Synopsis
Recognise the rapidly changing manic, depressive, psychotic and confused presentations after birth, secure immediate parent-infant safety, exclude physical causes and deliver specialist inpatient treatment without delay.
- Postpartum psychosis most often starts in the first two weeks, frequently within days, but assess any compatible sudden postnatal change as an emergency.
- Early clues include inability or no need to sleep, unusual energy, rapidly changing mood, irritability, fear, suspiciousness, confusion and behaviour that is markedly out of character.
- Established illness may include hallucinations, delusions, disorganisation, mania, severe depression, mixed symptoms or catatonia; insight is often impaired.
- Refer immediately for specialist assessment within four hours; if there is imminent harm or medical compromise, call 999 and arrange ambulance transfer.
- Maintain continuous responsible supervision and safe infant care without using accusatory language or expecting the family to manage transport alone.
- Check observations, glucose, neurological and obstetric features, medication, substances and collateral history while psychiatric care proceeds; physical and psychiatric disease can coexist.
- Most patients require hospital treatment, normally in a specialist mother and baby unit within twelve months of childbirth unless a specific reason prevents this.
- Specialist treatment commonly uses an antipsychotic; mood stabilisation, short-term treatment of severe agitation or insomnia, and ECT for life-threatening or resistant illness may be considered.
- Discuss breastfeeding only after immediate safety is established and revisit it as capacity and symptoms recover; feeding must not delay effective treatment or protected sleep.
- Recovery is usual with timely care, but discharge needs relapse prophylaxis, gradual restoration of caregiving, family education and a plan for future pregnancies.
Key red flags
Delusions involving the baby's identity, safety, special powers or required sacrifice, especially with intent or commands, demand immediate protective action.
Near-total sleeplessness with escalating energy, pressured speech, grandiosity, disinhibition or irritability may be the earliest visible manic phase.
Rapid fluctuation, bewilderment, disorientation, visual hallucinations, fever or abnormal vital signs raises delirium or neurological and obstetric causes requiring parallel medical investigation.
Suicidal intent, violent impulses, severe agitation, catatonia, refusal of food or fluid, absconding risk or inability to accept essential care needs emergency containment and senior review.
Seizure, severe headache, hypertension, focal neurology, heavy bleeding, hypoxia or collapse requires immediate resuscitation and acute obstetric or medical management, not psychiatric attribution.
Investigation priorities
Define mania, depression, psychosis, cognition, capacity, suicide, infant-related thoughts, aggression, self-neglect and absconding risk.
Management branches
A postnatal person develops sudden mania, psychosis, severe confusion or an extreme mood and behavioural change.
- Establish immediate danger, move infant care to a trusted responsible adult and maintain continuous supervision in a calm environment.
- Refer immediately to secondary mental-health care for assessment within four hours; call 999 for imminent harm, severe agitation or medical instability.
- Share gestation and birth timing, medication, risk, capacity, physical findings and collateral history, and arrange accompanied safe transport.