On Postpartum Psychosis: What do we know?

Author: Simone Vigod, MD, MSc, FRCPC

Editors: Romina Garcia de leon and Tashi Stampp (blog coordinators) 

Published: October 2nd, 2026

 

Question 1: What is postpartum psychosis, and how does it differ from postpartum depression or postpartum anxiety?

Postpartum psychosis is a term for a severe episode of mental illness that occurs exclusively postpartum – usually starting in the early days to weeks after delivery.  It is characterised by symptoms of mania (or a “mixed state” of mania and depression) and/or psychosis.  Mania is the “opposite” of depression, characterised by a very high or irritable mood, decreased need for sleep, racing thoughts, uncharacteristically high energy and/or impulsivity and often grandiosity – an inflated sense of power or special abilities. Psychosis is a mental state where an individual has lost touch with what is real, and it can occur alongside depression or mania, or on its own. 

Psychosis can present as hallucinations, hearing or seeing things that are not really there, and delusions, which are fixed false beliefs not based on reality or evidence. Psychosis is different from anxiety where a person worries that something bad might happen and knows that their worry is likely excessive, but has trouble controlling it. It is also different from obsessive thoughts such as recurring intrusive images, thoughts or ideas (even ones where people see themselves harming or think about harming their baby), but are frightened by the thoughts and do not intend to act on them. In psychosis, thoughts can also be jumbled or mixed up, called disorganized thinking. It would be rare to see “disorganized thinking” with postpartum anxiety or depression alone.

Postpartum psychosis is likely quite rare, perhaps about 1-2 in every 1000 deliveries. This is far less common than postpartum depression or anxiety which together affect about 200 in every 1000 postpartum women. Postpartum psychosis can be hard to diagnose. This is partly because symptoms can fluctuate widely even over the course of a day, and also because it occurs in the context of so many other environmental changes to which shifts in maternal mood and thought patterns are sometimes attributed (e.g., sleep deprivation, other new demands). Most patients and many clinicians are unfamiliar with it as it is so rare, which may make it harder to recognize than more common postpartum mental health issues such as depression or anxiety.  Making that differentiation is essential, however, since manic, mixed or psychotic symptoms may lead patients to harm themselves, their infants or other children in the home if not treated.

Check out the video series that we did for the CANMAT Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety and Related Disorders to learn more about postpartum depression, anxiety and psychosis, and better understand the differences between them.

 

Question 2: Are there any leads on what are the underlying mechanisms of postpartum psychosis?

The unique timing of postpartum psychosis with a very rapid onset in the early postpartum period when there have been so many recent neuroendocrine and hormonal changes strongly suggests a primarily biological etiology. There are elevated risks in family members of those who have experienced it, suggesting a genetic component, and individuals with bipolar disorder appear to be at very high risk. In fact genetic studies have shown that the genetics of postpartum psychosis are closer to those of bipolar disorder than they are to primary psychotic disorders such as schizophrenia.  

 

Question 3: Who is most likely to get postpartum psychosis? Are there ways to use these risk factors to form preventive interventions? 

In individuals with a previous episode of postpartum psychosis, there is a very high risk for recurrence (~29%). The risk for those with bipolar disorder (without a prior episode of postpartum psychosis) is also higher than for those with no mental illness or a history of depression only. Sleep deprivation has been linked to its onset, similar to its role in relapse in other major mental illnesses. In these cases, the best preventive strategy is to maintain stability through medication and sleep protection.  Medication strategies involve maintenance medications in those with known bipolar disorder, as well as prophylactic treatment upon delivery among those with a history of postpartum psychosis who were not taking maintenance medication during the pregnancy. Sleep protection strategies range from engaging support systems (partners, family, nursing) to avoid multiple nighttime wakenings to treatment of insomnia with psychological therapy and medication, if needed.

Postpartum psychosis can also occur in individuals with no personal or family history of any mental illness. Some researchers have tried to determine whether other factors like age, parity (i.e., how many pregnancies a person has had), education status, or other potential sociodemographic or psychological variables are linked to postpartum psychosis, but no clear risk factors have emerged in these cases. When there is no history or family history of postpartum psychosis or bipolar disorder, the best preventative strategy is to maintain awareness of symptoms for early identification and treatment. 

 

Question 4: How is postpartum psychosis treated, and how are remission rates?

Postpartum psychosis is considered a medical emergency, and requires treatment in an inpatient hospitalization setting for the safety of the patient and her child. It is important to rule out a medical (particularly a reversible) cause of the symptoms, as the presentation can be similar to what is seen with a severe infection, some autoimmune disorders (severe thyroid disease) and neurological conditions, such as anti-NMDA receptor encephalitis. Some countries have specialised inpatient units called “mother-baby units” where they can be treated safely without as much separation from their newborns as would be necessary if admitted to a general unit without support for infant care.  These are not available in Canada at this time.

Once the appropriate investigations have been conducted, the goal is treatment that can rapidly get the symptoms under control.  In the acute phase, at this point, the most agreed upon recommendation is to follow a step-wise approach of initial benzodiazepines, followed by antipsychotic medication if the benzodiazepine is not sufficient to calm initial agitation, and then the initiation of lithium, which can then be continued to prevent relapse.  In one study, almost all inpatients with postpartum psychosis went into remission with this approach during their inpatient hospitalization, and lithium protected against relapse at 1 year of follow-up. The protection against relapse was much less when patients were left taking antipsychotics alone after the acute phase. Electroconvulsive therapy (ECT) can be considered in the acute phase when this approach is not sufficient, and might even be a first course of action if the symptoms are very severe, such as if the patient is not eating or drinking, is actively suicidal, has psychotic depression or is otherwise demonstrating evidence of altered responsiveness (e.g., catatonia).

As a person recovers, careful monitoring and follow-up, as well as support for the patient and their family is highly important. In our CANMAT guideline for the Management of Perinatal Mood, Anxiety and Related Disorders published in the Canadian Journal of Psychiatry in 2025, we recommend involving caregivers, partners, the broader support system and even peer support to promote recovery.  

 

Question 5:  What do you think are the 3 most important points for patients, families and clinicians to know about postpartum psychosis?

 

In summary, I would say that I would want people to know:

1. Postpartum psychosis is treatable and is not your fault. Most people recover quickly and completely, and a large number never have another episode of illness. 
2. If you suspect that you or a loved one is suffering with postpartum psychosis, consider this an emergency – call 911 or 988, or go right away to your nearest emergency Department. 
3. It can sometimes be tricky to diagnose, with fluctuating symptoms amidst a new postpartum context where there are bound to be many changes. Ask for help, advocate for medical investigations to rule out possible underlying causes and follow the best evidence guidelines for treatment.

More information can be found in our CANMAT Clinician Pocket Guide and Seeds of Hope Patient and Family Guide, available in English and in French, here.