathy D., Howard LM. The characteristics and health needs of pregnant women with schizophrenia compared with bipolar disorder and affective psychoses. BMC Psychiatry 2015;15(1) (pagination):Article Number: 88. Date of Publication: 17 Ar 2015.

15.Davidsen K.A., Harder S., MacBeth A., Lundy J.M., Gumley A. Mother-infant interaction in schizophrenia: transmitting risk or resilience? A systematic review of the literature. Soc Psychiatry Psychiatr Epidemiol 2015;50(12):1785–1798.

16.VanderKruik R., Barreix M., Chou D., Allen T., Say L., Cohen L.S., et al. The global prevalence of postpartum psychosis: A systematic review. BMC Psychiatry 2017;17(1) (pagination):Article Number: 272. Date of Publication: 28 Jul 2017.

17.MunkOlsen T., Laursen T.M., Pedersen C.B., Mors O., Mortensen PB. New parents and mental disorders: A population-based register study. JAMA 2006;296(21):2582–2589.

18.Di Florio A., Forty L., GordonSmith K., Heron J., Jones L., Craddock N., et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013;70(2):168–175.

19.Forde R., Peters S., Wittkowski A. Recovery from postpartum psychosis: a systematic review and metasynthesis of women's and families' experiences. Archives of Women's Mental Health 2020;23(5):597–612.

20.Forde R., Peters S., Wittkowski A. Psychological interventions for managing postpartum psychosis: A qualitative analysis of women's and family members' experiences and preferences. BMC Psychiatry 2019;19(1) (pagination):Article Number: 411. Date of Publication: 19 Dec 2019.

21.Ruffell B, Smith DM, Wittkowski A. The experiences of male partners of women with postnatal mental health problems: A systematic review and thematic synthesis. J Child Fam Stud 2019;28(10):2772–2790.