Experts present scientific evidence to support classification of postpartum psychosis as a distinct disease

An international panel of leading experts on women’s mental health is recommending that postpartum psychosis be recognized as a distinct category of mental illness and classified accordingly within standardized medical coding systems.

The recommendation, known as a “consensus statement,” and a comprehensive review of the scientific literature on postpartum psychosis appear in Biological Psychiatry.

Postpartum psychosis is an acute and severe psychiatric illness that sets in within weeks after delivery. Most women with postpartum psychosis experience severe mood symptoms, including mania, mixed episodes, or depression with psychotic features. Impaired cognition, irritability, and agitation are also common.

The condition is considered a psychiatric emergency and, in most cases, requires hospitalization of the mother. If left untreated, postpartum psychosis is associated with high risks of suicide and infanticide. However, if it is detected and treated in time, patients respond well to treatment and most women return to their previous functioning.

Despite being one of the most distinct clinical phenotypes in psychiatry, postpartum psychosis is not recognized in the Diagnostic and Statistical Manual (DSM-5) or the International Classification of Disease (ICD), which are used to code diseases and medical conditions for treatment and billing purposes.

“The postpartum time period is characterized by profound endocrine, immune, neuroanatomical, and physiological changes in the brain that strongly suggest a biological basis for the illness. Genetic studies have shown a unique risk architecture that’s partly shared with, but distinct from, bipolar disorder. And epidemiologic studies show an enormous peak in incidence and prevalence of the condition,” says Veerle Bergink, MD, PhD, Director of the Women’s Mental Health Center at Mount Sinai and first author of the paper.

“The scientific evidence we present in our consensus statement justifies our recommendation that postpartum psychosis be classified as a distinct mental illness. The lack of accurate diagnosis and subsequent misinformed treatment has contributed to increased morbidity and mortality.

“Only by proper classification of the illness will we be able to improve patient outcomes. The time is now to make the change so we can help these women and save lives.”

The panel, in close collaboration with patient advocacy organizations and key interested partners, recommended classifying postpartum psychosis as a distinct category within the bipolar disorders chapter of the DSM and ICD because:

• The majority of women with postpartum psychosis present with affective symptoms—mania, a mixed episode of mania/depression, or psychotic depression
• Treatment response to lithium and electroconvulsive therapy, also standard treatments for bipolar disorder, is excellent for patients with postpartum psychosis
• Follow-up studies indicate that women who experience a first postpartum psychosis episode have a 50% risk of developing a bipolar disorder, but not schizophrenia
• Pregnant women with bipolar disorder face an exceptionally high risk of postpartum psychosis
• The genetic risk architecture for postpartum psychosis is distinct but overlapping with bipolar disorder

Due to the risks to the patient and the infant, the rapid escalation of severity, and its severe and sudden course, it is imperative that postpartum psychosis is recognized, diagnosed, and treated as early as possible. To facilitate such care, the panel recommends DSM-5 and ICD-10 include the following criteria for a diagnosis of postpartum psychosis:

• The onset of at least one of the following states within 12 weeks of childbirth, lasting at least one week and present most of the day, nearly every day, or any duration if hospitalization is necessary:
  • Mania/mixed state
  • Delusions
  • Hallucinations
  • Disorganized speech or formal thought disorder
  • Disorganized, confusional, or catatonic behavior
  • Depression with psychotic features

• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the postpartum period.
• The disturbance in mood and the change in functioning are observable by others.
• The episode is sufficiently severe enough to cause marked impairment in social functioning and in the care of the baby or to necessitate hospitalization to prevent harm to the patient, baby, or others.

A distinct category within the DSM is warranted because postpartum psychosis does not fit into the currently available categories of mental illness, and the available specifier “with peripartum onset” inaccurately describes the timing of onset of the illness.

The panel recommends that postpartum psychosis can be diagnosed in addition to other mental illness or as first-onset for patients without psychiatric history.

“We have been working with the American Psychiatric Association and the DSM steering committee since 2020 to find a solution that will facilitate diagnostic accuracy and the provision of timely and evidence-based treatment to improve the quality of treatment and outcomes for women with postpartum psychosis and to prevent the tragic outcomes of suicide and infanticide. We are committed to continue this work,” concludes Dr. Bergink.

An international panel of leading experts on women’s mental health is recommending that postpartum psychosis be recognized as a distinct category of mental illness and classified accordingly within standardized medical coding systems.

The recommendation, known as a “consensus statement,” and a comprehensive review of the scientific literature on postpartum psychosis appear in Biological Psychiatry.

Postpartum psychosis is an acute and severe psychiatric illness that sets in within weeks after delivery. Most women with postpartum psychosis experience severe mood symptoms, including mania, mixed episodes, or depression with psychotic features. Impaired cognition, irritability, and agitation are also common.

The condition is considered a psychiatric emergency and, in most cases, requires hospitalization of the mother. If left untreated, postpartum psychosis is associated with high risks of suicide and infanticide. However, if it is detected and treated in time, patients respond well to treatment and most women return to their previous functioning.

Despite being one of the most distinct clinical phenotypes in psychiatry, postpartum psychosis is not recognized in the Diagnostic and Statistical Manual (DSM-5) or the International Classification of Disease (ICD), which are used to code diseases and medical conditions for treatment and billing purposes.

“The postpartum time period is characterized by profound endocrine, immune, neuroanatomical, and physiological changes in the brain that strongly suggest a biological basis for the illness. Genetic studies have shown a unique risk architecture that’s partly shared with, but distinct from, bipolar disorder. And epidemiologic studies show an enormous peak in incidence and prevalence of the condition,” says Veerle Bergink, MD, PhD, Director of the Women’s Mental Health Center at Mount Sinai and first author of the paper.

“The scientific evidence we present in our consensus statement justifies our recommendation that postpartum psychosis be classified as a distinct mental illness. The lack of accurate diagnosis and subsequent misinformed treatment has contributed to increased morbidity and mortality.

“Only by proper classification of the illness will we be able to improve patient outcomes. The time is now to make the change so we can help these women and save lives.”

The panel, in close collaboration with patient advocacy organizations and key interested partners, recommended classifying postpartum psychosis as a distinct category within the bipolar disorders chapter of the DSM and ICD because:

• The majority of women with postpartum psychosis present with affective symptoms—mania, a mixed episode of mania/depression, or psychotic depression
• Treatment response to lithium and electroconvulsive therapy, also standard treatments for bipolar disorder, is excellent for patients with postpartum psychosis
• Follow-up studies indicate that women who experience a first postpartum psychosis episode have a 50% risk of developing a bipolar disorder, but not schizophrenia
• Pregnant women with bipolar disorder face an exceptionally high risk of postpartum psychosis
• The genetic risk architecture for postpartum psychosis is distinct but overlapping with bipolar disorder

Due to the risks to the patient and the infant, the rapid escalation of severity, and its severe and sudden course, it is imperative that postpartum psychosis is recognized, diagnosed, and treated as early as possible. To facilitate such care, the panel recommends DSM-5 and ICD-10 include the following criteria for a diagnosis of postpartum psychosis:

• The onset of at least one of the following states within 12 weeks of childbirth, lasting at least one week and present most of the day, nearly every day, or any duration if hospitalization is necessary:
  • Mania/mixed state
  • Delusions
  • Hallucinations
  • Disorganized speech or formal thought disorder
  • Disorganized, confusional, or catatonic behavior
  • Depression with psychotic features

• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the postpartum period.
• The disturbance in mood and the change in functioning are observable by others.
• The episode is sufficiently severe enough to cause marked impairment in social functioning and in the care of the baby or to necessitate hospitalization to prevent harm to the patient, baby, or others.

A distinct category within the DSM is warranted because postpartum psychosis does not fit into the currently available categories of mental illness, and the available specifier “with peripartum onset” inaccurately describes the timing of onset of the illness.

The panel recommends that postpartum psychosis can be diagnosed in addition to other mental illness or as first-onset for patients without psychiatric history.

“We have been working with the American Psychiatric Association and the DSM steering committee since 2020 to find a solution that will facilitate diagnostic accuracy and the provision of timely and evidence-based treatment to improve the quality of treatment and outcomes for women with postpartum psychosis and to prevent the tragic outcomes of suicide and infanticide. We are committed to continue this work,” concludes Dr. Bergink.