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Post-Partum Depression and Post-Partum Psychosis

Here's a psychiatrist's view of what's normal after childbirth—and what's not.

Pixabay, Public Domain
Source: Pixabay, Public Domain

The movie Tully plunges into territory rarely discussed in our society: the mental as well as physical strain on women during the weeks and months after giving birth. It has sparked discussions about the serious mental illnesses that can occur at this period in a woman’s life. That makes it most welcome.

But ‘Tully’ does not explain the cause of the main character’s experience. Are they real events? Are they the way the character is trying to understand herself better? Are they a fantasy manufactured in a time of need, something like the imaginary friends children may create?

Or: Are they manifestations of a serious mental disorder such as post-partum depression or post-partum psychosis?

Here’s a guide to understanding these possibilities. It is also a guide to what is normal and not normal after childbirth.

What’s normal

The ‘baby blues’ occur in up to 75 % of women during the first week or so after delivery. The mother may have a thought such as ‘no one called or came by this morning’ and break into sobs. Sometimes a thought isn’t even necessary: for no reason she can identify, she simply bursts into tears. This may be due to the sudden and major shifts in hormones and other substances that take place after pregnancy ends. It lasts no longer than hours or a few days, is self-limiting, and requires no treatment.

Feeling one’s mind is fuzzy, due to lack of sleep is also normal, as is occasional irritability. Some anxiety because of the 24-hour demand to keep this new young human alive is normal. So are occasional moments of resentment at the unceasing demands, even fleeting annoyance at the newborn mixed in with the predominant feelings of wonder and joy. Such moments. moods and thoughts are temporary and easily dispelled.

What’s not normal

Major Depressive Disorder with Post-Partum Onset

There are different forms of depression, and this is true during the postpartum period as well. Depressed mood can be a mild sadness, lasting for only a few days at a time, that can be shaken off when in the presence of favorite people or favorite music, for example.

But it is a Major Depressive Disorder (MDD) that begins in the weeks or months after delivery, or even during the pregnancy itself, that is of serious concern. Investigators have not yet pinned down its exact incidence, but estimate it occurs in up to one in ten births.

Because so many of the symptoms of MDD, such as lack of energy and trouble concentrating, overlap with what normally occurs after delivery, MDD may not be suspected. But when these symptoms coexist with a predominantly depressed mood that is present all day; when there is a loss of interest and a lack of pleasure; when the symptoms last for at least two weeks, that is not a normal consequence of childbirth.

Without treatment (psychotherapy and/or medication) the depression can last for months or years. It can also interfere with the mother’s ability to connect and interact with her baby, which will negatively affect the child’s development.

Postpartum Psychosis

This is different entirely from postpartum MDD. It is rare, occurring in approximately one or two women in 1000 births. The symptoms are more blatant than those of a mood disorder. There is profound confusion, mental clouding, and agitation. There are delusions and/or hallucinations; major difficulty with orientation, concentration and memory; and disorganized behavior that is very different from their previous functioning. Current thinking is that this illness is a variant of a bipolar episode. It must be treated quickly and aggressively.

Here are two examples illustrating the difference between the two.

These are excerpts from a novel about the unexpected and drastic impact of infertility and miscarriage in a woman with psychological vulnerabilities : The End of Miracles.

  • “I love you, Mama.” The sweet words are quite clear. It is a little child’s voice. “I love you, Mama.”… She knows absolutely that it is her child’s voice – even though the baby hadn’t grown old enough to speak ... But, oh, it feels so good to hear that voice… The following day, the child calls yet again, and Margo answers… As long as I know it’s not real, Margo thinks, what’s the harm?”

This is a hallucination, but Margo has good reality testing, and knows it is not real, so it is not psychotic.

  • Later, she thinks she is pregnant again. "She sees it: the very slight swell in her abdomen is definitely there. Comprehension comes quickly and with complete certainty: it's a miracle, but she is pregnant. She won't need to buy a pregnancy test kit because now that she's aware of what is going on, she definitely recognizes the signs... At first, the doctor is all smiles, although he chides her…for not coming to see him earlier. He feels her enlarged belly and peers at her cervix Then he turns solemn. He informs her that he does not think she is pregnant. ”We’ll run a double set of pregnancy tests to be absolutely certain.”… He calls her as soon as he has the results. “They’re negative. You definitely are not pregnant.” ”Sometimes lab tests aren’t correct, isn’t that right?”… ”Probably you are misperceiving gas bubbling through your intestines,” he declares… Margo finds his tone arrogant and insulting. How can he, who has never felt life as she previously has, claim that she is misperceiving these unmistakably unique feathery movements?”

At this point, her delusion—and possibly hallucination—can be a denial that borders on the psychotic. She ignores the reality of multiple negative pregnancy tests as well as the doctor’s report of his physical exam findings.

The doctor then orders an ultrasound to prove to her she is not pregnant. She readily agrees, certain it will prove she is pregnant. If she accepts the result she is shown on the ultrasound screen: that there is no baby there, however painful that acceptance may be, that is not severe denial or psychosis.

The diagnosis in ‘Tully’ is unclear - but serious

The writers of ‘Tully” do not give us enough specific information to decide whether the nurturing night-nurse is the product of a wish-fulfilling fantasy during a postpartum depression, one the mother knows is not real, or is a psychotic phenomenon where the mother believes that a person who does not exist, does.

However, "Tully" makes the audience wonder and think - which is always a good thing. It may also lead to more understanding that post-partum mental disorders occur not infrequently, and they can be quite serious.


The End of Miracles: A Novel, written by Monica Starkman MD, published by She Writes Press, 2016

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