A devastating case in the national news has brought postpartum mental health into a conversation that is painful, complicated, and desperately necessary. When tragedy happens, people want simple answers. Was the system listening? Was treatment adequate? Could anyone have seen this coming?
Dr. Stacey Cohen joins Dr. Thais Aliabadi and Mary Alice Haney to discuss why we have to be compassionate without making assumptions about a specific family or legal case. At the same time, we have to be crystal clear about one lifesaving point: postpartum psychosis is rare, but it is a psychiatric emergency. It is not the same thing as baby blues. It is not typical postpartum depression. Recognizing the difference can change the outcome for a mother, a baby, and an entire family.
Table of Contents
- Understanding Postpartum Mental Health
- Postpartum Psychosis Is Different
- Recognizing an Emergency
- Treatment for Postpartum Psychosis
- Treatment for Postpartum Depression
- A Plan for Families Before and After Delivery
Understanding Postpartum Mental Health
Why is this conversation so urgent?
We need to talk openly about postpartum mental health because so many women feel unwell after giving birth and do not know what is happening to them. They may be exhausted, frightened, ashamed, depressed, anxious, or afraid to admit thoughts that feel disturbing. Silence makes every one of those experiences harder.
The most serious postpartum conditions require families, partners, friends, obstetricians, pediatricians, and mental health professionals to recognize that something may be wrong. We cannot expect a person in the middle of a psychiatric crisis to always identify it themselves or voluntarily seek help.
When we discuss heartbreaking public events, our goal should not be to speculate about an individual’s diagnosis or history. We do not know all of the facts in any one case. The goal is awareness. We want families to understand what is common, what is concerning, and what is an immediate emergency.
What are the baby blues?
The postpartum blues are common and generally much less severe than postpartum depression or postpartum psychosis. In the early weeks after delivery, many new mothers experience tearfulness, emotional sensitivity, sadness, irritability, overwhelm, and rapid mood shifts.
There has been a huge physical event, an enormous hormonal shift, interrupted sleep, recovery from childbirth, and the sudden responsibility of caring for a newborn. Feeling emotionally raw during this period is not a personal failure.
But we should never assume that severe symptoms are just baby blues. If sadness, hopelessness, anxiety, inability to function, frightening thoughts, or strange beliefs are escalating rather than improving, it is time to ask for help.
How does postpartum depression differ from the baby blues?
Postpartum depression is a clinical depressive illness that can begin weeks to months after giving birth. It is more than a difficult day, a few tears, or ordinary exhaustion. A mother may have trouble getting out of bed, cry constantly, feel hopeless, have severe guilt, lose interest in things she normally enjoys, or experience thoughts of suicide.
Postpartum depression is also much more common than postpartum psychosis. We commonly estimate that it affects about one in seven or eight postpartum women, and it may be underreported.
Some people with postpartum depression have intrusive thoughts. These are unwanted, distressing thoughts such as, “What if I accidentally hurt my baby?” or “What if something terrible happens?” These thoughts can be horrifying precisely because they are not wanted. They are different from wanting harm to occur or believing harm must occur.
For a fuller overview of symptoms, causes, and treatment options, read our resource on postpartum depression and when to seek help.
Postpartum Psychosis Is Different
What is postpartum psychosis?
Postpartum psychosis is a rare, severe psychiatric disorder characterized by a break from reality. It affects approximately one in 1,000 postpartum women. It is not simply severe sadness, stress, or anxiety. It can include hallucinations, paranoia, delusions, profound insomnia, disorganized thinking, and a frightening disconnection from reality.
Psychosis means that the brain is not accurately interpreting reality. A person may hear voices, see things that are not there, believe others are trying to harm them, or hold fixed false beliefs. They may receive what feel like commands to do something. They may believe that a child is in danger in a way that is not true, or that harm is necessary to prevent a perceived catastrophe.
That is fundamentally different from an intrusive thought. A person with an intrusive thought may say, “I am terrified I could drop my baby.” A person experiencing a delusion may instead believe an action is necessary because of a false reality that feels completely true to them.
When does postpartum psychosis usually begin?
Postpartum psychosis most often begins very soon after delivery, typically during the first two weeks. It may sometimes emerge later, including in the first six to eight weeks. A first diagnosis many months after birth would be atypical.
However, the timeline can be complicated. A psychiatric illness may begin shortly after delivery and remain inadequately controlled. Continued severe sleep deprivation can worsen vulnerability well past the immediate postpartum period. It is also possible for an underlying condition, such as bipolar disorder or another psychotic illness, to emerge during the postpartum period or recur later.
That is why we have to be thoughtful with labels and avoid casually diagnosing someone from a news story. Whether a crisis is called postpartum psychosis, recurrent psychosis, bipolar disorder with psychotic symptoms, or another condition, the central issue is the same: psychosis requires immediate psychiatric evaluation.
Who may be at higher risk?
Postpartum psychosis is more often seen in women with a previous history of psychosis, bipolar disorder, or mania. A known psychiatric history gives us an opportunity to plan ahead before delivery. Ideally, the obstetrician, psychiatrist, patient, and family create a treatment plan for pregnancy and postpartum rather than waiting for symptoms to become severe.
But we should not assume that someone must have an obvious prior diagnosis. For some people, pregnancy or postpartum may be the first time a major mental health condition becomes visible. A person may have been young when they had earlier pregnancies or may not have previously displayed symptoms of schizophrenia, bipolar disorder, or another psychiatric illness.
Risk factors help us plan and stay alert. They do not tell us everything about an individual patient. What matters most is responding to symptoms quickly and seriously.
Recognizing an Emergency
What are the warning signs of postpartum psychosis?
We want families to trust their instincts when a postpartum mother seems profoundly unlike herself. The warning signs are not subtle when they are present. Someone may be talking to themselves, making little sense, not sleeping at all, seeming intensely paranoid, or responding to voices or messages that others do not hear or see.
Important red flags include:
- Hearing voices or seeing things that are not there
- Believing the television, strangers, or outside forces are sending personal commands or messages
- Fixed false beliefs that cannot be reasoned away
- Extreme confusion, rapid or disorganized speech, or behavior that does not make sense
- Severe paranoia or an altered sense of reality
- Command hallucinations involving self-harm or harm to a baby
- An inability to sleep combined with escalating agitation, fear, or bizarre behavior
- Signs of imminent risk to the mother or child
We should not debate, shame, or try to logic someone out of psychosis. Delusions are not ordinary worries. They are fixed beliefs that feel real to the person experiencing them.
When should a family seek emergency help?
Postpartum psychosis is an emergency every time. If someone is hearing voices, acting on strange commands, expressing delusional beliefs, appearing severely confused, or making statements that suggest immediate danger to themselves or a baby, the appropriate response is emergency evaluation.
We would send that patient directly to an emergency room for psychiatric assessment and likely hospitalization. This is not a situation to manage with a routine appointment next week. It is not something to wait out overnight. It is an emergency in the same way that a severe physical illness is an emergency.
If a postpartum person will not agree to go, families can call 911 and request a psychiatric emergency team. State clearly that the person recently gave birth and that there is concern for postpartum psychosis. A person experiencing psychosis often does not recognize that they are ill, which is exactly why loved ones may need to act.
If there is immediate danger, do not leave the mother alone with a baby or children while waiting for emergency help. The priority is safety and rapid medical care.
What should partners and loved ones say?
We want loved ones to lead with concern rather than accusation. A simple approach can be: “We are worried because you have not slept and you seem scared. We are going to get help now. You are not in trouble, and you do not have to handle this alone.”
Do not argue about whether a hallucination or delusion is real. Do not minimize alarming behavior because a person seemed fine earlier in the day. Psychiatric symptoms can fluctuate, and a temporary calm moment does not erase the need for evaluation.
Treatment for Postpartum Psychosis
How is postpartum psychosis treated?
The treatment pathway for postpartum psychosis is very different from the usual pathway for postpartum depression. Because psychosis brings immediate safety concerns, treatment generally requires hospitalization in a psychiatric setting.
Psychiatrists commonly use antipsychotic medication to treat psychotic symptoms. If there is mania or a history of bipolar disorder, mood stabilizers may also be necessary. The exact medication plan depends on the person’s symptoms, psychiatric history, medical situation, and whether they are breastfeeding.
The point is not that every postpartum mental health concern requires hospitalization. It does not. The point is that psychosis does. In outpatient care, we can often safely treat postpartum depression when there is no acute suicide or homicide risk. With postpartum psychosis, the risk is immediate enough that urgent psychiatric care is essential.
Why does sleep matter so much?
Sleep deprivation is a major issue in the postpartum period. It can worsen depression, anxiety, mania, and psychosis. It does not by itself explain every postpartum psychiatric illness, but it is one reason symptoms can continue or intensify beyond the earliest weeks after delivery.
This is why support at home matters medically, not just emotionally. Protecting sleep, sharing infant care when possible, asking family members to help, and creating a clear plan for who notices changes in mood or behavior are part of responsible postpartum care.
For patients already taking antidepressants or bipolar medication before pregnancy, we should make a plan with their treating clinicians during pregnancy. Medication changes, follow-up timing, sleep support, and postpartum warning signs should be discussed before the baby arrives whenever possible.
Treatment for Postpartum Depression
What are the standard treatments for postpartum depression?
Postpartum depression is treatable. Our core tools include psychotherapy, antidepressant medication, and practical support at home. We want patients to have someone they can tell, “I do not feel good,” without fearing judgment.
Traditional SSRI antidepressants are often first-line treatment. Many can be used safely during breastfeeding, and treatment decisions should be individualized with a physician. There is a persistent and harmful myth that all antidepressants are unsafe in pregnancy or while breastfeeding. That is not true.
In many situations, untreated depression and anxiety can create more risk to both mother and baby than appropriately selected medication. We always need to weigh benefits and risks carefully, but fear should not prevent someone from receiving needed treatment.
There is also a newer hormone-based medication, zuranolone, known by the brand name Zurzuvae, for postpartum depression. It is another option, although it is not necessarily the first treatment we reach for. For more about this medication and its role in care, see our overview of the new oral treatment option for postpartum depression.
Can treatment include options beyond antidepressants?
Yes. Some patients do not respond adequately to medication, cannot tolerate it, or simply want to discuss alternatives. Treatment is never one-size-fits-all.
Ketamine treatment can be an outpatient option for some patients with severe depression. In the approach discussed here, treatment involved six sessions over roughly two and a half weeks: three sessions during the first week, two during the second, and one during the third. Some patients experience significant improvement quickly, but ketamine also has risks and should be managed carefully by appropriate clinicians.
Transcranial magnetic stimulation, or TMS, is another non-systemic treatment option. TMS uses magnetic stimulation to target areas of the brain involved in depression. It can be useful for treatment-resistant depression and for patients concerned about taking medication.
Traditional TMS treatment often involves weekday sessions over 30 to 36 treatments, though sessions may be brief. Newer protocols include the SAINT protocol, which condenses treatment into one intensive week, and emerging one-day protocols using newer machines. These options are not available or practical for everyone, but they are meaningful examples of how treatment is evolving.
Does treatment mean a mother has failed?
Absolutely not. Seeking treatment is an act of protection, strength, and love. We need to stop treating maternal mental health care as optional or shameful. A mother who says she is depressed, anxious, unable to sleep, scared of her thoughts, or disconnected from herself deserves to be taken seriously.
We also need to remember that an obstetrician may be the first clinician to recognize postpartum depression. OB-GYNs see this condition often and can frequently begin treatment, monitor symptoms, and make a psychiatric referral when needed. But suspected postpartum psychosis is not a routine outpatient issue. That requires urgent psychiatric intervention.
A Plan for Families Before and After Delivery
What can families do before the postpartum period begins?
If there is a personal history of depression, anxiety, bipolar disorder, psychosis, trauma, or use of psychiatric medication, discuss it openly during pregnancy. This is not information to hide because of shame. It is information that helps us build a safer plan.
We can prepare for postpartum mental health by:
- Identifying the obstetrician, therapist, psychiatrist, and emergency contacts before delivery
- Discussing whether psychiatric medications should be continued, adjusted, or restarted postpartum
- Planning for sleep protection and practical help at home
- Asking a partner or family member to monitor for concerning changes in mood, behavior, sleep, or thinking
- Scheduling postpartum check-ins rather than waiting for a crisis
- Giving loved ones permission to call the doctor if they are worried
We have had partners call with concerns about their wives, and we want that call. “I am worried about her” is enough reason to bring someone in and assess what is going on. Families are often the first to see changes that a patient may be too overwhelmed, embarrassed, or unwell to report.
What is the most important message for someone who is struggling?
You are not alone. There is help. There are treatments. There are clinicians who understand this period and who can guide you through it.
Depression, anxiety, intrusive thoughts, and postpartum psychosis do not define someone’s character or worth. They are medical conditions that deserve real medical care. The earlier we speak honestly, ask questions, and seek treatment, the more likely we are to protect mothers, babies, and families.
We need to keep bringing awareness to postpartum depression and postpartum psychosis, not only for the women experiencing symptoms but also for the people around them. Partners, parents, friends, doctors, and family members can be the bridge to help when someone cannot make that bridge alone.
Concerned About Your Health? Talk to Dr. Aliabadi
Dr. Aliabadi is an expert OB/GYN who is knowledgeable in all aspects of women’s health and well-being. Dr. Aliabadi and her caring, supportive staff are available to support you through PCOS, endometriosis, menopause, childbirth, infertility, or routine gynecological care. We invite you to establish care with Dr. Aliabadi. Call us at (844) 863-6700 or
Frequently Asked Questions About Postpartum Psychosis and Depression
Is postpartum psychosis the same as postpartum depression?
No. Postpartum depression involves symptoms of major depression, such as hopelessness, crying, low energy, difficulty functioning, and sometimes intrusive thoughts. Postpartum psychosis involves a break from reality, which can include hallucinations, delusions, paranoia, severe confusion, and command hallucinations.
How common is postpartum psychosis?
Postpartum psychosis is rare, affecting approximately one in 1,000 postpartum women. Postpartum depression is far more common, estimated at about one in seven or eight women after birth.
When is postpartum psychosis an emergency?
It is always an emergency. Signs such as hearing voices, delusional beliefs, confusion, bizarre behavior, command hallucinations, or danger to oneself or a baby require immediate emergency room evaluation and psychiatric care.
What should we do if a postpartum mother will not go to the emergency room?
Call 911 and request a psychiatric emergency team. Explain that the person recently gave birth and that there is concern for postpartum psychosis. Do not leave a person who may be psychotic alone with a baby or children while emergency help is being arranged.
Can antidepressants be used while breastfeeding?
Many antidepressants can be used safely during breastfeeding, but the right medication depends on the individual. Discuss the benefits and risks with an obstetrician, psychiatrist, or prescribing clinician. Untreated depression and anxiety can also carry significant risks.
