Postpartum Psychosis Should Be a Distinct Diagnosis, Experts Recommend
Key Clinical Summary
- An expert panel recommends classifying postpartum psychosis (PP) as a distinct disorder within the bipolar spectrum in DSM-5 and ICD-11.
- Evidence highlights PP’s unique timing, clinical features, and biological mechanisms distinct from other psychoses.
- Correct classification could improve early detection, guide evidence-based treatment, and prevent suicide and infanticide.
An expert consensus panel is calling for postpartum psychosis (PP) to be recognized as a distinct diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and International Classification of Diseases (ICD-11). Published in Biological Psychiatry, the recommendation reflects growing evidence that PP represents a unique psychiatric condition within the bipolar spectrum marked by rapid onset, distinct biological underpinnings, and specific treatment response patterns.
Main Findings
PP is a rare but severe psychiatric emergency affecting 0.1–0.2% of women after childbirth, with an incidence at least 10 times higher than at any other point in life. Symptoms typically appear within the first 2 weeks postpartum and include mania, mixed or depressive episodes with psychotic features, irritability, and cognitive disturbance. Untreated, PP carries high risks of suicide and infanticide.
Working with patient organizations and key partners, the panel reviewed epidemiological, genetic, and neurobiological data. Findings demonstrate PP’s close relationship with bipolar disorder rather than schizophrenia; up to 50% of women with first-onset PP later develop bipolar disorder, while those with existing bipolar I disorder are at significantly increased risk of PP.
Genetic studies also report PP’s heritability at 37–55%, overlapping with bipolar disorder but involving distinct variants, including DNA methyltransferase 1 (DNMT1) and 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR). Neuroimaging reveals reduced gray matter volume in specific brain regions and altered network connectivity, further supporting PP’s biological specificity.
Clinical Implications
According to the authors, the recognition of PP as a unique disorder could substantially improve maternal mental health outcomes. The panel suggest that current DSM “peripartum” specifiers are insufficient, as they include pregnancy, whereas PP occurs exclusively postpartum.
To minimize the risk of delayed treatment, the panel emphasize that timely diagnosis and evidence-based management are critical. Lithium and electroconvulsive therapy (ECT) remain the most effective treatments, with lithium also reducing relapse risk within 1 year. Antipsychotic monotherapy carries higher relapse risk and is preferred as an adjunctive treatment.
Preventive strategies, particularly postpartum lithium prophylaxis for women with prior PP or bipolar I disorder, can markedly reduce recurrence.
Expert Commentary
“We recommend classification within the bipolar disorders chapter of the DSM because recognition of PP as part of the bipolar spectrum will improve clinical outcomes and facilitate evidence-based treatment,” wrote Veerle Bergink, MD, PhD, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, and coauthors. “This is particularly important for women who present with postpartum depression with psychotic features or psychosis without mania, who are currently not recognized as having a bipolar spectrum disorder.”
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The panel encourages the American Psychiatric Association (APA) and the World Health Organization (WHO) to formally classify postpartum psychosis within the bipolar disorders chapter of DSM-5 and ICD-11. Accurate diagnostic recognition, they argue, will enhance maternal safety, guide appropriate treatment, and reduce preventable deaths from suicide and infanticide.
