Tragic or Treated: Why We Cannot Miss Postpartum Psychosis

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“Take her! Take her! I have 2 kids in the bedroom. Don’t let them see this,” my husband Colin yelled as the cops entered our apartment. The NYPD wrestled me to the ground, handcuffed me, and strapped me to a gurney. I screamed as they wheeled me down the hallway believing I was leaving my babies behind to be killed.

For the 20 minutes before the police arrived, I had raced between trying to get to the roof to jump, and to our bedroom, to get our baby girls safely stowed in there and run. But Colin was quicker and stronger every time.

“If you are afraid she is going to hurt someone or herself, it is the best you can do. Hang up with me and call 911.” My husband was sitting on the floor of our bedroom, seeking advice from a friend, while I banged on the bedroom door. His body was wedged between a heavy dresser and the door, his feet propped against it to keep me from getting in, to our children.

Neither of us knew a thing called postpartum psychosis existed then.

Understanding Postpartum Psychosis

In our culture, new motherhood is often romanticized as the epitome of maternal love. However, new mothers have a vulnerable infant dependent on them while dealing with hormone changes, lack of sleep, and socioeconomic pressures, including the push to return to work.

Maternal mental health issues are the most common complication of childbirth, and postpartum psychosis—the most severe among them—has been recognized as a possible complication of childbirth for millennia.¹ Postpartum psychosis is linked to the most serious of mental health outcomes, both suicide and infanticide when untreated.^2-7 It is critical not to miss the diagnosis of postpartum psychosis. Yet, likely because it is not found in the DSM,^1,8-9 psychiatrists are often unaware of this eminently treatable condition.

Postpartum psychosis, across cultures, occurs in about 1 to 2 per thousand new mothers.^3,7,10 Symptoms of postpartum psychosis often present in the first couple weeks postpartum,¹¹ though they can also appear later in the postpartum year—such as when hormonal changes occur with cessation of breastfeeding. This disorder can happen to anyone—mothers who have no mental health history may experience the illness. But a personal history of bipolar disorder or a family history of postpartum psychosis are known to elevate the risk.^{2,3,5,9,11-14}

“I don’t feel like myself.” I said to my husband as we sped down the highway back to Manhattan after a weekend away. It was about a month after returning to work from maternity leave and our 2 babies, 2 years and 4 months, were strapped in the back seat.

“What do you mean?” He asked.

“I just feel anxious and a bit sad.”

“How about if you still feel this way in 2 weeks you go see somebody?” he said.

Once back in Manhattan, we were quickly mired in the responsibilities of working full-time with 2 little babies without family help. Taking time to go see someone felt like a luxury we did not have. And so not feeling like myself became the new normal. Good sleep became elusive, and anxiety propelled me to keep it all together at work and at home.

Until one Friday evening, 8 months postpartum, I went from not feeling like myself to believing I was being followed. The certainty of it hit me when I stepped on the subway after work and felt everyone’s eyes on me. The “revelations” started coming at warp speed: I was being recruited for some sort of money-making cult; it was join or die. Within a matter of hours and minutes I was convinced that the entire city was out to get me and my babies. That my husband was on their side. I began to fight for our lives. The battle was first internal: plotting how to escape our apartment with 2 babies on a December night unnoticed, keeping what I “knew” from my husband. But as my options and time ran out, it became external: punching him in the face to try and get to our girls to run, and when that failed fighting with him to try to get to the roof of our building to prove my loyalty to “them,” to show I would jump.

Less than 24 hours after managing high-stakes contracts Friday at work, I was handcuffed on the floor of our apartment and taken to Bellevue Psychiatric Hospital.

Identification and Treatment

Postpartum psychosis is both potentially deadly and highly treatable. The disorder presents not only with symptoms of psychosis, as its name suggests, but also can present with prominent mood symptoms—a dysphoric mania—and delirium-like symptoms such as confusion.^{2,3,7,8,11,14} Symptoms of hallucinations and delusions often develop quite quickly over hours or days—not like psychiatrists are used to seeing in cases of schizophrenia (which often develop over months).

With such severe symptoms as are seen in postpartum psychosis, developing so quickly, the risk of infanticide of a vulnerable baby or suicide of a suddenly delusional and scared new mom, become real. The risk of infanticide and of suicide without treatment is quite high^2-6—estimated at up to 1 in 20 untreated mothers. The ability to properly identify it is thus potentially lifesaving.

Mothers experiencing postpartum psychosis need identification and urgent treatment,¹¹ due to these elevated risks. Most require psychiatric hospitalization for a period of stabilization. Mothers with postpartum psychosis are treatable with mood stabilizers and antipsychotic agents, and therapy.^3,7,10 Once symptoms have improved and risk is reduced, with appropriate supports in place and psychoeducation of mothers and families—including to understand the illness, how to safeguard wellbeing, and early-warning signs of recurrence—most go on to take care of their babies and children.

My husband Colin was blind-sided when our apartment suddenly became a battlefield that Saturday morning: me, trying to save us from the cult I believed was closing in, and him, trying to save me from myself. Once I was taken away, he tried desperately to figure out what had snatched me, unsure whether the wife he had known was ever coming back. But for the 12 nights I was in the hospital, and for the 6 weeks in aftercare, no one mentioned postpartum psychosis as a possibility.

It was only 2 months later, when I happened into care with a psychiatrist who was a fellow in reproductive psychiatry that the illness that had hijacked me was named: postpartum psychosis.

Locked up in the hospital after suddenly losing the mind I had relied upon to who-knows-what, unfit to mother, I felt like a shameful mess. When the illness was finally named—postpartum psychosis—it gave me enough space to believe for moments at a time that maybe I was not forever damaged, maybe I had been sick. Naming it began in earnest my journey to reckon with the trauma and heal.

A DSM Official Diagnosis

Names have power. Diagnostic status holds power. Postpartum psychosis is listed in the ICD (as puerperal psychosis F53.1), but is not specified in the DSM.^1,8,9 Not having a name in the DSM means limitations on study and research about the disorder. Its absence there also means postpartum psychosis is often not in curricula. In turn, psychiatrists and trainees struggling to learn the major mental disorders often do not prioritize understanding the illness—despite its significant risks.

As a result, the patient experience suffers. In the worst case, it is missed or poorly treated and tragedy needlessly ensues. And in others, the patient’s experience anecdotally is similar to Meghan’s: partners and support systems delay getting help due to lack of understanding of the illness; clinicians struggle to recognize it for what it is; and, once identified, patients still are not given an official diagnosis—which can exacerbate uncertainty and fear, despite postpartum psychosis being a temporary and treatable condition. Unfortunately, the current suboptimal care for postpartum mental illness disproportionately affects women of color.^15-17

Outside of building clinical understanding, having a name also means new parents can have something to understand, something to read about, something to explain to themselves and others.^16-18 Mothers can begin integrating their experience in their healing journey.

Nine years later, through a commitment to my own wellness—via medication through acute recovery, and EMDR therapy, writing, movement, and mindfulness—I am more anchored in my own well-being than ever. And I am certain that things are harder for mothers than they need to be.

Two years ago, when a tragedy captivated the nation, a friend said to me, “It’s weird when this happened to you 7 years ago, no one knew it existed. And that’s still kind of true.”

In moving from healing into advocacy, I would be haunted to learn how long the cycle of tragedies without meaningful change had been going on. Haunted to learn that despite women bravely sharing their devastating stories for nearly 40 years¹⁹ and the policy failures that enable it to lurk in the shadows in the United States, I still had no idea it existed when I was pregnant in 2015.

Concluding Thoughts

Regardless of whether postpartum psychosis is in the DSM or not, psychiatrists need to be aware of the condition and able to recognize and diagnose it. Postpartum psychosis is not merely within the bailiwick of subspecialty reproductive psychiatrists—all psychiatrists should have an understanding. A large percentage of general psychiatry patients are women of reproductive age, and as noted above, postpartum psychosis can strike those who have no mental health history—and rapidly evolve. Jones poignantly noted: “In no other scenario can we identify individuals, currently well, who are at such a high risk of experiencing a severe episode of mental illness in a defined two-week period.”⁹ With knowledge, psychiatrists can recognize this highly treatable illness, and prevent tragedies by acting quickly.

Additional education is available about reproductive psychiatry for training programs and psychiatrists who recognize the need to know more, such as through the free online National Curriculum on Reproductive Psychiatry,²⁰ and the BMJ educational series.²¹ Part of the problem is not knowing what we do not know.

Ms Cliffel is a writer and mindfulness teacher who uses storytelling, yoga, sitting, and sound as mechanisms to liberate the mind in service of living our best lives. She does all this, including work on her memoir about postpartum psychosis, while raising 3 wonderful humans in Cleveland, Ohio. Dr Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry; a professor of psychiatry, reproductive biology, and pediatrics; and an adjunct professor of Law at Case Western Reserve University in Cleveland, Ohio. She served as editor of the GAP volume, Family Murder: Pathologies of Love and Hate, which won the APA’s Manfred Guttmacher award.

References

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2. Perry A, Gordon-Smith K, Jones L, Jones I. Phenomenology, epidemiology and aetiology of postpartum psychosis: a review. Brain Sci. 2021;11(1):47.

3. Friedman SH, Reed E, Ross NE. Postpartum psychosis. Curr Psychiatry Rep. 2023;25(2):65-72.

4. Cliffel M, Friedman SH. Postpartum psychosis, two sides of the story. J Am Acad Psychiatry Law. 2024;52(4):486-493.

5. Luykx JJ, Di Florio A, Bergink V. Prevention of infanticide and suicide in the postpartum period—the importance of emergency care. JAMA Psychiatry. 2019;76(12):1221-1222.

6. Lysell H, Dahlin M, Viktorin A, et al. Maternal suicide–register based study of all suicides occurring after delivery in Sweden 1974–2009. PLoS One. 2018;13(1):e0190133.

7. Spinelli MG. Postpartum psychosis: detection of risk and management. Am J Psychiatry. 2009;166(4):405-408.

8. Friedman SH, Sorrentino R. Postpartum psychosis, infanticide, and insanity—implications for forensic psychiatry. J Am Acad Psychiatry Law. 2012;40(3):326-332.

9. Jones I. Postpartum psychosis: an important clue to the etiology of mental illness. World Psychiatry. 2020;19(3):334-336.

10. 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):1-7.

11. Friedman SH, Prakash C, Nagle-Yang S. Postpartum psychosis: protecting mother and infant. Current Psychiatry. 2019;18(4):12-21.

12. Perry A, Gordon-Smith K, Di Florio A, et al. Mood episodes in pregnancy and risk of postpartum recurrence in bipolar disorder: The Bipolar Disorder Research Network Pregnancy Study. J Affect Disord. 2021;294:714-722.

13. Bergink V, Bouvy PF, Vervoort JS, et al. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry. 2012;169(6):609-615.

14. Screening and diagnosis of mental health conditions during pregnancy and postpartum: ACOG Clinical Practice Guideline No. 4. Obstet Gynecol. 2023;141(6):1232-1261.

15. Kozhimannil KB, Trinacty CM, Busch AB, et al. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011;62(6):619-625.

16. Fusar‐Poli P, Estradé A, Mathi K, et al. The lived experience of postpartum depression and psychosis in women: a bottom‐up review co‐written by experts by experience and academics. World Psychiatry. 2025;24(1):32-45.

17. Atkins R. Coping with depression in single Black mothers. Issues Ment Health Nurs. 2016;37(3):172-181.

18. Forde R, Peters S, Wittkowski A. Recovery from postpartum psychosis: a systematic review and metasynthesis of women’s and families’ experiences. Arch Womens Ment Health. 2020;23(5):597-612.

19. Japenga A. Ordeal of postpartum psychosis: illness can have tragic consequences for new mothers. Los Angeles Times. February 1, 1987. Accessed February 26, 2025. https://www.latimes.com/archives/la-xpm-1987-02-01-vw-60-story.html

20. National Curriculum in Reproductive Psychiatry. Accessed February 26, 2025. https://ncrptraining.org

21. BMJ Best Practice. Accessed February 26, 2025. https://bestpractice.bmj.com/