Episode 276: Postpartum Psychosis: Symptoms, Warning Signs, Risk Assessment, and Treatment with Dr. Furey and Dr. Puder
This episode is awaiting CME Approval
Transcription edit: Joanie Burns, DNP, APRN, PMHNP-BC
Research help by: Carter Bakarich, B.S.
Other Places to listen: iTunes, Spotify
David Puder, M.D., has no relevant financial relationships with ineligible companies to disclose. Dr. Katrina Furey is the founder and educator of Repro Psych Academy, an on-demand educational platform providing case-based training in reproductive psychiatry for mental health professionals. She has no financial relationships with pharmaceutical companies or other commercial entities relevant to the content of this presentation.
Welcome back to the podcast. I am joined today by Dr. Katrina Furey. She is a board-certified reproductive psychiatrist, Yale trained, in private practice, has an online program, Repro Psych Academy, for training on reproductive psychiatry. She also practices mostly reproductive psychiatry. She is someone who is a colleague of Brandon Kitay, who was on my podcast in the past. Shout out to him. He did some great episodes on ketamine [see episode 137]. And you work, as well, in kind of like a hotline for when an OBGYN/psychiatrist/pediatrician needs a reproductive psychiatrist specialist. And so it's great to have you on the podcast. Obviously, if you're paying attention to the news, there is some stuff about this going on. So yeah, why don't we just start out talking a little bit about what is postpartum psychosis?
What Is Postpartum Psychosis? Symptoms, Onset, and Diagnostic Challenge (00:50)
Furey:
That's a great question. Thank you so much for having me. So what is postpartum psychosis? Actually, I wish there was a straight answer, but since there is no definitive diagnostic criteria in the DSM-5, therein, I think, lies the first problem when it comes to identifying and treating postpartum psychosis. Right? It's hard to treat a condition if people aren't told exactly what to look for to diagnose it in our medical model, so sometimes it gets missed. When we think about classic postpartum psychosis, it is psychotic symptoms that develop soon after delivery. Classically, it's within 24 hours to three weeks. I believe the average onset is right around eight days, usually within the first two weeks. But if you talk to women who have experienced this, or you talk to experts like Dr. Margaret Spinelli, and some other experts in the field, they will, and they have been advocating to expand that timeframe up to 12 weeks (Bergink et al., 2026).
Furey:
There was a 2025 consensus statement really urging the DSM to expand that timeline. So most cases develop very early. We believe it's due to that swift drop in the hormones. However, up to like three months is still that high-risk time. And even beyond that, women can develop psychotic symptoms in the postpartum period. And the jury's out. I think the field is still unsettled as to whether that would be qualified as classic postpartum psychosis or if it is, you know, other psychotic symptoms developing within the postpartum period that would've developed around then anyway, since most women, like if you're going to develop a bipolar disorder or a schizophrenia spectrum disorder tends to happen a little later for women than men in your late 20s, early 30s, which is around when a lot of women are having children. So that's what makes all of this very complicated (Bergink et al., 2026).
Furey:
But, again, it's psychotic symptoms of delusions, hallucinations, paranoia, as well as you can have mood symptoms like anxiety, irritability, restlessness, and decreased need for sleep.
Puder:
Okay. Yes. So you rattled off some symptoms. I think we should go through some of those just to kind of…. But I think one thing that you said that was so interesting, because I'm watching this Lindsay Clancy court case and the cross-examination, and he is aware that postpartum psychosis is not in the DSM. You know? And it….
Furey:
Yes, very aware.
Puder:
It's like….
Furey:
Do you know it used to be? It used to be in DSM-2 and 3, and then it got removed.
Puder:
And there is, you know, in the DSM with peripartum onset, but then it always happens in the first four weeks, or most of it. Right? Most of it, most of the time, psychotic symptoms in the first four weeks. So this is an emergency. This is like, drop everything. This is the one patient to take care of. I've had a couple of these just this year. And maybe I can de-identify it and talk about it a little bit. Thank God, it went well. But okay. So, delusions. What are some of the delusions that you've seen? And maybe we'll start with that one, and then we'll talk about some of the other symptoms.
Furey:
Sure, sure. So, oftentimes, in postpartum psychosis, the delusions are centered around the infant or kind of the family unit as a whole. Not all the time, though. So, I think that's the other thing about postpartum psychosis that can be so tricky is that most of the psychotic symptoms, most of the time, will be centered around the baby, but not all the time. And so, a lot of the delusions might be, is the baby possessed? Is the baby cursed? Is the baby not really a baby, but an adult masquerading as a baby? Like, things like that. I've also seen cases where it gets really tricky to decide where that line is between a very anxious preoccupied mother with, “Is something wrong with my baby?” And when does it cross over into being delusional? So there can be a lot of preoccupations with the baby's health, with them thinking something's wrong with the baby that other people aren't seeing.
Furey:
Oftentimes, there may also be some paranoia that goes along with the delusions about, “How much can I trust my partner or my family or their doctor or the people around me,” or, “Can I not really trust those people?” And then, of course, you can also just have other random delusions, like, you know, paranoia that someone's following you, someone's listening to you, someone's talking to you through the radio. A very important delusion that we see in postpartum psychosis that has been connected to the high-safety risk is this idea of delusions of control. Are you familiar with that?
Puder:
Yes. But go ahead, define it.
Furey:
So when you believe that something outside of you is controlling you. So the woman really believes that whether it's God, the devil, aliens, the universe, or some unknown entity, it's like they've lost control of their own body, their own autonomy, their own, like, decision-making, and something else is controlling them. And so, you know, forensic psychiatrists who really look at this stuff have found a correlation between delusions of control and that risk of violence being pretty high. So that's one of the biggest red-flag symptoms (Ullrich et al., 2014), especially if it gets paired with, you know, paranoia or command auditory hallucinations telling you, you have to do X, otherwise Y is going to happen. And so, again, I think we can also imagine how scary it must be for women to experience this and to be able to openly talk about it or put words to their experience when they're in such a vulnerable timeframe as well (Bramante & Di Florio, 2025).
Postpartum Psychosis vs. Postpartum OCD: Distinguishing Intrusive Thoughts From Psychosis (05:26)
Puder:
Oh, yeah. But I mean, they do not want to talk about these things out loud. Right? So this is where it gets complicated because they're not always telling the psychiatrist, they're not always telling their husband. Sometimes they're keeping these thoughts very internal. Right? But they're distressed, they're anxious. And so sometimes it can be hard to pull out, you know, what are the delusions? You have to create a connection, you have to decrease the fear that these things are going to be seen as bad. Sometimes people have obsessive thoughts, OCD, postpartum obsessionality. How do you differentiate that? Let's say a woman has a thought, "I am going to hurt my child." It's ego-dystonic, meaning they don't want that thought, but they keep having this obsessive fear that they're going to hurt their child. How do you differentiate that from more of a psychotic thought?
Furey:
That is a great question. And I'm glad you asked it, because I think that there's a lot of miseducation about this. You may have learned, like I did, that there's a real cut-and-dry way to figure this out. Right? If the intrusive thought is ego-dystonic, and you're frightened by it, and it's not in alignment with your values, then you probably have anxiety or OCD, and you're probably not going to act on it. But if you're having these intrusive thoughts and they're not distressing, and you do want to act on them, they're ego-syntonic, then you probably have psychosis. That's when we should worry. It sounds great to make it that simplistic, but I will tell you, in real practice, it's not always that simplistic. And in patients I've worked with, and in women I've spoken to through organizations like Postpartum Support International (they have a wonderful postpartum psychosis task force), and every year at the conference, they have a lot of panels where women with lived experience share their experience.
Furey:
They're doing wonderful work. But it's through all of that experience that I've learned that a lot of patients have some slivers of insight. It's not like insight is either on or off. And so a lot of women will describe having these intrusive thoughts and being terrified by them, and they don't want to act on it, but they're still having them. And so I think this is where it gets tricky and you have to take the whole clinical picture in mind and really try to drill down on, is this more aligned with anxiety? You're not seeing those other symptoms that often go along with postpartum psychosis, like decreased need for sleep. If a woman isn't sleeping as much because she's anxious, she's probably tired during the day. And the reason she's not sleeping is probably because she's up worrying about the baby. Whereas with postpartum psychosis, a lot of the time we just see this delirium-like picture.
Furey:
Which often goes along with a decreased need for sleep. And so there's a little bit of a qualitative difference, but it is tricky to discern.
Puder:
Really good. Yeah. I want to pull out some of these threads that I think are especially tricky.
Furey:
I feel like I'm - It's so
Puder:
You're doing great. You're doing great.
Furey:
Yes. It's very tricky.
Puder:
No, you're doing great. I think one very clear example of postpartum OCD, kind of new onset, that I had was that the mother becomes fearful that her child is going to be contaminated, that she's going to hurt her child. The compulsion was to stay away from the child, to not touch the child. To want to clean the house. She was cleaning the house, like, four to six hours a day. And so the compulsions are often hours and hours a day. OCD is a doubting disease. I'm curious how you kind of think about this differently in terms of postpartum onset. But when I think of OCD, I treat a lot of OCD as doubtings. They have a constant doubt of something.
Furey:
What if? What if? What if?
Puder:
Yes. And they're doing the compulsion to gain certainty. So the cleaning allows them a moment of certainty. But the sleep and irritability are another big factor of this postpartum psychosis picture. Right? Irritability is very common. I think I'd like to hear your thoughts on that specifically, and then the sleep. I'm glad you brought that up, as well.
Early Warning Signs of Postpartum Psychosis: Anxiety, Irritability, Restlessness, and Sleep Changes (09:24)
Furey:
Yes. So irritability is very common in the postpartum period across the board. And I would say that I think you can see it with any of the postpartum conditions, depression, anxiety, psychosis. I'm not aware of it being more common in psychosis compared to other conditions. I think with psychosis you can have mood symptoms, whether hypomania, mania, or depression or not. Sometimes you just have the psychotic symptoms. But most of the time, you have some kind of anxiety or restlessness. And so, for me as a reproductive psychiatrist, when I hear my newly postpartum patients, or also my patients with bipolar disorder who are getting into their third trimester, when I hear them start to talk about things like, "I'm so anxious. I'm having trouble sleeping." Like, almost this inner restlessness, that makes me very worried. And I try to really ask them to drill down on what are you anxious about?
And do you actually feel worried? Like, are you worrying? Or do you feel physiologically anxious? Or are you actually getting restless and kind of revved up? 'Cause I think a lot of people will use that word anxiety to mean all sorts of different things.
Puder:
Really, really helpful. Yes. Okay. So, diagnosis. I want to make sure we're clearing most of our thought process. Sometimes, can you just have it more of a depressed picture with the psychosis? And any thoughts on that specifically?
Furey:
You definitely can. You definitely can. I think the thing with postpartum psychosis is the cases that are quote unquote “easy” to spot would be the woman who is acting very bizarre, very euphoric, very manic, not sleeping, running around, maybe having hyper-religiosity, delusional beliefs like that. Like, that kind of case, I think we're all going to be like, okay, there's something up here. Right? Especially if it's presenting in that first month postpartum. I think the cases that get trickier are the ones that have this early prodrome. And I don't mean, sometimes it can be weeks or months long, but it can even be like a couple hours or days where it looks more like that irritable anxiety picture. And then they're not sleeping. Right? And then it kind of starts to snowball. Those cases can also be evidence of postpartum psychosis, and it's really about teasing apart or picking up on the psychotic symptoms, the delusions, the hallucinations, the paranoia.
Furey:
And again, as psychiatrists, we all know this is very tricky, and these are very hard symptoms to ask about. And so I think we also have to be really careful in our own observations of our patient in case they are withholding some of these symptoms. I've worked with countless women who, they don't have postpartum psychosis, they have postpartum OCD, but they're terrified to bring up the intrusive images and thoughts that they're having because they're so graphic and violent, which it turns out intrusive thoughts are more graphic and violent in the postpartum period. Who knew? But that's what the evidence shows. And so it's important also to be a very astute observer of their behavior. And then to also talk to the other people in their life to really get at, are they different? What are you observing?
Furey:
And depression can certainly go along with this. And I think that's where it gets tricky because some of these cases will very much look like postpartum depression and anxiety at first, until some of those more psychotic symptoms develop.
Filicide, Neonaticide, and Infanticide: Understanding Risk and the Forensic Literature (12:52)
Puder:
Very good. Yeah. I think one of the things I was looking at was specifically filicide. There's been some cohorts where they've looked at filicide versus severe postpartum mental illness versus healthy population. One study in particular I looked at was Brammente and Di Florio (2025) looked at 30 in the filicide group. And they were looking at what the differences are in terms of these populations. And I think maybe the first thing to say is that filicide is actually very rare.
Furey:
It is very rare.
Furey:
The safety risk is high, right? Like, when you compare the rate of filicide in this condition compared to other conditions, but overall, it's still low? Is that the point you're trying to make?
Puder:
That, I think that's the first point, as providers. Because I've heard some providers say after this Lindsay Clancy case, “I don't want to treat anyone postpartum.”
Furey:
I know. I've heard that too. And that breaks my heart, because it's like, “No, we can do this. We need people.”
Puder:
We need to do this. We don't want hurdles in the way of women seeking care postpartum. They need to be seen quickly. Right? They need to be seen. This is a medical emergency.
Furey:
Right. And to reassure the patients, too, that you're not doomed to have this awful, terrible, tragic outcome. Our interventions work and the treatment works.
Puder:
So, okay. One of the things I noticed was that none of the people with OCD actually went on to do the filicide in this one group, which is kind of interesting. It's like, if you were more of the obsessive type of ruminant, you know, the pure OCD, like obsessive, distressing thoughts, that doesn't mean you're actually going to harm the child.
Furey:
Right. Right.
Puder:
So that was one thing I wanted to say. The group that ended up being different from the severe postpartum had worse psychotic symptoms [the odds ratio was 8.3], worse insomnia (odds ratio 9.8), and they had more schizophrenia, bipolar diathesis (odds ratio of 4.8), and family history of violent death was also elevated (Bramante & Di Florio, 2025).
Furey:
Oh, that's interesting.
Puder:
27% in the filicide group versus, 3% in the severe postpartum psychosis. But one thing I would say is that, as I'm looking into these studies more and more, and I don't know if you kind of agree with this, but there's no predictive model on how to predict it. The data is so sparse, and I'm hoping I can come back maybe a couple weeks from now with some larger sense of predictive power. But right now, what I'm seeing, and I don't know if you agree with this or not, but there's no predictive power to, “Oh, okay, this person's especially at risk for hurting their child.”
Furey:
I think, unfortunately, you're correct, because, and I think this sort of is indicative of the bigger problem when it comes to perinatal mental health disorders, particularly postpartum psychosis, is because I just think it's so hard to study when we don't have a clear diagnostic code or a way of us all agreeing on a diagnosis to then study it, and then randomize it. And all the things we usually do, let's say if we were going to look at STEMIs versus NSTEMIs. Right?
Furey:
We all kind of have to agree on that difference to then look at two different groups. But if we're diagnosing postpartum psychosis in different ways, how do we really study it in a more evidence-based, larger kind of way? So I think we end up relying on case reports, cohort studies, or the very handful of forensic reproductive psychiatry experts who have interviewed the women who have committed filicide to try to piece together the similarities and differences. So I think you're exactly right. It's very hard to figure that out and to predict.
Puder:
There's, in the forensic literature, they differentiate the timing of how soon after these events occur. So within the first 24 hours, they call that neonaticide. Right? And what I was seeing was that these people, in this group, in this study, out of the five of them, four had personality disorders, three had dissociation, all had low socioeconomic status. Four of the five had less than eight years of education, total. They had no acute postpartum psychiatric effective diagnosis at the time. None had any psychiatric care at the time. So that group was a little bit different than the 11 women in the infanticide group. The infanticide is, what they call, first year or within the first year. The median was about five months. And, it seems like the bipolar spectrum was larger in this group.
Puder:
Maybe I'll just show you my notes here. So of the 11 group, these two, in the context of a lifetime psychotic disorder, five had bipolar II disorder, four had unipolar depression. Positive psychotic symptoms were present in every case. Three women also met criteria for dissociative disorders. Two women, hypomanic symptoms. And then eight out of 11 women had experienced a psychiatric episode during pregnancy. Six major depressive disorder. Two psychosis. Only one woman had a history of psychosis prior to pregnancy. Only one woman had a previous concern regarding child safeguarding. At the time of the infanticide, no women had been, were taking antipsychotics or mood stabilizers. Four women were on SSRI monotherapy, three on sertraline, one combined with Zolpidem, one escitalopram. This included one woman that had a previous history of bipolar disorder, and two who later developed hypomanic episode after the infanticide.
Puder:
So, and then, finally, five women were not receiving any psychiatric care and had no contact with services, despite previous history of severe psychiatric disorders. So this was in this one cohort, with 30 women.
Furey:
And I think that is aligned with what I have been taught and learned from other reproductive psychiatrists. That, again, it's kind of like catatonia where, excited catatonia you can easily spot, but the depressive slowdown catatonia can kind of get missed when you're thinking about a big inpatient unit. Right? That quiet, little old lady in the corner could fly under the radar. Sadly, I feel like it's a similar thing with postpartum psychosis, where the floridly manic, bizarre, delusional, revved up patient, you're going to spot easier. But the quieter, sort of preoccupied, depressed patient is also very risky. And that mixed picture, when you have a little hypomania, but also some depressive symptoms, those are also risky. And so, that was one thing that I learned in my training, is that the cases that have very severe depression, plus psychotic features, plus those delusions of control, that's your highest risk patient.
Furey:
Like, that's the one you really got to worry about.
Assessing Safety and High-Risk Symptoms in Postpartum Psychosis (19:33)
Puder:
Yes. It's like Philip Resnick. I remember him talking about this at a conference. I don't know if you've heard him speak. He's actually an infanticide expert. This is what he did. His early research interviewed a lot of women. And when I first heard him talk about it, he had a lot of compassion for these women, who kind of got swept into this. You know? And, so he talked about how the dangerous thing is when you have the delusion, and then on top of that, you have the command auditory hallucination and you feel this moral obligation. You're not going to cover up the scene of the crime. You're not going to put gloves on to commit the atrocity. You're not going to hide from the police after. It's because you're not in your own mind, doing something that's horrible.
Puder:
So, you know, concealing crimes was more of an antisocial, psychopathic confabulation of psychosis type of thing.
Furey:
And that is directly aligned with what I have heard, as well, from women who have survived postpartum psychosis, who maybe did act violently or something happened, is that, in the moment, they don't feel in control. I've had it described to me as, like they're a puppet being controlled and that the command auditory hallucinations are telling them something even worse will happen if you don't do this. And I just think that's the part for these cases that really just gets me, because I just can't imagine how utterly terrifying that must feel like. And how confusing and how so many of the women who've survived have said things like, “I knew this was bizarre, and yet I really believed it. And I didn't want to tell anyone because what would you think if I told you this?”
“You're going to think I'm crazy.” And it's just so complicated. Right? Because it's like you want the women to feel safe enough to tell you these things. And yet, have we really built a system where that's the reality?
Fluctuating Mental Status, Confusion, and Why Postpartum Psychosis Can Be Missed (21:37)
Puder:
I mean, this is where I think as clinicians, the more we learn about it, the more we know about it, the more comfortable we feel having these types of conversations with patients, patients will feel that comfort. Right? They'll know we're advocating for them. They'll know that we're trying to help them. I've had this one patient, in particular, years ago, she was in an inpatient CD unit, and she goes floridly manic.
Furey:
What's a CD unit?
Puder:
A chemical dependency unit. So you're not expecting this person to be, to all of a sudden become floridly manic. But she went from like having a normal conversation to six hours later being floridly manic. And I spent like an hour switching her units, talking to her, you know, and then one week later she comes back and she doesn't remember me at all. She had no recollection of ever having a conversation with me. And I spent hours with this person. Right?
Furey:
It's so true.
Puder:
Not every patient will remember what happens in the midst of their mania. Whether they did something good or if they didn't do something good. I mean, what if they did something bad or they didn't do something bad? They're not going to remember it either way.
Furey:
And I think that sort of speaks to another hallmark sign for postpartum psychosis, which is that delirium, fluctuating mental status. I know we can see this with other types of psychosis too. I'm thinking about, in training, prednisone-induced psychosis or something else like that. But we see this, as well, with postpartum psychosis, and I think it can really trip people up, is that over the course of hours, like over the course of a day, a woman might be a little confused in the morning or not seem like herself, not really understand what's going on. Maybe not floridly psychotic in terms of, like, talking to someone in the corner or, you know, having very obvious paranoia, but just being off. And then, by the end of the day, they might be kind of back to themselves. They seem kind of back to it.
And I think some people will think, “Oh, she just needs a nap. She just had a baby.” Like, you know, “She'll get better.” But those of us who work with postpartum psychosis know that's actually a very telling sign and something that you want to intervene on very quickly. And I think that goes against some other conditions where there might be more of a “let's wait and see” kind of model approach. So that fluctuating mental status is really important to keep an eye on. And sometimes, we also have to keep in mind that you’ve also got to rule out any potential medical causes. And that can be sometimes the way to get a patient into the ER for a good assessment is to just remind them you've just had a baby. You know, you're not acting quite right.
“I know you feel okay,” if they do, “But let's, let's just get you checked out. Let's just make sure everything's okay.” And there is a lot of truth in that because you want to make sure there's not a medical cause as well.
Emergency Evaluation of Postpartum Psychosis: Medical Workup and Psychiatric Assessment (24:38)
Puder:
So many good points. The confusion seems to be unique and kind of like an added thing to look for in postpartum psychosis. The confusion, from what I'm reading in the literature, from what I've seen, the medical workup is great. Great points. Infection, you're thinking of mastitis, endometritis, you're thinking of autoimmune thyroid issues, are more common. You're thinking of anti-NMDA receptor encephalitis, potentially, especially if they have other symptoms as well, neurological symptoms, metabolic neurologic disturbances, as well (Jairaj et al., 2023). So, you know, it may make sense. And I would say this, if you're a therapist and you have a patient, and this is like day eight, and they seem to be having these symptoms, and there's no one to take them to the ER, take them to the ER.
Puder:
Yeah. We gotta get them there. Exit out of the frame, to get them to the ER, to talk to the ER doctor, explain what they think's going on. Demand an expert consult. Right?
Furey:
Demand that they're watched for two to like, ideally two to three days. And I know that's very hard in our healthcare system these days, but, what's so tricky with postpartum psychosis is if they show up to the ER and they look good and no one does a workup, that can be a missed opportunity to intervene.
Puder:
Yes. I'm thinking you really have to do a warm handoff. Like, if you've heard some things that are concerning, and the psychotic symptoms, I can almost assume that a busy ER is not going to see it. You know? They may not see the psychotic symptoms. They may not understand it. So you really have to do a warm handoff in this case.
Furey:
I totally agree.
Postpartum Psychosis and Bipolar Disorder: Risk Factors, Recurrence, and Long-Term Outcomes (26:15)
Puder:
Yes. Okay. There was another thing that I was thinking about, so there's a thought that there is a risk of bipolar disorder developing in about 50% of people who have first onset postpartum psychosis. So they later go on to develop bipolar disorder. This isn't the case for schizophrenia, correct? Do you see this as more of a bipolar issue or more schizophrenia issue, personally?
Furey:
Yes, so this is a really good question.
Furey:
Regarding bipolar disorder, so far, the evidence that we have, which is limited, is that women are 23% more likely to experience psychosis in the first month after childbirth compared to any other point in their life. However, what we have come to find is that about one to two women will experience postpartum psychosis out of every 1,000 live births. So about one to two per thousand live births is the running statistic for postpartum psychosis. I think we also have to keep in mind, though, that there have been case reports of postpartum psychosis following miscarriage that don't get captured in that data, as well as following stillbirth. So again, when we think about it, clinically speaking, we would call it rare. Like, if you look up, what is the definition of a rare disorder? This would qualify. However, it's about as common as other disorders like Down Syndrome, for example, is also about one to two in a thousand (VanderKruik et al., 2017).
Furey:
When you think of last year, there were about 3.5 million live-born children. If you do the math, which I'm not smart enough to do in my head right now, but that's around three to 4,000 women who probably experience postpartum psychosis. So that's a good chunk of people. So again, it's much less common than baby blues, postpartum depression, postpartum anxiety, postpartum OCD. All of those conditions are more common. However, it can still happen. And it's not such a zebra that we're never going to see it. Does that make sense?
Puder:
Makes sense, yes. And I think it's worth emphasizing that if you have a prior history of bipolar, that the risk for having postpartum psychosis is 17%, so it's pretty high. Also, if you have had previous postpartum psychosis, the risk of a future one is 23%, interestingly. So the way that I understand this actually came from a really good article. It's the 2026 Postpartum Psychosis and Bipolar Disorder: Review of Neurobiology and Expert Consensus Statement on Classification, by Bergink et al.
Puder:
And one of the things that he's arguing for is that this gets added into the DSM under a bipolar spectrum phenotype. So it's postpartum psychosis in the bipolar spectrum phenotype. Right? So, his argument for this is that lithium is the best medication to prevent relapse, better than an antipsychotic. A lot of these patients will go on to later have bipolar disorder. The risk of having bipolar disorder makes the risk of postpartum psychosis much higher (Bergink et al., 2026). And, there is also, is this a unique thing or is this bipolar?
Puder:
What he would say is a lot of women will go on to be completely normal. So they won't have future issues once they come out of this. So in one prospective cohort, 68% of women had episodes confined only to the postpartum period (Rommel et al., 2021). So really, it's amazing.
Furey:
I don't know the exact data or where it stands right now, but as of two years ago, at the Postpartum Support International Conference, the task force was talking about how they are doing some research about different genetic polymorphisms. And they are seeing that when they look at the genes, and this is where it's like way over my head, the genes are more like bipolar disorder than the schizophrenia spectrum disorders, and yet, not every case. There are a good chunk of patients that don't have a future mood episode. So that's where I think we just, we don't fully know. We don't fully understand.
Treatment of Postpartum Psychosis: Lithium, Antipsychotics, Breastfeeding, and Relapse Prevention (30:20)
Puder:
I think one of the things that came out of this paper is to be very careful about putting them on an SSRI. And I think that that is good wisdom. Because, if we're talking about the first four weeks after birth, lithium, in one really good paper that I saw, it showed that it reduced risk of relapse. More than the antipsychotic. And lithium is an antidepressant. Now, there's a question of, well, what about for breastfeeding? Do you have any thoughts on that?
Furey:
I do. I have a lot of thoughts. So my thoughts would be that mom's mental health is paramount. If we're thinking lithium, we're thinking we really need to keep mom well. It's not contraindicated in breastfeeding. You can certainly breastfeed if you're taking lithium. You just need to have a really nuanced discussion of the potentials, things to watch out for, for the baby. And you also would want to make sure that the baby is full-term, doesn't have any neurological or respiratory issues, and you'd want to just talk about it with the pediatrician (Vigod et al., 2025). Usually, if you're a patient that I'm seeing who's on lithium and you're pregnant, we have all those conversations upfront. But in the postpartum period, if you've never been on a medication, and we're suspecting postpartum psychosis, I agree with you, I want to start lithium, and I also want to make sure mom is sleeping.
Furey:
So sleep is another prescription. In the postpartum period, at least a five to six-hour chunk every night (Bergink et al., 2025). And sometimes, that will affect your ability to breastfeed just depending on the other factors in terms of if you're able to maintain a milk supply, if you're sleeping during that chunk or not. And those can be tough conversations to have with mom. And yet, we have to think about overall, what's going to be best for the baby and the mom is a well mom and a mom who is not becoming more and more psychotic. So it's complicated. I don't think if you have to take lithium, I don't think that means there's no hope to breastfeed. Maybe we think about, can you combo feed? Can we do a little bit of both? Or if it's better for mom overall to just switch to formula, let's do it.
Puder:
Right. So one of my patients this year that had postpartum psychosis, manic, not sleeping, psychotic. I don't want to describe it in too much detail because it's a patient.
Furey:
Sure, sure.
Puder:
But lithium started right away, 900mg. Push it up after the lab test to 1200mg. And then, I think, maybe even 1500mg. And this was all done, like, in a week, and then that wasn't working. So we add a little olanzapine, 5mg, and then 10mg. I think we might have gone up to 15mg or 20mg. I forget. Still not sleeping. Ativan, 1mg. And boom. Once we had 15mg of olanzapine, 1500 of lithium, one milligram of Ativan, sleeping well. And really good parental support from the father. Really good family support. Amazing family support. So this was all handled outpatient. I don't know if I would do that again. But that's what was done. After reading about the medical issues, I think I'd be hesitant to do that.
But this person did have a history of bipolar. And after three or four weeks talking lucidly, not psychotically, not having psychotic thoughts…
Furey:
So they can get better.
Puder:
In this one study, when they looked at lithium, antipsychotic, and Ativan, they found that the combination of those three, about 90- 99% or so went into remission. And then they weren't doing the Ativan forever. They were doing it for five to 10 days (Bergink et al., 2015; Jairaj et al., 2023). Whatever's needed to get you to sleep.
Furey:
Yes. Get to sleep. Right, right.
Puder:
So any nuance?
Furey:
That's exactly right.
Puder:
I want to learn from you though. Like, push against how I'm doing things. Would, how do you normally start to try to think about treating a patient who comes to you?
Furey:
I think, again, I am hesitant to treat this in the outpatient setting on my own, unless it's a patient who I know really well, I know exactly what has worked before in the past, and I'm following her really closely. If this was a newer patient to me, or someone was calling me for the first time, I would send them to the ER just because of the safety risk. And again, just to reiterate, you are more likely to have postpartum psychosis and not kill someone than you are to have postpartum psychosis and kill someone. However, the safety risk is so high that I, we just take it very seriously. Right? And to do the medical workup and to have monitoring and to make sure you're getting better quickly so you can titrate those meds up very fast. I think that's another good reason to get evaluated in the ER and probably admitted, is so we can get those meds on board and titrate them up fast.
Furey:
And because they are so sedating a lot of the time, you want to make sure you're being monitored. Also, ECT [electroconvulsive therapy] is a great treatment option for postpartum psychosis, and it works quickly. So that's another thing that I think, just to remind people, is always on the table, and is not contraindicating breastfeeding (Vigod et al., 2025). And so, again, that's another tool to kind keep in mind. But usually, I think the biggest thing that I hope people listening will take away from this is, if you start to get that prickly feeling on the back of your neck, those red flags, those pink flags, as we call them, those softer, early signs are coming, like that confusion. Like, I had one patient, that was the first sign, was just this, this feeling of, like, “I feel like I'm losing track of time.”
Screening, Early Intervention, Sleep, Family Support, and Recovery From Postpartum Psychosis (36:02)
Furey:
And this was the patient with a known history in the past, and so I said, "Nope, let's go up on your Seroquel, and let's talk to your OB about delivering the baby because you're full-term." And, that was enough for me to say, “Okay, that's a situation where we don't want to wait.” But for anyone who's evaluating someone in your office, and they have no prior mental health history, they still could have postpartum psychosis. However, you want to make sure it's not one of the other more common postpartum mental health conditions. So I think we're getting more used to screening with things like the Edinburgh [Postnatal Depression Scale (EPDS)], which can look for symptoms of depression and anxiety. But then if they score positive, please do more assessment to rule out any personal prior or family history of bipolar disorder, whether mania, hypomania, or depression, because that's going to be the real clincher as to do you start an antidepressant or do you move to something like lithium.
Furey:
And if this were my patient, they were depressed, they didn't have active psychotic signs yet, but they had a pretty strong family history of bipolar disorder, I would be more conservative and hedge my bets and talk to them about starting lithium. And again, that's a harder conversation to have, to start someone on lithium for the first time. But I think when you really lay out the facts. You know, you can….
Puder:
Yes. Lithium is a great med. I've done multiple episodes on it, and it's, I think it's way underutilized [see episodes 57, 58, and 214].
Furey:
Oh, I love lithium. I agree. And it's also natural.
Puder:
Yeah. Yeah.
Puder:
This particular patient had a good pediatrician, and they checked the infant's blood level, and it was undetectable on the lithium. Sometimes it can be higher, especially, like, early on if the…. I guess later on, if lithium is added, I think it's safer for the infant. But, you know, work with the pediatrician, read the data, consider breastfeeding or not breastfeeding, what the risks are.
Furey:
And it's not a reason to not breastfeed. Right? I think that's an important thing to come across, is that just because you're taking lithium, that doesn't mean there's absolutely no way you can breastfeed. Much like any other medication, we just watch the baby for signs of toxicity, which would be similar to what we'd see in an adult. It's just, again, like you're saying, early on when that baby's metabolism is so new and things like that, you just keep a closer eye on the baby. And there's ways to try to time it around feeding and stuff like that too.
Puder:
The other thing that I think is a key statistic is suicide risk is higher for people with postpartum psychosis.
Furey:
I know. It's heavy.
Puder:
Looking at this suicide statistic and in these long-term follow-ups of postpartum psychosis, in patients who are actively ill, the rate of suicide in different studies was four to 11%, right? So there is a high risk period of time. And even some of these suicides were after discharge from psychiatric hospitals, which I think it just goes to show that we really need to have good follow-up to explain why these, if they're on medications, make sure they're not having side effects of medication (Brockington, 2017). Make sure that they're actually helping. And then, in this one census paper they talked about the benzodiazepines, antipsychotics, and lithium being kind of the mainstay of this bipolar type of issue.
Furey:
The trifecta.
Furey:
And I think at this point, we would all agree to treat it as bipolar until proven otherwise. So if your patient doesn't have a history of bipolar, that's still how we treat it. You get better outcomes if you include a mood stabilizer like lithium with the antipsychotic rather than just the antipsychotic (Vigod et al., 2025).
Puder:
Yes. I'll show you. There was one article, actually posted this on the screenshot. This is one article that this consensus guy, Pryor, wrote. And he was looking at a group that was either maintained on antipsychotic or with the lithium.
Puder:
Or maintained on the antipsychotic. And the people that were maintained on the lithium have a lot less relapse.
Puder:
I agree with you, treat as bipolar until proven otherwise. This is a heavy topic. I hope that if you're listening to this you can tell Dr. Furey's heart in treating these patients. I definitely see it, your passion, passionate educating other psychiatrists. I definitely want to have you back on. Maybe we could pull some more studies together and kind of dig into….
Furey:
Yes, that would be great.
Puder:
There's so much, so much to learn here and grow, and I think the more that we can feel comfortable, knowing this stuff, kind of being ready for it, the more when it happens we will be able to help. People won't feel so helpless.
Furey:
Right, exactly. Exactly. And these cases do get better. I think that's one of the things that's so remarkable about postpartum psychosis and why a lot of us who are in reproductive psychiatry, it's those kinds of cases that first get you going, "Huh, look at that." Because it can be so dramatic, just the onset of the symptoms, the way they can fluctuate, it can seem like patients are kind of coming in and out of the psychotic symptoms, but then that they do get better, and they can come back to lucidity and you can keep the family whole. I mean, there's nothing more powerful than that.
Puder:
Beautiful. Yeah. And I would say also, we really haven't talked about this, but I usually speak strongly to the husbands, or the partner (Bergink et al., 2025). And I'm like, "Hey, this is not a time to work. This is a time to be at home, to take FMLA." I told a dad just last week, "It's time to take FMLA. Be up in the middle of the night and take care of the kid when the kid is waking up so that your wife can sleep eight hours.” You know, if we're going to put them on medications to make them sleep, they should not be expected to wake up.
Furey:
They have to sleep.
Puder:
They have to sleep. This is a time to call mom and dad. This is time to pull in all the resources possible.
Furey:
All the troops. All the troops. As many troops as possible. Right. 100%.
Puder:
Yep.
Furey:
And sometimes you do have to think creatively, like you're saying. And I think including the partner, the family, and the support system, both when you're getting that collateral information, when you're trying to make a diagnosis, but also when you're educating everyone about what's going on is, I would say, especially in the acute phase when, like, you're saying, the patient might not remember what you're telling her or talking about, it's critically important.
Puder:
Yes. And the other thing I would say to providers, this is kind of a practical point. I used to run an IOP for people with medical and psychiatric issues. So we'd work for the OB department. They would send all the postpartum cases to my IOP, and I would keep putting them on disability and FMLA. I would extend it for the full year. I would be like, “Yeah. You are not going back to work. We are putting you….” So sometimes we'd keep them in the program so that we could just, you let them have all of that baby bond. Heal. Time to heal, right? Heal and process, because they could have, like what you said, they could have a sense of loss. They had this idyllic version of what would happen, and then this nightmare happens, and then they need to process what that felt like because it felt awful.
Furey:
Right.
Puder:
And it's not.
Furey:
Let alone going back to work and all the stress of that.
Puder:
Yes. So this is one of those conditions I do some, I don't know what kind of justice you call this, but put them on long-term disability for 12 months and let them improve (Vigod et al., 2025).
Furey:
Hey, you got to work in the system you're in.
Puder:
Yep. So yeah, okay. Any closing thoughts or any things that you feel like we haven't quite discussed yet?
Furey:
I think that, we're saying this is a severe psychiatric emergency that does warrant emergent evaluation by a specialist, and yet, it is treatable. And any one of us, any provider, can learn how to pick up these signs. So don't feel like you have to avoid treating this patient population. We need good, quality providers now more than ever. There's so many trainings out there and there's a lot of help available to providers too, which I know we'll include in the show notes, but things like Postpartum Support International have free psychiatric consultation lines. Thirty states have access to mental health hotlines where you can call to get real-time consultation. There are a lot of organizations doing a lot of advocacy work. So there's a lot of positive movement going on.
Furey:
So even though we talked about a lot of heaviness and it is very serious and very scary, I hope that people also leave feeling like there is hope and you can intervene and people can get better.
Puder:
Yeah, that's great. And I'm going to put on the website, usually I'll do a transcription of the podcast. We'll put some of these articles that we talked about. I'll put all those resources you just mentioned. Maybe you can help me put those down. Also, your own teaching and training, which, I think would be very helpful for providers to do. Check it out. I'll put a link to you on the website, psychiatrypodcast.com. And yeah, I'm hoping to have you back. This was great. This was really helpful.
Furey:
I'd love to. Yes, anytime. Thank you. And thank you for getting it together so quickly.
Puder:
Yes. It's very important. Okay. So we'll leave it there for today. And, , and then we'll just chat after. Okay. Okay, bye.
Furey:
Okay. Sounds good.
References
Bergink, V., Burgerhout, K. M., Koorengevel, K. M., Kamperman, A. M., Hoogendijk, W. J., Lambregtse-van den Berg, M. P., & Kushner, S. A. (2015). Treatment of psychosis and mania in the postpartum period. American Journal of Psychiatry, 172(2), 115–123. https://doi.org/10.1176/appi.ajp.2014.13121652
Bergink, V., Suleiman, M., Hennen, M.-A., & Robakis, T. (2025). Management of bipolar disorder in pregnancy and postpartum: A clinicians’ guide. CNS Drugs, 39(8), 763–777. https://doi.org/10.1007/s40263-025-01202-7
Bergink, V., Akbarian, S., Byatt, N., Chandra, P. S., Cirino, N., Dazzan, P., De Witte, L., Di Florio, A., Dolman, C., Jones, I., Kamperman, A., Mahjani, B., Meltzer-Brody, S., Munk-Olsen, T., Nagle-Yang, S., Osborne, L. M., Rasgon, N., Robakis, T., Thippeswamy, H., Vigod, S. N., & Payne, J. L. (2026). Postpartum psychosis and bipolar disorder. Biological Psychiatry. Advance online publication. https://doi.org/10.1016/j.biopsych.2025.10.016
Bramante, A., & Di Florio, A. (2025). A case-control study of filicide/infanticide in 90 mothers. Archives of Women’s Mental Health. https://doi.org/10.1007/s00737-023-01401-5
Brockington, I. (2017). Suicide and filicide in postpartum psychosis. Archives of Women’s Mental Health, 20(1), 63–69.https://doi.org/10.1007/s00737-016-0675-8
Jairaj, C., Seneviratne, G., Bergink, V., Sommer, I. E., & Dazzan, P. (2023). Postpartum psychosis: A proposed treatment algorithm. Journal of Psychopharmacology.https://doi.org/10.1177/02698811231181573
Rommel, A.-S., Molenaar, N. M., Gilden, J., Kushner, S. A., Westerbeek, N. J., Kamperman, A. M., & Bergink, V. (2021). [Article title not provided]. International Journal of Bipolar Disorders, 9, Article 31.https://doi.org/10.1186/s40345-021-00236-2
Ullrich, S., Keers, R., & Coid, J. W. (2014). Delusions, anger, and serious violence: New findings from the MacArthur Violence Risk Assessment Study. Schizophrenia Bulletin, 40(5), 1174–1181. https://doi.org/10.1093/schbul/sbt126
VanderKruik, R., Barreix, M., Chou, D., Allen, T., Say, L., & Cohen, L. S. (2017). The global prevalence of postpartum psychosis: A systematic review. BMC Psychiatry, 17, Article 272.https://doi.org/10.1186/s12888-017-1427-7
Vigod, S. N., Frey, B. N., Clark, C. T., Grigoriadis, S., Barker, L. C., Brown, H. K., Charlebois, J., Dennis, C.-L., Fairbrother, N., Green, S. M., Letourneau, N. L., Oberlander, T. F., Sharma, V., Singla, D. R., Stewart, D. E., Tomasi, P., Ellington, B. D., Fleury, C., Tarasoff, L. A., . . . Van Lieshout, R. J. (2025). Canadian Network for Mood and Anxiety Treatments 2024 clinical practice guideline for the management of perinatal mood, anxiety, and related disorders: Guide de pratique 2024 du Canadian Network for Mood and Anxiety Treatments pour le traitement des troubles de l’humeur, des troubles anxieux et des troubles connexes périnatals. The Canadian Journal of Psychiatry, 70(6), 429–489.https://doi.org/10.1177/07067437241303031
Resources for patients:
PSI (Postpartum Support International) HelpLine:1-800-944-4773 — call or text, 8am-11pm EST every day. Press 1 for English, 2 for Spanish.
National Maternal Mental Health Hotline:1-833-TLC-MAMA (1-833-852-6262) — free, confidential, 24/7
Resources for providers:
PSI Perinatal Psychiatric Consult Line (they can schedule an appt to talk to reproductive psychiatrist for free): https://postpartum.net/professionals/perinatal-psychiatric-consultation/
PSI Provider Directory: https://psidirectory.com/
State-based perinatal psychiatry access programs: https://postpartum.net/professionals/state-perinatal-psychiatry-access-lines/
Connect with Dr. Furey
-Private Practice: https://www.sound-psychiatry.com