Postnatal Depression and Postpartum Psychosis: Recognition, Assessment and Management

Pregnancy, childbirth and the first year after birth are opportunities to identify and treat mental illness within maternal and child health services. Postnatal depression is a depressive episode during pregnancy or after birth; postpartum psychosis is a rare, rapidly evolving psychiatric emergency often linked to bipolar-spectrum illness. Care must protect the mother, infant and family while respecting dignity, breastfeeding goals, culture and reproductive choices.

Learning objectives

• Differentiate baby blues, postnatal depression, anxiety, bipolar episodes and postpartum psychosis.
• Screen and assess maternal mood, suicide/infanticide risk, psychosis, functioning, infant safety and social support.
• Plan psychological, social, pharmacological and emergency care while considering pregnancy and lactation.
• Recognise obstetric, medical, substance-related and medication causes of mental symptoms.

1. Common perinatal presentations

2. Risk factors

• Previous depression, bipolar disorder, psychosis, postpartum psychosis or severe premenstrual symptoms.
• Suicide/self-harm history, family history of bipolar or postpartum psychosis, abrupt sleep loss and stopping maintenance medicine.
• Unplanned pregnancy, obstetric complications, neonatal illness, pain, anaemia, thyroid disease or difficult birth.
• Domestic violence, poverty, isolation, stigma, conflict, migration, bereavement, infertility treatment and lack of practical support.
• Alcohol/drug use, HIV/TB, chronic illness, medication interactions and breastfeeding difficulties.

3. Assessment in maternity and primary care

1. Privacy and consent: speak with the mother alone when safe; explain confidentiality and its limits.
2. Symptoms/course: mood, pleasure, anxiety, sleep, energy, appetite, guilt, bonding, intrusive thoughts, psychosis and duration.
3. Bipolar screen: past elevated/irritable periods, reduced need for sleep, grandiosity, impulsive spending/sex, psychosis and family history.
4. Risk: suicidal thoughts/plan, thoughts of harming infant, command voices, access to medicines/pesticides/weapons, domestic violence and ability to supervise baby.
5. Medical review: vitals, bleeding, pain, infection, anaemia, thyroid symptoms, seizures, pre-eclampsia/postpartum hypertension, delirium and substance exposure.
6. Collateral: partner/family observations of sleep, behaviour, confusion, spending, speech and infant care.
7. Function: feeding, hygiene, breastfeeding, sleep opportunities, bonding, support and safe accommodation.

4. Screening tools

The Edinburgh Postnatal Depression Scale (EPDS), PHQ-9 or locally validated tool can identify symptoms and monitor change. A positive screen is not a diagnosis and must be followed by clinical assessment. Ask directly about self-harm even if the EPDS score is low. Screen at antenatal, postnatal and child-health contacts according to local service capacity and referral pathways.

5. Differential diagnosis and investigations

• Baby blues, major depression, bipolar disorder, postpartum psychosis, PTSD, OCD, panic and adjustment disorder.
• Delirium, eclampsia/postpartum hypertension, thyroid disease, anaemia, infection/sepsis, hypoglycaemia, epilepsy, head injury and medication effects.
• Alcohol or drug intoxication/withdrawal, HIV/TB, severe sleep deprivation and adverse effects of steroids or other medicines.
• Targeted tests: glucose, FBC, electrolytes/renal/liver function, thyroid tests, urine/protein and blood pressure for pre-eclampsia, infection tests, toxicology, ECG and pregnancy status where relevant.

6. Management of postnatal depression

• Mild symptoms: psychoeducation, practical support, sleep protection, problem-solving, behavioural activation and low-intensity psychological interventions.
• Moderate/severe symptoms: structured CBT/IPT or other therapy, antidepressant when indicated, family support and close follow-up.
• Psychotic depression, severe self-neglect or suicide risk: urgent specialist care, safety containment, medication and possible ECT.
• Include the infant: support feeding, bonding, safe caregiving, immunisation/clinic attendance and caregiver relief. Do not blame the mother for difficulty bonding.

7. Medicines, pregnancy and breastfeeding

Choose medicines through shared decision-making: untreated severe illness also harms mother and infant. Review previous response, gestation/postpartum stage, breastfeeding, comorbidity, dose, interactions and infant monitoring. Use current Uganda formulary, product information and specialist perinatal advice.

8. Postpartum psychosis

Postpartum psychosis often begins within the first two weeks, but any rapid postpartum change is concerning. Symptoms may include extreme insomnia, confusion, fluctuating attention, elation or despair, bizarre beliefs about the infant, voices, visual experiences, disorganisation, aggression or catatonia. Insight may be absent.

1. Ensure immediate safety of mother and baby; do not leave them alone if risk is present.
2. Call urgent psychiatric, obstetric and medical support; assess ABCDE, glucose, blood pressure, temperature, seizures, infection, thyroid and substances.
3. Arrange emergency specialist admission, preferably a mother-and-baby unit where safe and available; do not delay life-saving transfer when unavailable.
4. Treat mania, psychosis, depression, catatonia or delirium according to specialist protocol; ECT may be needed for life-threatening or treatment-resistant illness.
5. Support the family and plan infant care, breastfeeding, sleep and safeguarding.

9. Intrusive thoughts versus psychosis

Unwanted intrusive images of accidental infant harm can occur in anxiety/OCD. They are usually distressing, recognised as unwanted and not accompanied by intent. Delusions, command hallucinations, loss of reality testing, intent, preparation or inability to resist require emergency assessment. Ask calmly and directly; asking does not create the thought.

10. Prevention and follow-up

• Create a written perinatal plan before birth for people with previous bipolar disorder or postpartum psychosis.
• Protect sleep, arrange night-time support, maintain medicines safely and involve family with consent.
• Review mood, psychosis, BP, thyroid/anaemia, breastfeeding, contraception, infant growth and caregiver burden.
• Arrange early follow-up after discharge, with clear emergency contacts and relapse signs.
• Integrate mental health into ANC, postnatal, immunisation and community health visits without stigma.

11. Worked cases

Postnatal depression

A mother six weeks after birth has persistent sadness, guilt, poor sleep even when the baby sleeps, poor appetite and thoughts that the family would be better without her. Ask about plan/means, bipolarity, psychosis and support; create urgent safety and treatment plan rather than attributing symptoms to normal motherhood.

Postpartum psychosis

A mother ten days postpartum has slept almost not at all, believes the baby is possessed and hears commands. Treat as an emergency: separate the baby from immediate risk, arrange urgent psychiatric/obstetric assessment and specialist admission.

Intrusive harm thoughts

A mother has frightening unwanted images of dropping the baby but feels horrified and avoids being alone. Assess intent, reality testing, compulsions, depression and support; this may be postpartum OCD, but escalate immediately if intent, psychosis or inability to maintain safety appears.

12. Quick self-test

1. How do baby blues differ from postnatal depression?
2. Name five postpartum-psychosis red flags.
3. Why must bipolarity be screened before an antidepressant?
4. What does EPDS provide and what can it not do?
5. What should happen immediately when mother and infant safety is uncertain?
6. Name three medical causes to exclude.
7. Why are valproate and lithium special reproductive-safety decisions?

Answers

1. Baby blues are brief and self-limited with preserved function; depression is persistent, impairing and may include suicidality, psychosis or impaired care.
2. Rapid confusion, severe insomnia, bizarre beliefs, hallucinations, mania/depression, disorganisation, command voices, catatonia and thoughts of harming self/baby.
3. Antidepressant monotherapy may precipitate mania or rapid cycling and delay mood-stabilising treatment.
4. EPDS screens/quantifies depressive symptoms; it does not diagnose, assess bipolarity, exclude psychosis or replace direct risk assessment.
5. Do not leave them alone; ensure immediate supervision and arrange urgent psychiatric, obstetric and medical assessment.
6. Eclampsia/postpartum hypertension, thyroid disease, anaemia, infection/sepsis, hypoglycaemia, epilepsy, delirium and substance/medication effects.
7. They can affect fetal/neonatal safety and require specialist monitoring; untreated severe bipolar illness also carries serious risk.

References

• NICE: Antenatal and postnatal mental health.
• WHO: Integration of perinatal mental health in maternal and child health services.
• WHO: Perinatal mental health.
• WHO: Thinking Healthy manual.
• Use Uganda Ministry of Health maternity, newborn, reproductive-health, safeguarding and emergency mental-health protocols.