Episode 278: Postpartum OCD vs Postpartum Psychosis: Intrusive Thoughts of Infant Harm, How to Screen, and Lithium Prevention with Dr. Katie Unverferth
This episode is awaiting CME Approval
Other Places to listen: iTunes, Spotify
Puder:
All right. Welcome back to the podcast. I am joined today by Katie Unverferth. She is the director of the UCLA Women's Life Center and Medical Director of the UCLA Maternal Mental Health Program. She was chief resident in reproductive psychiatry, UCLA with Vivien Burt, who many of you might know as one of the leaders in the field, and then did a mood disorder fellowship. She maintains a reproductive psychiatry practice in Santa Monica. Some of you may have heard the last episode we did on postpartum psychosis with Katrina Furey [see episode 276]. We talked about postpartum psychosis, onset, safety, lithium, emergency frame. Today, we want to talk more about ruminative depression, postpartum OCD, and the line that separates ordinary ego-dystonic intrusive thoughts from psychosis. So welcome to the podcast.
Unverferth:
Thanks for having me. Glad to be here.
How Common Are Unwanted Intrusive Thoughts in Pregnancy and Postpartum? (00:59)
Puder:
I want to just maybe start about how common unwanted thoughts are in pregnancy for the majority of women. Maybe you can go through what are some of the common unwanted thoughts. How uncommon are they? And then what is normal?
Unverferth:
Yes. Yes. So we know that intrusive thoughts are kind of these unwanted thoughts or images that pop into someone's mind sort of unbidden. Right? They're influenced a lot by emotional factors, environmental factors. They often attach to things that you value and care about. Right? So I think in pregnancy, that can take the form of intrusive thoughts of something happening to the pregnancy. Accidentally losing the pregnancy. We see a lot of fears of contamination in pregnancy, like, "Oh, what if I ate that and I shouldn't have?" Right? Or with the recent foodborne illness outbreak, I'm sure that there have been intrusive thoughts around lettuce. Right? Taco Bell lettuce. I think what we see in the postpartum is that postpartum is a really high stress time. Intrusive thoughts get louder, they're more present during really high stress times.
Unverferth:
And because you have an infant, the infant is what a lot of times the intrusive thoughts attach to. So we see some studies really show that 100% of new moms will have intrusive thoughts of accidental harm coming to their infant. Like, “What if I accidentally drop my baby?” And then about 50% have intrusive thoughts of intentionally harming their infant. One common example of that would be, like, “What if I smother my baby with a pillow?” It can be really violent, these kinds of harming, intrusive thoughts. What we know is that for the majority of women, these thoughts are against their values, ego-dystonic, and it makes them unlikely to harm their baby. Right? A lot of times, they sort of avoid being around their baby if they think they're going to harm their baby.
[Estimates depend on how, when, and whom researchers sample. In a U.S. cohort deliberately recruited to include both high and low prenatal obsessive-belief scores, 82.4% reported suffocation/SIDS intrusions and 25.8% intentional-harm intrusions at six weeks postpartum (Abramowitz et al., 2025).]
Unverferth:
So I think that we have to separate this from psychotic thoughts, where psychotic thoughts are more ego-syntonic, where they sort of, it doesn't distress you in the same way that it might when someone has an intrusive thought. And it's associated with other psychotic symptoms, like ideas of reference, delusions, hearing voices, seeing things that aren't there.
What Horror Tells You Clinically: Ego-Dystonic Intrusive Thoughts vs Psychosis (03:27)
Puder:
Yes. Okay, so when the mother is horrified by the thought, what does the horror actually tell you clinically?
Unverferth:
Yes, the horror tells you that it's ego-dystonic. It tells you that it is against their values. They are less likely to do it. Right? It is much more likely to be part of either OCD, postpartum depression, postpartum anxiety, or sometimes intrusive thoughts just sort of occur on their own. What really separates intrusive thoughts from OCD is the severity, the frequency, sort of the stickiness of the thought, the distress, and then obviously the compulsions. Right? So someone who's engaging in compulsions, like checking regularly to make sure their baby is breathing because they're having intrusive thoughts that their baby stopped breathing. That would be someone who would be more likely to fit the criteria for OCD. What makes this complicated though, is we know that intrusive thoughts can also occur in postpartum psychosis. Right? Someone who has postpartum psychosis could still have ego-dystonic intrusive thoughts.
Unverferth:
It's just that they also have symptoms consistent with postpartum psychosis. So you do always want to do a full evaluation to make sure that they're not hearing voices, seeing things that aren't there, checking. You want to check how they're sleeping. You want to check to make sure that there aren't associated symptoms with it.
How to Ask About Thoughts of Infant Harm Without Triggering Concealment (04:42)
Puder:
Okay. So how do you ask about these thoughts? So, let's say the mother is very nervous that a mental health professional physician is going to be calling CPS because they're having these horrible thoughts. So what would you tell them to sort of keep them from hiding these thoughts from you?
Unverferth:
Well, first, I start with psychoeducation on intrusive thoughts. Like before, I will explain what an intrusive thought is before I ask someone about it. Right? So I won't just be like, "Are you having thoughts of harming your baby?" I'll say, "Intrusive thoughts are sort of these unwanted images or thoughts that pop into your mind randomly. We know everybody has these at different points in time. For example, if people stand on a high building, sometimes they'll have a thought of, like, ‘What if I jumped off?’ It doesn't mean they want to, they're distressed by it. What we see is that in the postpartum, sometimes those thoughts can attach to an infant. So sometimes people will have thoughts of actually harming their infant or intentionally harming their infant, but we know that it is not aligned with their values.”
Unverferth:
“They're not likely to harm their baby. Are you having anything like that?” I won't always go into that level of detail, but what you want to do is you really want to normalize it. In my practice, I've seen people who come to me with really the belief that they're losing their mind. This belief that they're becoming psychotic because they're so horrified by the intrusive thoughts. They think that it means something new or true about them, and that's sort of this line I'll use, is like, "Intrusive thoughts don't mean anything new or true about you and so it's really important to not change your behaviors in response to these intrusive thoughts.”
[Fear of being judged, being locked up, or having the baby removed recurred in a qualitative analysis of 43 public blog posts. Among 191 applicable responses in a two-site psychiatrist survey, 101 (52.9%) reported asking psychotic mothers only about general homicidal thoughts rather than specifically about filicidal thoughts; these studies address different clinical contexts and support normalized, specific inquiry, but neither estimates population symptom prevalence (Beck, 2022; Friedman et al., 2008).]
Why High-Profile Cases Increase Intrusive Thoughts After Birth (06:23)
Puder:
That's great. Okay. Sorry, just kind of gathering my thoughts here. So it doesn't, because I'm imagining in the midst of all that's going on in the news, the Lindsay Clancy case, like some women who are postpartum who are having intrusive thoughts, maybe they don't want the intrusive thoughts. They're like, "This is a nightmare.” You know, “This is horrible."
Unverferth:
Right.
Puder:
So I imagine that some people are having this sort of extra intrusive thought, like, "Could I do that?"
Unverferth:
Right. I think the Clancy case has brought up a lot of intrusive thoughts for people. I would be shocked if it hadn't. I think especially this fear of loss of control, like, “What if I lose control and actually harm my children?” Right? I think the truth is that it's extremely rare. Harming your children in that way is not common. I think seeking help from a medical professional is very important to have a full evaluation to see if the intrusive thoughts are kind of standalone, if they cluster with other things. Most intrusive thoughts resolve. We know that intrusive thoughts really peak within the first few weeks postpartum. It's the same time when we see that postpartum OCD incidence really peaks. They do tend to get better with time. What I've told people and what I also think is true is that….
Unverferth:
Pregnancy is a time of huge brain changes. It's a time of huge hormonal changes. And what we know is that the brain is really primed to sort of protect your infant. And so, in some ways, you can think of the intrusive thought as really trying to protect your infant. Right? It's trying to protect the infant from harm. Right? We know that for some people, these kinds of [thoughts], these go too far, it goes awry, right? That the volume is too loud, it's scary, it can make it really hard to be present with your baby. But in some ways, your brain is just really trying to protect itself and protect the baby, right? And so we know that it will get better. If it is more OCD, then exposure and response prevention (ERP) with CBT in combination with an SSRI has been very helpful.
Unverferth:
If it's part of a postpartum depression or postpartum anxiety, getting evidence-based treatments for that, I think is really important, can be helpful as well. But, it is very scary. The truth is that the majority of people with postpartum intrusive thoughts are almost a universal experience. Again, like, nearly 100% of people will have intrusive thoughts of accidental harm, about 50% intentional harm, but it doesn't increase the likelihood in that context of harming your baby.
Where Common Postpartum Intrusive Thoughts Become Postpartum OCD (08:48)
Puder:
Okay, so where's the line between common postpartum intrusive thoughts and actual postpartum obsessive compulsive disorder?
Unverferth:
Yeah, the line is really in the severity and sort of the appraisal of the thought. Like when I was postpartum, I had postpartum intrusive thoughts. It would be like, "What if I drop my baby?" And I'd be like, "Ugh, yuck." And then I would go about my day. Right? The difference is someone with OCD would be like, "Oh my God, why did I think that? Why did I have that thought of dropping my baby? Does that mean that I don't love my baby? Maybe I shouldn't even be a mom. This means I should never hold my baby." And so what we see is there's this sort of this belief system that connects it to the compulsion. And what that does is we know in the brain that when you engage in compulsive behaviors, you're sort of teaching the brain that that thought was really important.
Unverferth:
You need to value it, you need to pay attention to it, and you need more of those thoughts to sort of protect yourself. And so then what we see is the volume of the intrusive thoughts really ramps up. So in that context, we would have the obsession with the compulsion. So that would be what would then become OCD. OCD obviously has very specific diagnostic criteria. There are different rating scales that you can do to really assess the severity and functional impairment. But that would be the difference. Whereas someone else would have the intrusive thought and then they would just kind of let it go. With OCD, it's much stickier. It's associated with much more distress. There are belief systems that are attached to it and there are compulsions that are engaged in.
Common Compulsions in Postpartum OCD (10:15)
Puder:
Nice. And what rituals do you most often see? We've talked about some of them, but just to reiterate checking the baby's breathing, avoiding knives, refusing to be alone with the infant, reassurance seeking is a compulsion as well. Googling. ChatGPT.
Unverferth:
ChatGPT. Definitely ChatGPT. Yes. Those are the main ones. I think you've gotten them. We see a lot of avoidance. So avoiding being alone with the baby. I've seen sometimes when family systems sort of comply with the avoidance where the whole family is taking care of the baby because they're worried about the mom being alone even though this is more pure OCD in this person. And so that's the opposite of what we recommend. So a lot of the work in the perinatal intensive outpatient program where I'm the medical director, we will have the mom do more and more of the care for their infant in a supervised setting to build up their confidence. A lot of reassurance seeking, especially with partners, friends, family members, therapists sometimes who aren't trained in behavioral therapy can really sort of engage in this compulsive reassurance seeking as well.
Unverferth:
Lots of checking with the breathing. A lot of, what's the word I'm looking for? Kind of like difficulty. Also can be like difficulty delegating care of the infant. So there can be avoidance, but there can also be sort of a refusal to let anybody else help. The belief that you're sort of the only person who can take care of the infant, which can also be a compulsion. Right? Because you're really, to your own detriment, maybe not allowing other people to help.
[In a small cross-sectional dyadic study, concurrent depression (not OCD diagnosis or symptom severity) was the only independent predictor of observed maternal sensitivity. In a larger general-population cohort with low average symptom burden, early postpartum OC scores were not independently associated with later bonding or parent-reported child development at age two (Blum et al., 2022; Challacombe et al., 2016).]
New-Onset Postpartum OCD vs Worsening of Preexisting OCD (11:47)
Puder:
In your clinic, do you often see women coming in who seem to have postpartum OCD have a prior history of OCD, or is it first onset usually?
Unverferth:
Yes, it's a great question. I see both. I see a lot of people who do develop OCD in the postpartum. But what we see is if we look at their history, you know, maybe when they were kids, they were really concerned about getting sick or they always had to check on their parents to make sure that they were safe. Or they've even had more clear OCD illness in the past, but they haven't really sought treatment. They might not have taken medications. And then what we see is that in the postpartum, when intrusive thoughts are attached to the infant, they're often much more distressing, and so they drive people to treatment for the first time. It is also possible that someone develops OCD for the first time in the perinatal period. We know there's a higher incidence of OCD in pregnancy and postpartum.
[Fairbrother, Beck, and Keeney (2024) timed two clocks, not one, in 97 people who already met SCID-5 OCD criteria in the current perinatal period. Symptom onset is not the same as disorder onset.
Of those 97, 69 had the disorder start in a perinatal period [71%]. Among those 69, 57 started postpartum [83%] and 51 started in a first perinatal period [74%]. Symptoms started perinatally in 59 of the 97 [61%], which means a sizable group already had OC symptoms before this pregnancy and only crossed into full disorder after the baby. In the 59 whose symptoms and disorder both began perinatally, 47 had complete timing data. Their mean hop from first symptoms to full disorder was 3.2 weeks [SD 5.8, range 0 to 32.5]. When both clocks started outside a perinatal period, that hop was about 3 years.
So you will see both presentations Unverferth described. Some people show up with a childhood or untreated history that only becomes intolerable once the intrusions attach to the infant. Others look like true first-onset perinatal OCD, and when that happens it often happens fast, usually postpartum, and often in a first perinatal period. This sample is current perinatal OCD, not a population incidence rate.(Fairbrother et al., 2024).]
Unverferth:
Again, that's probably related to the stress of the time. Right? We know that OCD is worse with stress. The hormonal changes that are happening, there's some thought that oxytocin might be involved. So there definitely are certain triggers for new onset OCD, and then we know that these intrusive thoughts are a near universal experience. So if you have a brain that's sort of sensitive to those factors, you could develop OCD for the first time in the postpartum. A lot of times when I'm screening for intrusive thoughts, and if someone tells me they have intrusive thoughts, I really encourage them to try to not change any of their behaviors. I'm not a CBT therapist, but I'll be like, "Okay, well, I hear that you're having the intrusive thoughts. The most important thing to do is to try to just move forward in the way you would've without the intrusive thoughts.”
Unverferth:
“I don't want you engaging in avoidance or checking behaviors." I don't know if that necessarily prevents the development of OCD in someone who would've developed it, but it at least gives them a really quick and dirty understanding of what exposure and response prevention is, which is just don't do the compulsions. Right?
How Clinicians Should Handle Reassurance Seeking
Puder:
Yes. So how do you, as the provider, let's say that you notice them coming to you a lot, seeking reassurance. How do you not give them reassurance?
Unverferth:
Yes, that's a great question. I think I'll answer, It kind of reminds me of the same thing I recommend for someone with illness anxiety. You can go to the doctor, you should get everything checked out once, but you can't go over and over again. Right? So same thing with the patient. I'll answer any question once, but if we're going over the same thing over and over again, I might be starting to notice this pattern of reassurance seeking. I'm also very lucky in my practice that I have a lot of really great cognitive behavioral therapists that I collaborate with and work really closely with, and so they're probably more adept than I am at really identifying reassurance seeking really quickly and putting bounds around it with patients. And I find that to be really effective too.
Treatment of Postpartum OCD: High-Dose SSRI Plus ERP (14:34)
Puder:
Yes. Great. Great. Okay, so what are the treatments you recommend for postpartum OCD?
Unverferth:
Yes, for postpartum OCD, the treatment is really not very different from OCD at other times in your life. You want a serotonergic antidepressant at typically higher [doses] than you would expect for depression or anxiety. You sort of push it to the upper limits, in combination with cognitive behavioral therapy. So cognitive behavioral therapy we do the exposure and response prevention where you expose someone to the feared, intrusive thoughts, and then prevent them from doing the compulsions, and you do it in a stepwise approach, building up to what they can tolerate. That combination is the most effective for OCD and the postpartum. Some programs, and I think we've done this before, is actually sometimes even having moms hold knives. Like, they're scared of chopping vegetables, they're scared of holding knives, and you have to sort of work them up to increasing their comfort with it.
[Evidence note: The only postpartum OCD psychotherapy RCT is Challacombe et al. (2017), a pilot of 34 mothers. Twelve hours of intensive CBT, typically four 3-hour sessions over two weeks, with optional monthly follow-ups, produced a 30% or greater Y-BOCS reduction in 12 of 17 treated mothers versus 3 of 16 usual-care controls; 6 of those 16 also received some CBT. There is no postpartum RCT of high-dose serotonergic antidepressants, or of medication plus ERP versus either alone. Mulcahy et al. (2023), a Delphi panel of 15 professionals and 14 consumers, endorsed CBT with ERP as first-line and said SSRIs or TCAs should be considered after individualized review of severity, history, overdose risk, and pregnancy or breastfeeding. Combination therapy was endorsed only as possibly better than monotherapy for some people. That is consensus, not comparative drug evidence. (Challacombe et al., 2017; Mulcahy et al., 2023).]
Unverferth:
I think OCD is very treatable, but we know that without treatment, OCD really can have quite a chronic course. It doesn't just remit. Whereas, you know, depression is more episodic. We expect that eventually it will get better. With OCD, and especially postpartum OCD, because the intrusive thoughts lead to these compulsions, and that makes the intrusive thoughts stronger, it's this cycle you really do have to intervene pretty directly with antidepressants and cognitive behavioral therapy.
[Evidence Note: Depression can also become chronic: a systematic qualitative review of longitudinal studies summarized that about 30% of postpartum-depression cases in community samples and roughly 50% in clinical samples remained depressed throughout and beyond the first postnatal year; definitions, follow-up intervals, and samples varied (Vliegen et al., 2014).]
Rating Scales for Postpartum OCD: DOCS and Y-BOCS (15:59)
Puder:
Okay. I wanted to pull up the DOCS (Dimensional Obsessive-Compulsive Scale). Have you, do you use this to kind of get an idea of how severe postpartum OCD is?
Unverferth:
Yes, I'm familiar with it. A lot of times we will do assessments with the Y-BOCS.
Puder:
I think it's helpful because, think about all the people that listen to this podcast. There's probably a lot of people who are not going to be able to refer to a specialist. Right? So then to have a tool in their tool belt where they can…. The Y-BOCS is great, but this is another one that I've seen in the literature for this. One of the things I noticed, first of all, was that one of the questions here is, “About how much time have you spent each day thinking about contamination or engaging in washing or cleaning because of contamination?” And it's like, “Less than one hour a day, one to three, three to eight, eight hours per day.” And I was thinking about how common it would be for someone with severe OCD, they could be doing this six to eight hours a day.
[Evidence Note: In a Canadian diagnostic-accuracy study, the DOCS (Dimensional Obsessive-Compulsive Scale) total outperformed the EPDS (Edinburgh Postnatal Depression Scale) for perinatal OCD screening, but the optimal DOCS threshold varied by assessment wave and early-postpartum specificity was only .67; a positive screen still requires diagnostic assessment (Fairbrother et al., 2023).]
Puder:
We may not know that unless we ask them. So that was one of my thoughts on that one. I don't know if you have any….
Unverferth:
Yes. I think it's also interesting too, the level, what someone sometimes will consider as tolerable. And I think it varies so much depending on the life stage and life circumstances. Right? I see this a lot in the postpartum, really. Postpartum, a lot of times, is when someone really gets treatment for their psychiatric condition that might have been under the surface for a long time. Right? So with OCD, maybe it was okay in their life to engage in an hour or two of compulsions a day before they had an infant. Right? But then, when there's an infant in the picture, your time is so precious and you're so busy with all of these different tasks that an hour or two really becomes intolerable. And so we see that a lot of times, this is the first time people get treatment.
Unverferth:
You see the same thing with postpartum depression. If someone engaged in a lot of behavioral strategies to treat their postpartum depression, like exercising, yoga, therapy, seeing friends, going on walks, you know, hobbies. Right? In the postpartum, you just don't have that time in the same way. And so it really drives people sometimes to try medications for the first time, to seek out evidence-based therapies because they're not able to cope in the same way they used to.
[Evidence Note: A positive depression screen is a case-finding signal, not proof of unipolar depression: among 826 diagnostically interviewed women with positive postpartum EPDS screens, 22.6% had a primary bipolar diagnosis. ACOG therefore recommends bipolar screening before starting pharmacotherapy for depression or anxiety when it has not already been done (American College of Obstetricians and Gynecologists, 2023; Wisner et al., 2013).]
Puder:
Yes. So a lot of these questions are going through the different types of symptoms we've talked about, looking at the amount of time people are spending on it. Do you want to talk about the Y-BOCS at all, because you're more familiar with that one. Maybe I'll just pull that up and show people what that looks like.
Unverferth:
Yes. The Y-BOCS we use a lot in the perinatal intensive outpatient program. So it's a clinician-given [administered] screener, but it does a really good job of looking at the severity of OCD symptoms. It really runs through this large checklist of different OCD symptoms. So a lot of times when I've used this with patients in my private practice, you sort of find things that weren't obvious at the beginning, like the religious obsessions that come up in the Y-BOCS. Like, "I am excessively concerned with morality." You know, that's not always something that comes up right away when you're thinking about OCD. Or, “I fear losing things,” a different miscellaneous object obsession. So, I like this. I have found this very helpful when someone thinks that they might have OCD but isn't sure.
Unverferth:
Sometimes running through the checklist with them can be really helpful. They'll be like, "Oh, I didn't know that all of these things were OCD." In the perinatal period, I do think that the intrusive thoughts tend to be more typical. It could be anything, but it does tend to be related to the infant or around the health of the infant, or contamination. Those types of things. But yes, that's how we use it. We use it as an aid for the diagnosis of OCD, and I think it can also help patients understand what things might be consistent with OCD that they might not have realized before, too.
Ego-Dystonic vs Ego-Syntonic Infant Harm Content: Red Flags (19:55)
Puder:
Cool. Okay. So now let's shift to the line between ego-dystonic versus ego-syntonic infant harm content. Where's that line for you? And what are the things that when you hear it, you're like, "Oh," kind of raises your red flags?
Unverferth:
Yes. So what you're looking for a lot of times is distress. So if someone is very distressed, they're anxious by the thought, they're popping into their mind unbidden, they're doing these behaviors to safeguard the infant, we know it worsens the OCD [in the long term], but in the short term, these are the things you're looking for. Are they worried that they're going to hurt the infant? You're looking at what symptoms these intrusive thoughts are associated with. So if it's associated with postpartum depression, if it is associated with compulsions, if it's associated with postpartum anxiety, I think that is typically more reassuring, but I do think it is very important to also assess for psychotic symptoms. So again, people can have these classic intrusive thoughts with postpartum psychosis, but in that case, you are also assessing for visual hallucinations, auditory hallucinations, waxing and waning, perplexity, confusion, these kind of classic symptoms that go with postpartum psychosis, and that would really differentiate it.
[Evidence Note: Thought content alone does not classify risk: guidance emphasizes whether thoughts are unwanted or ego-dystonic, insight, distress, avoidance or neutralizing, intent, psychotic symptoms, and the broader mental state. In a small inpatient study of women with severe postpartum psychiatric disorders, infant-focused psychotic ideas were the only significant predictor among three variables entered into the model for serious or life-threatening infant-harm behavior; this selected sample is not an individual risk calculator (Chandra et al., 2002; Hudepohl et al., 2022; Mulcahy et al., 2023).]
Unverferth:
With regard to ego-syntonic versus ego-dystonic, I think it can get complicated if someone is so scared of their OCD that they sort of believe their OCD, if that makes sense. Someone who's having such vivid, intrusive thoughts, they're like, "Well, what if I did? What if I want to? Maybe I want to. What does it mean?" Right? Someone who's really overwhelmed by it, I think sometimes it can get blurrier than you would expect with someone with really, really, really severe OCD. But often when you're looking at someone in the postpartum, it's the constellation of symptoms that helps you differentiate postpartum psychosis versus postpartum OCD.
Irritability, Agitation, and Mixed Features in Postpartum Psychosis (21:56)
Puder:
Okay, one thing I read in the literature is that it's more frequent to have irritability, kind of the bipolar psychosis. It's more frequent to have irritability than the manic grandiosity.
Unverferth:
Yes, right. More, almost more of this mixed presentation.
Puder:
Right. So how do you see the irritability? Like, any stories jump to your mind in that postpartum psychosis with the irritability?
Unverferth:
Yes. With the irritability, I've often seen it. I think irritability by itself is not always the best differentiator. I do think it's less common to see the euphoric grandiosity. Most of the time, people I've seen with postpartum psychosis seem sort of haunted, like, more scared, anxious, can't sleep, overwhelmed, loss of touch with reality, sometimes this loss of orientation. The irritability, I think, can sometimes be a driver for them not to seek treatment, like, "I don't need treatment. I'm fine. Leave me alone." Right? Or we can see it with the partner. I often see that there are. Delusions related to the partner either cheating on them, or taping them, or out to get them. And so I've sometimes also seen violence toward the partner as part of a postpartum psychosis diathesis.
Unverferth:
And so sometimes I'll see irritability in that way, but I think it is more helpful as a differentiator from a grandiosity than a symptom to look for in and of itself, because I wouldn't view irritability necessarily alone as a symptom of postpartum psychosis because then we get into this continuum of what about postpartum rage, right? Which we know is something a lot of women feel in the postpartum, can have a lot of different diagnostic underpinnings.
Postpartum Psychosis Insomnia vs Normal New-Parent Sleep Loss (23:45)
Puder:
So what about the sleep? Because it seems that a lot of women postpartum are having issues with sleep. So how do you differentiate postpartum psychosis from not sleeping versus normal postpartum, “I can't sleep”?
Unverferth:
Yes. Postpartum psychosis and not sleeping is the classic way that it happens. Someone doesn't sleep during delivery. Right? So they have a really long labor. Sometimes labor can be days, and then they don't sleep moving forward. So with postpartum psychosis, someone isn't sleeping, but they might not identify as tired. It would also be associated with these increased, perhaps, goal-directed activities, this like agitation, which maybe is more what we're looking for. Maybe agitation would be a better word for irritability in my clinical experience. Like, restless, agitated, but irritable, I guess, is sort of non-specific to me.
Puder:
I appreciate that. I agree with you. Irritable's too common.
Unverferth:
“I'm irritable.” Right? I guess perhaps that was why I was like, I don't know what to do with “irritable." “Agitated,” I would say agitation is more common with what I see. So perhaps pacing, overwhelmed, not sleeping. The insomnia that we see with postpartum psychosis is different in that, again, it's not associated with just simple feelings of overwhelm. It's associated with this kind of triad of symptoms that we often associate with postpartum psychosis, which is worsening insomnia, worsening agitation, which leads to this sort of loss of touch with reality. Right? These psychotic symptoms, which can be more prominent visual hallucinations, which is what we see with postpartum psychosis. So I think, again, it's the constellation of symptoms that really matters rather than, I don't think we could be like, "Well, you know, it could be that someone with postpartum psychosis has more severe insomnia.”
[Evidence Note: A clinical review summarizing a 130-case latent-class cohort reported that 25% were disorganized, 20% disoriented, 10% had disturbed consciousness, and only a minority had frank hallucinations; the delirium-like constellation, not visual hallucinations alone, is the more characteristic signal (Osborne, 2018).]
Unverferth:
Maybe they're only sleeping one or two hours, where someone with anxiety might be sleeping four or five. But I don't think that there's literature to really separate that out. It's more that, what else is happening? Is there a change in behavior from baseline? What does that change in behavior from baseline look like? Is there disorganized behaviors? Is there confused behavior in addition to the insomnia? But I do think that people hear that the prodrome of postpartum psychosis is like worsening insomnia, agitation, irritability maybe. And they're like, "Well, is that me? What does that mean?" But with a lot of the postpartum psychosis, that kind of classic postpartum psychosis, there's obviously a pretty distinct change in behavior with these confusional episodes, the psychotic episodes, the delusions, with this agitated, mixed manic state. Right?
[Evidence Note: In a prospective cohort of 51 women whose psychosis was limited to the postpartum period, median initial-symptom onset was postpartum day 8 and 37 (72.5%) had a prodrome; among the 33 whose prodrome began postpartum, its median duration was five days, supporting serial assessment rather than a single sleep cutoff (Bergink et al., 2011).]
Puder:
Okay. And then what are they doing when they're not sleeping? Maybe that's the important question, right? It's like usually when you ask these patients you've interviewed, what are they doing when they're not sleeping? Are they trying, are they just laying peacefully in bed trying to sleep? Are they frustrated they can't sleep or what?
Unverferth:
Yes. More agitated, right? So again, this pacing, this overwhelm. Most of the time they're not coming to me seeking help. Most of the time the partner is bringing them in, right? A lot of times with postpartum psychosis, there's also like, there can be a lack of insight, right? So the partner is bringing them to the ER. The partner is calling around saying, "Something is wrong with this new mom. She thinks people are out to get her. She's hearing voices. She's seeing things that aren't there. She seems confused. She thinks…." You know, that is what's driving someone to get care. It's rare that I have someone who's, I don't think I've ever had someone reach out to me and be like, "I think I have postpartum psychosis." It's almost always a partner, psychiatrist, therapist who's like,
Unverferth:
“This is a distinct change in behavior. I'm really worried about them.” And so I think it can be a lot of different things. I would say, I guess the image in my mind is pacing. Just unsettled, overwhelmed, anxious, not sleeping. I guess it's hard to paint a… it can be kind of different for everybody. But no, I don't think they're resting peacefully in bed typically.
Puder:
Yes. They're Googling you and asking you if you are listening to this podcast, that may be a good sign.
Unverferth:
Right. Right. That's good.
Confusion, Disorganization, and Delirium-Like States in Postpartum Psychosis (28:07)
Puder:
That's your anxiety driving curiosity. Okay. What about disorganization? Like the confusion, the disorganization, almost like a hypoactive delirium, coming in and out of different states. Describe that to me.
Unverferth:
Yes. Well, so they will be confused about where they are, what's going on. Sometimes they don't know where their baby is. They're worried about their baby's safety, right? It doesn't seem… they're not there with you in the room. They can start doing something and then sort of lose their train of thought in a very severe way, different from how every new mom loses their train of thought, right? It's this confusion, this profound confusion where people are sort of watching them and their behavior seems not typical, or disorganized, right? So, one example that I've seen is, a patient who was on the unit was having a visitation with her baby and was holding her baby and was going, "Where's my baby? Is my baby okay? Those people on the TV are coming after me and they're going to get my baby." But she was holding her baby.
Unverferth:
So really this profound kind of sense of they're not in reality, right? Another one of my patients was in the ER. Her husband had brought her to the hospital because her husband was worried about this change in behavior. And she didn't know why she was there or what was happening, was confused, and then also thought that everybody was experimenting on her in the hospital. They were coming to get her. She was hospitalized for postpartum psychosis. So, it is this more like disorientation as well as this disorganization, like not doing things in the correct way, not making sense. There can be kind of this like difficulty communicating what's happening, difficulty explaining why they're doing something can be part of it.
Puder:
Yes. One of the things I've been looking at lately is the research on memory in a manic episode. And how poorly people remember things afterwards. They may not remember a big chunk of time even because in that sort of delirious state, or delirium's the same thing, right? Like if someone's delirious, in the hospital, post-surgery, they're seeing like gremlins on the wall. They may be completely unable to remember that two weeks later, but the family does remember. The family's like, "No, this was really hard."
Unverferth:
Right.
Puder:
And they're like, "No, I don't think it was that bad. I don't want to take my meds anymore."
Unverferth:
Yes. Right. We can see that the partners, obviously, this is incredibly traumatic for the woman and I'm not diminishing that at all, but we can also see that it's very scary for the partners, right? The partner can feel like they sort of have, the non-birthing parent can feel like they've lost their partner, right? And it can make it, I've seen it be very difficult if people do choose to have more children, for that partner to sort of get over the fear and understand that there are things we can do to prevent postpartum psychosis too.
How to Prevent Postpartum Psychosis in High-Risk Patients (31:03)
Puder:
Okay. Maybe you could mention that. What do we do to prevent postpartum psychosis?
Unverferth:
Yes, it's a great question. So postpartum psychosis is fairly preventable. We have some studies that really show that lithium is one of the best medications we have to prevent postpartum psychosis. So this is a conversation I'll have with women. Sometimes I see people in the third trimester, they perhaps have a history of bipolar type one, they're not on medications. That happens not uncommonly, right? Someone's like, "I'm pregnant. I don't want to be on my medications. I'm not going to be on my medications." They sort of show up to psychiatric care in the third trimester. So in that patient, what I'm talking about is the increased risk of postpartum psychosis. I'm educating on postpartum psychosis signs and symptoms. I'm bringing in a partner, if they're partnered, if not, their closest family member or friend to educate them on the signs and symptoms. I love the action on postpartum psychosis handouts.
[Evidence Note: Prevention evidence is strongest in identified high-risk groups, not the general postpartum population. A 37-study meta-analysis estimated overall postpartum relapse at 35%; among women with bipolar disorder, relapse was 66% without medication during pregnancy versus 23% with prophylaxis, a nonrandomized pooled comparison rather than a causal treatment estimate (Wesseloo et al., 2016).]
Unverferth:
They have handouts both for the patient, preventing or learning about postpartum psychosis, but also for friends and family members, which I think is so helpful to sort of have it from these two different perspectives. So I send those. And then in that patient, I'm strongly recommending lithium. I think there are two ways of doing it. So you can either start lithium in the third trimester, so sort of before they deliver, try to get it to a therapeutic dose, or you start it immediately postpartum, meaning the night after they deliver, because it's interesting how many logistics are around it when you're like, "Yeah, I'm going to start lithium in the postpartum." But you're like, "When? And at what dose, and how?" And so the night they deliver, they take sort of the dose you would expect to be therapeutic.
Unverferth:
It's great if you have data points, right? So if you have data points that maybe on lithium 900, their level was 0.8, that's ideal. We would start 900 milligrams of lithium the night they deliver, with a goal level of 0.8 to 1.0. And I think that's important because you really want it in this anti-manic range. You don't want it in this maintenance range, because if we're going to use lithium, we want it to work, and the best data is keeping it within that range for patients who have a history of postpartum psychosis. So this is a subsequent pregnancy after they've had postpartum psychosis, we know they're at a very high rate of relapse, with or without bipolar disorder diagnosis. You would either start lithium the immediate postpartum or you could use what worked before. So if someone did really well on antipsychotic monotherapy, you could theoretically start antipsychotic monotherapy.
[Evidence Note: In a nonrandomized high-risk program, none of 20 women whose prior psychosis was limited to the postpartum period relapsed when prophylaxis began within 24 hours after delivery, versus 4 of 9 who declined it; the small self-selected comparison does not establish a randomized treatment effect (Bergink et al., 2012).]
Unverferth:
It's just that the best data for relapse prevention and for prophylaxis is with lithium. Interestingly, in one study, it showed that Depakote was ineffective. I've seen some sort of creative psychiatrist being like, "Well, Depakote has low levels in breast milk, so what if I use Depakote?" But there's not very good evidence for Depakote, and we don't recommend that as, you know, treatment or prophylaxis of postpartum psychosis.
Acute Treatment of Postpartum Psychosis (34:00)
Puder:
Yeah. Great. So we talked about prophylaxis, if they're high risk. And if, if they come in and they are [experiencing] postpartum psychosis, what's the next day look like for you in treating them?
Unverferth:
Are they on medications or not on medications?
Puder:
Not on medications.
Unverferth:
Not on medications and have postpartum psychosis. So for me, I am getting them to the hospital as soon as possible. I both want them to go to have a medical evaluation because I want to make sure that there's no other neurological or immunological condition that's causing these symptoms. And also for safety and containment, right? So, it's an inpatient psychiatric hospitalization. If you have a mother-baby unit, that's incredible. I think that's much better.
[Evidence Note: In a consecutive cohort of 96 patients, four sera showed neuronal-surface reactivity and two were anti-NMDA-receptor-antibody positive; cerebrospinal fluid was not obtained. Neurologic signs or marked extrapyramidal symptoms after low-dose haloperidol should heighten suspicion, but this small serum-screening study does not imply that most postpartum psychosis is autoimmune (Bergink et al., 2015a).]
Puder:
Where are those?
Unverferth:
There's one in California. There's one in Northern California. I think there are a few scattered across the country. We obviously need more, right? That's a much more therapeutic healing environment than being separated from your baby in a psychotic state, right?
[Evidence Note: Expert consensus identifies joint mother–infant admission or a specialty perinatal psychiatric unit as the ideal treatment setting when available, while noting that such units are not widely available worldwide (Bergink et al., 2026).]
Puder:
Yes. It's interesting because there's such a dearth of good inpatient experiences in my current location. I get nervous. But okay, so you send them to the hospital, get a good workup.
Unverferth:
Yes. Get a good workup. Usually we're starting at least lithium, plus or minus an antipsychotic. And you would use an antipsychotic, if there's agitation, really prominent psychotic symptoms. Usually you would do the combination. Plus or minus a benzodiazepine if they need help with sleeping. Once they are close to their baseline or close enough to their baseline, they're discharged from the hospital, usually I'm stepping them down to a PHP or an IOP for additional monitoring and support. I would say roughly after a few months, so I would say three-ish months is usually when I'm trying to taper the antipsychotic, if they were on the antipsychotic plus the lithium. I really want them to have no psychotic episodes for at least a few weeks, maybe a month or two before we would really cautiously taper the antipsychotic.
[Evidence Note: In a prospective, nonrandomized cohort of 64 women treated with a response-contingent algorithm—benzodiazepine/sleep restoration, then antipsychotic, then lithium—63 (98.4%) remitted within the first three steps and 51 (79.7%) had sustained remission at nine months; the naturalistic step assignment prevents isolating any drug's causal effect (Bergink et al., 2015b).]
Unverferth:
And then you continue lithium out for around a year. People will say different timelines, but around a year. If this person does not have a history of bipolar disorder, like you have done the most thorough H&P of your life and there's no evidence of bipolar disorder, at that point, you can really cautiously taper the lithium. This is another one of those times where you really have to bring in the partner, you really have to do psychoeducation. Right? There's a lot of sitting down and being like, "Okay, looking back, what were the first signs for you? What was the very first thing?" And sometimes it is this irritability. Right? Is it this irritability? Was that the first thing? What did that look like? How was it a different flavor than your run-of-the-mill irritability?
[Evidence Note: In the same cohort protocol, women who achieved remission on antipsychotic plus lithium were advised to taper the antipsychotic gradually and continue lithium through nine months postpartum; clinically stable participants were then assisted in tapering medication. This supports a general maintenance timeframe, not a universal schedule or randomized comparison (Bergink et al., 2015b).]
Unverferth:
Was it sleeping less? We had one patient recently where it was these perceptual kinds of changes where it was like the leaves look a little bit different, or the paintings look a little bit different, and that was her first sign. And so you want everybody to be on the same page about this, and then you slowly and cautiously taper the lithium. And then I think this can be the hardest part for people, because we know it's about fifty-fifty between, who ends up having a bipolar spectrum illness and who really will only have postpartum psychotic episodes in the postpartum period. It's a bit of a waiting game to see how someone does. Right? And I think that can be so hard for people where they're like, "Well, what is my diagnosis?" And we're like, "Well, right now, we know you have postpartum psychosis, but only time is really going to tell if this is a bipolar illness or if you are one of those people who's just only going to have episodes in the postpartum."
[Evidence Note: A six-study meta-analysis of 645 women followed for 11–26 years estimated that 43.5% had no severe episode outside the postpartum period, while 56.5% had at least one non-postpartum recurrence; heterogeneity and older Western European cohorts limit individual prediction (Gilden et al., 2020).]
Puder:
I see a lot of bipolar in my clinic. I get a lot of patients who have tried everything but lithium.
Unverferth:
Oh, interesting.
Puder:
And they will have had true bipolar, true manic episodes, psychiatric hospitalizations, sometimes even life-threatening suicide attempts. And the only thing that they tried is antipsychotics, Depakote, Lamotrigine, everything but lithium.
Unverferth:
Interesting. You think it's the lab testing? What do you think it is?
Puder:
I think providers are still nervous about doing lithium. I think that there's no drug reps pushing lithium.
Unverferth:
Yes, I guess that's true.
Puder:
And, I don't know, maybe if you went to a residency that wasn't doing a lot of lithium, maybe you didn't get used to it. So any more thoughts on lithium?
Unverferth:
Yes. I feel in reproductive psychiatry, it's really pounded into your head that lithium is the gold standard of care for bipolar disorder. It's still the gold standard of treatment for bipolar disorder in pregnancy, even with the small increased risk of cardiac malformations. And then with postpartum psychosis, it's kind of the same thing where it's like lithium is the best evidence for both acute treatment and then prevention. And so I feel reproductive psychiatrists use lithium all time. But I guess that makes sense.
Lithium in Pregnancy, Delivery, and Breastfeeding (39:20)
Puder:
What do you say to someone who comes to you in the first trimester, or maybe before they get pregnant, they're like, "I'm on lithium, I'm stable, bipolar. I'm afraid of the side effects during pregnancy." What’s the conversation look like for you?
Unverferth:
Yeah, that's a great question. I think, you know, when you're seeing someone for the first time, you really want to get a sense of their history, right? So, you know, what were their manic episodes? If we're assuming bipolar type one, like, what were their manic episodes like? Were there psychotic features? How severe was it? Were they, have they been hospitalized multiple times, only a few times? What's their course been like since they're on lithium? Because you want to, you still want to find the medication that works the best for them, right? We can't just assume that it's the medication they're on. So if they say, "Lithium has been amazing for me. I've been totally stable for the last few years since I've been on it. I had a really rocky course before." Then, in my mind, I'm thinking, "Okay, we probably need to keep the lithium on board with this patient." Then we're really talking through what we know about lithium in pregnancy and postpartum, and I think in med school all of us were taught lithium and Epstein's anomaly, you have to be really cautious, right?
Unverferth:
What we know is that the absolute increased risk of cardiac malformations is present, but is smaller than was previously thought. So it's about one in 100 increased risk of cardiac malformations with lithium. That risk does seem to go up with higher doses. So if someone is on 1200 milligrams, there's a higher risk than someone who's at 600 milligrams. So I'm also, when that person is coming to me, I'm curious what dose they're on. You know, if someone's on 600 milligrams and rocking and rolling, some studies show that there's really not a statistically significant increased risk of cardiac malformations at that dose. If they're on higher doses, it doesn't mean that we need to stop it. It just is, there's just psychoeducation. What we recommend is, we recommend they be seen by an OB regularly for routine screening.
Unverferth:
We will sometimes recommend that they have a fetal echocardiogram when they're on lithium in pregnancy. However, I think also when they're seen by an OB, when they get the anatomy scan, if there's anything that's abnormal, they will be referred for a fetal echocardiogram, so I don't necessarily make that recommendation across the board. When lithium is taken in pregnancy, we know that lithium levels change throughout the pregnancy, and so you can check levels regularly and dose adjust, especially if someone has more brittle bipolar disorder, you would want to check levels really regularly. Other institutions will sort of recommend dosing the lithium clinically, meaning if someone starts to have breakthrough symptoms, you can adjust the dose but you don't need to adjust it just based on one lithium level. You continue the lithium through delivery and into the postpartum.
Unverferth:
So there used to be this idea that you might hold the lithium for a few days before delivery. We don't recommend that because you'd sort of be withdrawing this mood stabilizer right at the time we know they're vulnerable for postpartum psychosis. I think something that people sometimes forget, and is important to counsel on, is the interaction of lithium with NSAIDs. So like ibuprofen, we know it is really commonly given for pain control after delivery. And so if someone is on lithium, you need to educate them, but also make sure that they're reminding their OB about that interaction. We also know that sometimes if someone has some kind of renal impairment, maybe as part of preeclampsia, that their lithium level could get toxic. And so it's really important, again, to just make sure that you're on board communicating with this patient who's communicating with their OB and remembering all of these medical interactions or these medical conditions that can really change lithium levels.
Unverferth:
But for the most part, I feel very comfortable using lithium in pregnancy. I think when you use it in pregnancy, you can use it with breastfeeding. The majority of my patients who have bipolar type one, who are on lithium during pregnancy, I think we can kind of think about it as a marker for symptom severity and for illness severity. The majority of those patients with me are not exclusively breastfeeding. A lot of my patients in that situation are either combo feeding or choosing not to breastfeed, really from a sleep protection standpoint. We know that when someone's exclusively breastfeeding, you know, it really requires pretty extreme sleep deprivation, right? You have to be up, usually every two hours overnight for weeks, if not longer. And for someone with a bipolar disorder, that's really not feasible. It's kind of a counseling idea.
[Evidence Note: In a retrospective cohort of 30 carefully selected, closely monitored breastfeeding dyads, no severe infant adverse event was identified, but two infants had unexpectedly high lithium concentrations and about 25% had inadequate early weight gain, although there was no nonbreastfed comparison group; the findings apply mainly to healthy full-term infants under strict monitoring (Heinonen et al., 2022).]
Puder:
Nice. So what if said person, who's struggling, that maybe you got stable, is going back to work and they have to work night shifts.
Unverferth:
Yes. That's a great question. I would probably write them for a medical accommodation that says that they cannot work night shifts. I would really not recommend it. I've written medical accommodation letters. Even for patients with just major depression, I see a lot of people who have worsening of their mental health conditions with night shift because of the circadian rhythm disruption. So I would strongly recommend against that. If there's no option, I would say proceed very cautiously and I might add something onto the lithium, like a second mood stabilizer to really help give them a little bit of extra stability. Mostly, I would just not recommend it.
Puder:
Yes. I wouldn't recommend it.
Clinical Takeaways for Postpartum OCD and Postpartum Psychosis (44:40)
Puder:
Any, any final thoughts? As we kind of wrap up our time together, any things that are still in your mind, like, you want every clinician to know? Or maybe just summarize the big takeaways you would want them to walk away with?
Unverferth:
Yes. The big takeaways. So I think postpartum psychosis is infinitely treatable. The truth is, most people recover, and recover usually within weeks to months. I think that treatment with lithium plus or minus an antipsychotic, plus or minus a benzo is very effective. We know that in studies, the majority of people have remission of their symptoms on that combination. I think, “Don't be afraid of lithium,” I think is a really important thing to highlight here. And then, I think it's just really important, you have to bring in the partner if you are concerned about postpartum psychosis, if you're worried about postpartum psychosis, because we know that there can be insight, lack of insight and confusion with this disorder. And so you have to ask the partner how they're doing, are there any changes in behavior?
[Evidence Note: At about nine months in a prospective cohort of 78 women, 74.4% had good overall functioning and 88.5% had resumed prior work or household roles, but 16.7% relapsed—usually with depression—and relapse was linked to substantial functional impairment (Burgerhout et al., 2017).]
Unverferth:
Are you noticing any disorganization? I had a patient one time who really had a delusion that her partner was cheating on her and she would become aggressive and violent with him. But when I would interview her, I'd be like, "Have you had any thoughts, any changes in behavior, any thoughts of thinking that your partner was cheating on you?" She'd be like, "Absolutely not." And then I would call her partner and be like, "Yes, on Monday she ran out of the house because she thought that she had seen me." You know, and so I think really keeping them extremely involved in the care is so important.
Puder:
So important.
Unverferth:
With perinatal OCD, and intrusive thoughts, I think you can change lives by psychoeducation on what intrusive thoughts are, by letting people know that it's almost a universal experience of the postpartum to have intrusive thoughts. Of course, you have to evaluate for risk factors that might suggest it's not just an intrusive thought, like psychotic symptoms, but for the majority of patients, really educating and normalizing that experience.
Puder:
Great. Well, this was a great pleasure in connecting with you and learning from you, and I'm sure everyone's grateful at this point hearing this.
Unverferth:
Thanks so much for having me.
Puder:
So if you want Katherine Unverferth to come back, Dr. Unverferth, you will let me know. And she's also on Instagram. She's active there. I would go check her out. She has very nice short videos. Very concise. I'll put your website on my podcast.
Unverferth:
Yes. Good. You can find me at UCLA or in my private practice.
Puder:
Great. All right. Thanks. We'll leave it there for today.
Unverferth:
Thanks.
Additional Pregnancy and Postpartum Episodes
Episode 013: Postpartum Depression with Dr. Pereau
Episode 033: Perinatal Mood and Anxiety Disorders
Episode 184: Pregnancy Planning for Patients Taking Psychiatric Medications or with a Mental Health History
Episode 276: Postpartum Psychosis: Symptoms, Warning Signs, Risk Assessment, and Treatment with Dr. Furey and Dr. Puder
References
Abramowitz, J. S., Hellberg, S. N., Krasnow, J., Friedman, J. B., Myers, N. S., Nestadt, P. S., Ojalehto, H. J., Juel, E. K., Samuels, J., Kimmel, M. E., Osborne, L. M., Storch, E. A., Nestadt, G., & Musci, R. J. (2025). Prenatal obsessive beliefs predict postpartum obsessive-compulsive symptoms: A prospective study. Psychiatry Research, 351, 116620. https://doi.org/10.1016/j.psychres.2025.116620
American College of Obstetricians and Gynecologists. (2023). Screening and diagnosis of mental health conditions during pregnancy and postpartum. Obstetrics & Gynecology, 141(6), 1232–1261. https://doi.org/10.1097/AOG.0000000000005200
Beck, C. T. (2022). Narrating perinatal obsessive-compulsive disorder through blogs. MCN: The American Journal of Maternal/Child Nursing, 47(5), 273–280. https://doi.org/10.1097/NMC.0000000000000842
Bergink, V., Lambregtse-van den Berg, M. P., Koorengevel, K. M., Kupka, R. W., & Kushner, S. A. (2011). First-onset psychosis occurring in the postpartum period: A prospective cohort study. The Journal of Clinical Psychiatry, 72(11), 1531–1537. https://doi.org/10.4088/JCP.10m06648
Bergink, V., Bouvy, P. F., Vervoort, J. S. P., Koorengevel, K. M., Steegers, E. A. P., & Kushner, S. A. (2012). Prevention of postpartum psychosis and mania in women at high risk. The American Journal of Psychiatry, 169(6), 609–615. https://doi.org/10.1176/appi.ajp.2012.11071047
Bergink, V., Armangue, T., Titulaer, M. J., Markx, S., Dalmau, J., & Kushner, S. A. (2015a). Autoimmune encephalitis in postpartum psychosis. The American Journal of Psychiatry, 172(9), 901–908. https://doi.org/10.1176/appi.ajp.2015.14101332
Bergink, V., Burgerhout, K. M., Koorengevel, K. M., Kamperman, A. M., Hoogendijk, W. J., Lambregtse-van den Berg, M. P., & Kushner, S. A. (2015b). 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., 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., … Payne, J. L. (2026). Postpartum psychosis and bipolar disorder: Review of neurobiology and expert consensus statement on classification. Biological Psychiatry, 99(9), 740–747. https://doi.org/10.1016/j.biopsych.2025.10.016
Blum, S., Mack, J. T., Weise, V., Kopp, M., Asselmann, E., Martini, J., & Garthus-Niegel, S. (2022). The impact of postpartum obsessive-compulsive symptoms on child development and the mediating role of the parent-child relationship: A prospective longitudinal study. Frontiers in Psychiatry, 13, 886347. https://doi.org/10.3389/fpsyt.2022.886347
Burgerhout, K. M., Kamperman, A. M., Roza, S. J., Lambregtse-van den Berg, M. P., Koorengevel, K. M., Hoogendijk, W. J., Kushner, S. A., & Bergink, V. (2017). Functional recovery after postpartum psychosis: A prospective longitudinal study. The Journal of Clinical Psychiatry, 78(1), 122–128. https://doi.org/10.4088/JCP.15m10204
Challacombe, F. L., Salkovskis, P. M., Woolgar, M., Wilkinson, E. L., Read, J., & Acheson, R. (2016). Parenting and mother-infant interactions in the context of maternal postpartum obsessive-compulsive disorder: Effects of obsessional symptoms and mood. Infant Behavior and Development, 44, 11–20. https://doi.org/10.1016/j.infbeh.2016.04.003
Challacombe, F. L., Salkovskis, P. M., Woolgar, M., Wilkinson, E. L., Read, J., & Acheson, R. (2017). A pilot randomized controlled trial of time-intensive cognitive-behaviour therapy for postpartum obsessive-compulsive disorder: Effects on maternal symptoms, mother-infant interactions and attachment. Psychological Medicine, 47(8), 1478–1488. https://doi.org/10.1017/S0033291716003573
Chandra, P. S., Venkatasubramanian, G., & Thomas, T. (2002). Infanticidal ideas and infanticidal behavior in Indian women with severe postpartum psychiatric disorders. The Journal of Nervous and Mental Disease, 190(7), 457–461. https://doi.org/10.1097/00005053-200207000-00006
Fairbrother, N., Albert, A., Keeney, C., Tchir, D., & Cameron, R. B. (2023). Screening for perinatal OCD: A comparison of the DOCS and the EPDS. Assessment, 30(4), 1028–1039. https://doi.org/10.1177/10731911211063223
Fairbrother, N., Beck, Q. M., & Keeney, C. L. (2024). Perinatal timing of obsessive-compulsive disorder onset. The Journal of Clinical Psychiatry, 85(3), 24m15266. https://doi.org/10.4088/JCP.24m15266
Friedman, S. H., Sorrentino, R. M., Stankowski, J. E., Holden, C. E., & Resnick, P. J. (2008). Psychiatrists' knowledge about maternal filicidal thoughts. Comprehensive Psychiatry, 49(1), 106–110. https://doi.org/10.1016/j.comppsych.2007.07.001
Gilden, J., Kamperman, A. M., Munk-Olsen, T., Hoogendijk, W. J. G., Kushner, S. A., & Bergink, V. (2020). Long-term outcomes of postpartum psychosis: A systematic review and meta-analysis. The Journal of Clinical Psychiatry, 81(2), 19r12906. https://doi.org/10.4088/JCP.19r12906
Heinonen, E., Tötterman, K., Bäck, K., Sarman, I., Svedenkrans, J., & Forsberg, L. (2022). Lithium use during breastfeeding was safe in healthy full-term infants under strict monitoring. Acta Paediatrica, 111(10), 1891–1898. https://doi.org/10.1111/apa.16444
Hudepohl, N., MacLean, J. V., & Osborne, L. M. (2022). Perinatal obsessive-compulsive disorder: Epidemiology, phenomenology, etiology, and treatment. Current Psychiatry Reports, 24(4), 229–237. https://doi.org/10.1007/s11920-022-01333-4
Mulcahy, M., Long, C., Morrow, T., Galbally, M., Rees, C., & Anderson, R. (2023). Consensus recommendations for the assessment and treatment of perinatal obsessive-compulsive disorder (OCD): A Delphi study. Archives of Women's Mental Health, 26(3), 389–399. https://doi.org/10.1007/s00737-023-01315-2
Osborne, L. M. (2018). Recognizing and managing postpartum psychosis: A clinical guide for obstetric providers. Obstetrics and Gynecology Clinics of North America, 45(3), 455–468. https://doi.org/10.1016/j.ogc.2018.04.005
Vliegen, N., Casalin, S., & Luyten, P. (2014). The course of postpartum depression: A review of longitudinal studies. Harvard Review of Psychiatry, 22(1), 1–22. https://doi.org/10.1097/HRP.0000000000000013
Wesseloo, R., Kamperman, A. M., Munk-Olsen, T., Pop, V. J. M., Kushner, S. A., & Bergink, V. (2016). Risk of postpartum relapse in bipolar disorder and postpartum psychosis: A systematic review and meta-analysis. The American Journal of Psychiatry, 173(2), 117–127. https://doi.org/10.1176/appi.ajp.2015.15010124
Wisner, K. L., Sit, D. K. Y., McShea, M. C., Rizzo, D. M., Zoretich, R. A., Hughes, C. L., Eng, H. F., Luther, J. F., Wisniewski, S. R., Costantino, M. L., Confer, A. L., Moses-Kolko, E. L., Famy, C. S., & Hanusa, B. H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry, 70(5), 490–498. https://doi.org/10.1001/jamapsychiatry.2013.87