Risk Factors for Postpartum Psychosis: Who Is Most Vulnerable

If you or someone you know may be experiencing postpartum psychosis, call 988 (Suicide & Crisis Lifeline) or go to the nearest emergency room immediately. Postpartum psychosis is a medical emergency that requires urgent care.

Understanding Risk Does Not Mean Inevitable Outcome

Knowing your risk factors for postpartum psychosis is not a reason to panic, it is a reason to prepare. Having one or more risk factors does not mean postpartum psychosis will occur. It means that awareness, monitoring, and proactive planning with your psychiatric and obstetric care team can meaningfully reduce both the likelihood and the severity of an episode if one does occur.

Primary Risk Factors

The strongest risk factor for postpartum psychosis is personal or family history of bipolar disorder. Research published in Archives of Women's Mental Health and reviewed by the MGH Center for Women's Mental Health shows that women with bipolar disorder have a risk of postpartum psychosis of approximately 20 to 30 percent, compared to 0.1 to 0.2 percent in the general postpartum population. If this history exists in your family, proactive psychiatric consultation before or during pregnancy is genuinely important.

A prior episode of postpartum psychosis is the single strongest predictor of a subsequent episode. Women who have experienced postpartum psychosis once have a recurrence risk in subsequent pregnancies estimated at 25 to 57 percent. This does not mean a second pregnancy is impossible or inadvisable, many women go on to have healthy subsequent pregnancies with appropriate monitoring and, where indicated, prophylactic medication begun in pregnancy or immediately postpartum. But it does mean that subsequent pregnancies require a specific, coordinated care plan established well in advance.

Secondary and Contributing Factors

Sleep deprivation is a significant contributor to psychotic episode risk in vulnerable individuals. The postpartum period involves the kind of sustained, fragmentary sleep loss that, in women with underlying mood disorder vulnerability, can precipitate a breaking point. This is one reason why peripartum sleep preservation, ensuring the at-risk woman gets at least four to five hours of consolidated sleep, is considered part of prevention in high-risk cases. For more on the sleep-mental health connection, see our guide on sleep deprivation and postpartum depression.

First delivery is associated with higher risk than subsequent births, possibly because the hormonal shift and sleep disruption are most severe and least anticipated. Stressful life events, lack of social support, and abrupt discontinuation of psychiatric medication during pregnancy also contribute to risk.

What Having Risk Factors Means Practically

If you have significant risk factors, particularly bipolar disorder or a prior postpartum psychosis episode, the most important step is to establish a relationship with a perinatal psychiatrist and therapist before delivery, or ideally as early as pre-conception. Postpartum Support International maintains a provider directory for finding specialists in perinatal mental health. Your partner and support people should be part of this conversation, they need to know what to watch for and who to call.

Some high-risk women and their providers choose prophylactic medication begun immediately after delivery, before symptoms appear. The evidence base for this approach is limited but growing, and the decision is highly individual, weighing the risk of an episode against medication risks and preferences, including breastfeeding preferences. There is no universally right answer, but there is a right process: making the decision thoughtfully, with good information, in collaboration with a provider who understands both the obstetric and psychiatric picture.

Sources & Further Reading

Postpartum Support International, Postpartum Psychosis

Action on Postpartum Psychosis, Risk Factors

MGH Center for Women's Mental Health, Postpartum Psychiatric Disorders

Marcé Society for Perinatal Mental Health