The Truth About Postpartum Psychosis

When our son was born a little over a year ago, the first few months were filled with what I’ve since come to call rational-but-irrational thoughts: Is he too hot? Too cold? What if he chokes on his spit-up? When he rolled onto his side last night, was his breathing restricted? He just got shampoo in his eyes and went ballistic. What if he goes blind?

Never mind that my wife and I followed all the necessary precautions: we layered his clothing with Goldilocks-level precision, wrapped him as snug as a Chipotle burrito before bed, and emptied our wallets for the all-natural, imported, very baby-safe shampoo. When the biggest, most beautiful event in your life is also completely uncharted territory, you can’t get the smell of baby poop out of your nose, and eight hours of sleep—hell, four hours of sleep—feels more like an absurd fantasy than an attainable goal, you’re just not quite yourself.

But for a small subset of new parents—mothers who experience postpartum psychosis—that feeling of not being yourself is something far more real, confusing, and terrifying. There are the “pink flags” that usually appear within the first two weeks after delivery: insomnia, restlessness, agitation, irritability, and rapid mood swings. But in as little as a few hours, the mother begins to lose touch with reality as the core psychotic symptoms appear: bizarre delusions, auditory and visual hallucinations, paranoia and confusion, hyperactivity and racing thoughts, tearfulness and withdrawal, and, in some cases, catatonia.

The truth is we understand very little about postpartum psychosis, which doesn’t have a single established cause. Some theories say there’s a genetic component. Others say it’s linked to bipolar disorder, or to the abrupt hormonal or immune-system changes that occur after delivery. Regardless, childbirth itself appears to be the trigger, but only certain brains are vulnerable to it.

In my moments of uncertainty as a new parent, I could eventually find my way back to solid ground. The baby’s fine. I’m fine. But with postpartum psychosis, the mother’s ability to gut-check slips away. The anchor is gone. You lose your sense of what’s real. You lose yourself.

Right now, much of the attention on postpartum psychosis is centered around the heartbreaking case of Lindsay Clancy, the mother who killed her three small children during an alleged episode in 2023. And while the court case has brought much-needed awareness to the condition, shining a light on both its presence and severity, it’s also unleashed a flurry of armchair diagnoses, misinformation, and harsh judgement both in and outside of the healthcare community.

As a new parent, this story hit me hard. But so did the public reaction. Any parent will tell you how exhausting, isolating, and guilt-inducing raising a child can be, especially in the early days when it’s easy to make mistakes. Add a severe mental illness to the mix, one that distorts your perception of reality and erases your very sense of self—plus the overwhelming trauma, confusion, and shame that follow—and the suffering is incomprehensible. Instinctively, I wanted to look away.

Still, as a journalist, another part of me became intensely curious. How does a mother go from feeling mostly normal, or experiencing those fairly common pink flags, to experiencing a full-blown break with reality? How do you even treat postpartum psychosis? And if the condition is so severe, why aren’t we doing a better job of identifying it?

Beyond the Baby Blues

My curiosity eventually led me to Hilary Waller, a therapist who specializes in postpartum and perinatal issues, including miscarriage, infertility, bereavement, lactation issues—and postpartum psychosis.

“Anyone who tells you pregnancy is going to be easy, joyful, or blissful is wrong,” she says. “Parts of it can be, but those are myths.” Among the most common things Waller hears from clients is that after confiding in their doctor that they were having intrusive thoughts, they were dismissed or villainized. Both are wrong, Waller says. “The average OB isn’t trained in postpartum psychology, so mental health care needs to be a routine part of prenatal health and reproductive endocrinology. Period.”

I tell Waller I’m a new parent myself, that I’ve had my fair share of irrational and bizarre worries. It’s common, she tells me. Staggeringly common.

“Ninety-eight percent of new parents experience unwanted intrusive thoughts,” she says. “That can range from What if I burn the baby in the bath to I was standing with my crying baby next to the window and I had this image of throwing her out of it.” But postpartum psychosis takes these delusions to a whole different level—and it’s more common than people think.

“We see one or two cases for every thousand deliveries,” Waller says—not statistically insignificant. “That’s an important part of educating the public,” she adds. “Psychosis isn’t rare, we just see it less often than other conditions.” So how is a therapist supposed to spot it, especially if the symptoms can appear as pink flags, or they’re waning at the time of a session and can’t be observed by the provider?

One of the first things Waller learned in her training was that every client who walked through her door should be assessed with a mood disorders questionnaire, or MDQ, which includes a screening for bipolar disorder.

“It’s helpful for two reasons,” she says. “First, because a personal or family history of bipolar disorder is a leading risk factor for psychosis, and second, because it normalizes talking about psychosis and bipolar disorder. I’ll tell clients that I give everybody this routine screening, because bipolar disorder can be triggered by some of the hormonal shifts that happen in pregnancy. This way, it doesn’t feel like I’m stigmatizing or attacking. It’s just part of the conversation.”

Waller says another assessment is crucial: a sleep questionnaire. “We know that no new parent sleeps, so asking about sleep is almost laughable,” she says. “But sleep is a factor we can control, and while it isn’t preventative, it can be protective against the onset of bipolar disorder or psychosis. I’ll ask, ‘When the baby is sleeping at night, are you able to fall asleep? What’s disrupting your sleep? Is it physical discomfort? Is the baby waking you? Is it noise outside your bedroom?’ The assessment is extremely detailed so that I understand what’s disrupting the sleep—symptoms of a perinatal or postpartum mood and anxiety disorder, or the natural disruptions of new parenthood—and so I can understand the impact of the lack of sleep on the mother.” As part of the assessment, she also asks whether the mother has social support in place to help her sleep.

If active psychosis is confirmed, the client is immediately referred to a hospital for emergency care. Waller’s clients have gotten that emergency care, been stabilized with medication, and eventually step down the treatment ladder, processing what they’ve been through.

“The work is to help them create a stable life with routines and protected sleep,” she says, “but we’re also doing trauma and grief work around whatever happened during the experience and how their identity shifted as someone who’s had psychosis in the context of motherhood. We’ve got a lot of work to do to restore that person’s sense of I’m a good, confident, capable mother.”

Waller also makes a practice of talking to her clients’ other providers, including lactation consultants, nurses, physicians, and psychiatrists. This way, she’s fully briefed on their recovery journey and can better spot a potential relapse in advance. Waller says the importance of this integrated care team can’t be overstated.

“If you’re not reading the full chart, you can easily miss a critical detail. So whether I see a pink flag or a red flag, I want to get on the phone with every provider the client has had to get their full history and whatever records I can.” The Clancy case, she says, is the perfect example of what can happen if providers aren’t talking to one another.

“Most of us in this specialty have been following this case for years,” she adds. “It’s really made me reflect on my clinical practice, because this could happen to any of us.”

A Living Nightmare

This could happen to any of us.

These words stick with me as I begin my phone call with Kristina Dulaney, a registered nurse, hotline counselor, mother of two—and a survivor of postpartum psychosis.

Dulaney’s episode began in 2015, nearly six months after the birth of her second child—far later than the three-week period after giving birth when mothers are, statistically, most susceptible to postpartum psychosis. Dulaney says she had most of the major symptoms—delusions, hallucinations, insomnia, hyper-religiosity, and paranoia.

“It blindsided our family,” she says. “My husband was watching me call him different names, not knowing who he was. He saw a version of me he never should’ve seen.”

Dulaney says she doesn’t remember much of the two-week hospitalization that followed, where she was confined to a psychiatric unit “literally battling for my mind and my life.” She was assigned a 24/7 “sitter,” and was regularly given antipsychotics, antidepressants, and injections to calm her down. None of the hospital staff mentioned that there was a better-equipped treatment facility just 45 minutes away.

Even though Dulaney says her nearby extended family and husband were incredibly supportive during those two weeks, taking her kids to and from daycare and visiting her at the hospital throughout the day, everyone was flying blind. Nobody knew what was going on or how long recovery might take—until two days into treatment, when a nurse practitioner noticed the telltale signs of postpartum psychosis and informed her husband. “She told him, ‘It’s going to get better,’” Dulaney says. “‘A year from now, this will just be a memory.’ He really held on to that.”

The discharge process was rough, to say the least. “There was no sit-down meeting with my husband to talk about a plan,” Dulaney explains. She was referred to inpatient therapy, and given directives that said she couldn’t drive, work, or be left alone by herself or with her kids. With little guidance, Dulaney and her family were now picking up the pieces, trying to make sense of what had just happened.

Back at home, Dulaney went through her nursing records and college notes to see if there’d been any mention of postpartum psychosis. She found nothing. When she followed up with her OB-GYN and told him she’d never learned about it in nursing school, his response was curt: “Well, that’s a hell of a way to find out about it.”

Six months after being discharged, Dulaney and her family moved. But the care network in their new hometown was severely lacking. Her new therapist had never heard of postpartum psychosis—and on several occasions, tried to rediagnose her. A sense of injustice began to crystallize.

“I started to realize that this was not okay,” she says. “We should’ve never been blindsided. Nurses had been doing home visits after we had the baby, but I was never screened. I knew I needed to do something.”

In 2018, Dulaney founded Cherished Mom, an organization dedicated to promoting perinatal mental health and bringing attention to maternal suicide and postpartum psychosis. Along the way, she’s also been setting the record straight.

“There’s a lot of misconceptions and a lot of stigma,” she says. “Psychosis survivors aren’t rocking in a corner. We can appear normal and functional. And when I’ve told people I had postpartum psychosis, a few have asked if I’ve killed my kids. Since the Clancy trial, the commentary has been horrendous.”

But are therapists any more enlightened?

“I think we’ve moved the needle over the last several years,” Dulaney says, “but tragedies are still happening, so there’s more work to be done. There are more trainings now, and more therapists are aware of postpartum psychosis, but I also think the care community is afraid to give the diagnosis because they don’t want to scare families. But what’s scarier, providing education, or losing a mother or child?”

Fixing a Blind Spot

What will it take for the field to fill in the gaps around treating postpartum psychosis?

Therapist Karen Kleiman, founder and director of The Postpartum Stress Center, as well as the author of 14 books on perinatal mental health, including Good Moms Have Scary Thoughts, says we’ve been here before.

“I’ve been doing this work for 40 years,” she tells me. “I was knocking on doors when people didn’t know what postpartum depression was. I sat through Andrea Yates, the mother who drowned her five children in 2001. Four decades after I started this work, the same failures of understanding continue to surface.”

Kleiman says that postpartum psychosis can be difficult to recognize and understand, even among clinicians who specialize in postpartum mental health.

“Historically, our job has been to reassure mom that if she’s anxious about her scary thoughts that’s a good sign, because they’re a normal, universal phenomenon. That they’re anxiety-driven and will eventually diminish. That she doesn’t need treatment unless the anxiety is so pervasive that it interferes with her ability to function.” But there are challenges facing even well-informed clinicians. They might easily conflate psychosis with a more common anxiety, or assume that distress about a thought rules out something more serious.

“While distress over frightening or intrusive thoughts can provide important clinical information,” Kleiman says, “it shouldn’t be treated as a standalone test of what’s happening.” Rather, she explains, clinicians need to consider the broader clinical picture, including intention, behavior, and other symptoms. That’s harder than it sounds.

“When tragedies like the Clancy case gain widespread attention, many women feel more scared and less secure about coming forward with their symptoms,” Kleiman says. “There are providers who are misinformed and could be missing something, but we can all miss something. We’re dealing with a mom who’s compelled to make sure everybody sees her as healthy because she’s fearful that she’s going to be labeled a bad mom and someone’s going to take her baby away. So she can be extraordinarily good at looking good, even if she’s severely depressed or experiencing psychotic symptoms.”

So what’s the solution if your client has every intention of not disclosing their symptoms? Kleiman says it requires tapping into your clinical intuition, your perception skills, and your innate listening abilities.

“We can’t expect someone who’s very sick to reveal the extent to which she’s suffering,” Kleiman says. “So we have to look at the story behind what she’s telling us. We have to ask the hard questions. We have to go in between her words and not just take everything at face value. Look her in the eyes. How does she sound? How does she make you feel? And are you creating the safe place that’s going to increase the likelihood she’ll tell you what’s really going on?”

The silver lining in all this, Kleiman says, is that postpartum struggles—whether they’re mild, moderate, or severe—are all treatable. “That’s what breaks my heart about this particular trial. These illnesses respond well to treatment. The catastrophic outcomes are avoidable.”

How long will it take to fill in the gaps—in screening, communication, and care—that still leave families vulnerable? Progress seems to be moving slowly, but there’s reason for optimism. Clinicians are asking better questions. Families have more language for what they’re experiencing. And postpartum psychosis, once barely spoken about at all, is slowly emerging from the shadows. Listening to Waller, Kleiman, and Dulaney, I get the sense that the care gaps are becoming harder to ignore.

My son is almost 14 months old now. He’s sturdier than he was in those early days, when every hard surface, pointy corner, and temperature shift felt like a disaster waiting to happen. But occasionally, the old fears find me. Did I clean that pacifier well enough? Was that tumble harder than it looked? Usually, the answers arrive almost as quickly as the questions, and the fear loosens its grip. I recognize these thoughts for what they are, and find my way back to solid ground.

As a father, I know I’m looking at postpartum psychosis from a distance. Whatever fears I’ve had as a new parent are fundamentally different from what mothers like Dulaney have endured. But hearing their stories has made me more grateful for the ability to trust my own mind, and more aware of what it means when that ability is taken away. If there’s hope after postpartum psychosis, it’s that lost ground isn’t lost forever. Slowly, people find their footing again.

“The recovery is a little like surviving a stroke,” Dulaney explains. “It’s slow. You have to be patient and remind yourself that this isn’t a race. I remember telling a psychiatrist on the intensive outpatient program that I didn’t know what had just happened, that I felt frustrated and angry. Her response stuck with me: ‘You’re like a soldier returning from battle. You have to be gracious with yourself.’”