Postpartum Depression vs Psychosis: The Key Differences

If you or someone you love is seeing or hearing things others don't, believing things that worry everyone around her, or going days without sleep after having a baby, call 911 or go to the nearest emergency room now. Do not leave her alone with the baby until she has been seen.

It's 3 a.m. and the baby is finally asleep on your chest. A picture flashes through your mind of something terrible happening to her, and before your heart has even slowed down you're searching your phone: "postpartum psychosis." You've heard the stories on the news. Now you're lying there wondering if that is what's happening to you.

Moms ask me about this a lot, and I understand why. As a psychologist and a mom, I want to give you a clear answer, because the difference between postpartum psychosis and postpartum depression really matters. One is a common, treatable mood problem you can work on in a therapy office. The other is rare, and it is a medical emergency.

Postpartum psychosis vs depression: the short answer

Postpartum depression changes how you feel. Postpartum psychosis changes what feels real.

With depression, you are sad, flat, anxious, guilty, or exhausted, and you know something is wrong. You may hate the thoughts you're having, but you can tell they are thoughts. With psychosis, a mom loses touch with what is real. She may see or hear things no one else does, or believe things that feel completely true to her but alarm everyone around her. Often she doesn't realize anything is wrong at all.

Postpartum psychosis symptoms and warning signs

Postpartum psychosis usually comes on fast, over hours or days rather than weeks. These are the signs I want every mom and every family to know:

• Seeing or hearing things others don't. Voices, sounds, people, or images that no one else notices.
• Beliefs that feel completely true but worry the people around her. That the baby is in danger from someone, that the baby has been switched, that she has a special mission or special powers, that something on TV is a message just for her.
• Going days without sleep and not feeling tired. Not the ordinary newborn kind of exhaustion. She has the chance to sleep and doesn't need it, and may seem wired, busy, or unusually energized.
• Confusion. Seeming foggy or lost, not tracking a conversation, forgetting where she is, speech that jumps around or doesn't make sense.
• Thoughts that feel like they make sense, or like something to act on. This is the one I most want you to hear. A thought about harming herself or the baby that feels reasonable, right, or like an instruction is an emergency.
• Big, fast swings in mood or behavior. Elated one hour and terrified or furious the next, or acting in ways that are completely unlike her.

If you are a partner, parent, or friend, trust your gut. You do not need to be sure it is psychosis. "She is not acting like herself, and something is very wrong" is enough.

What to do in a postpartum psychosis emergency

Call 911 or take her to the nearest emergency room. Tell them she recently had a baby and when. If she has seen an OB, psychiatrist, or therapist, call them too, but don't wait to hear back before getting her to emergency care.

Until she has been seen by a doctor, someone should stay with her, and she should not be left alone with the baby. This is not a judgment about her as a mom. Psychosis is an illness that can distort what she sees and believes, and keeping both of them safe for a few hours is how you protect her.

Treatment usually starts in the hospital, where doctors can keep her safe, help her sleep, and start medication. You don't need to know the details of that in the moment. Your only job is to get her there.

Is it psychosis, or scary intrusive thoughts?

This is where most of the moms reading this actually are, so I want to be very clear.

Almost every new mom has sudden, unwanted thoughts or images of something bad happening to her baby: dropping her on the stairs, slipping in the bathwater, the knife on the counter. I had them too. I knew they were the ordinary kind, and they still gave me a jolt.

Those thoughts horrify you. You push them away, you might avoid the stairs or the knife, and you would never want to act on them. That reaction is the sign that your mind is working the way it should. Intrusive thoughts are not psychosis, and they don't mean you are dangerous. If they come often or take over your day, they're very treatable. Here is more on why these thoughts are not dangerous, and here is how postpartum OCD is treated.

The difference is how the thought feels. A thought that scares you is intrusive. A thought that feels like it makes sense, or like something you should do, is an emergency, and so is seeing or hearing things others don't.

Who is at higher risk

Postpartum psychosis can happen to someone with no history at all, but it is more likely if you have:

• Bipolar disorder
• A previous episode of postpartum psychosis
• A family history of bipolar disorder or postpartum psychosis, especially in a parent or sister

If any of these apply to you, the most important thing you can do is make a plan before the baby comes. Talk with your OB and a psychiatrist during pregnancy about your history, any medication you take, and how you will protect your sleep after birth. Don't stop a psychiatric medication on your own because you're pregnant; make that decision with your prescriber. Make sure your partner or a family member knows the warning signs above and knows to call 911 if they see them. If you've had depression after a past baby and are pregnant again, I wrote about planning for that here.

Postpartum psychosis treatment and recovery

Here is the part that the news stories leave out. Postpartum psychosis is rare, and it is very treatable. With fast care, most moms recover fully, and many go on to feel like themselves again within weeks to months. Therapy is often part of recovery afterward, for processing what happened, rebuilding confidence with the baby, and planning for the future.

When it's depression instead

If what you're feeling is heavy, sad, numb, anxious, or irritable, and you know these are thoughts and feelings rather than facts, that is much more likely postpartum depression or anxiety. It is common, it is real, and it does not fix itself by waiting. Here are the symptoms of postpartum depression, and here is how it differs from the baby blues. You can also read my guide on when a postpartum mental health problem is an emergency.

If you ever have thoughts of harming yourself or feel you can't keep yourself or your baby safe, call 911 or go to the nearest emergency room. You can call or text 988 any time, and the National Maternal Mental Health Hotline is open 24/7 at 1-833-852-6262. The Postpartum Support International HelpLine is 1-800-944-4773.

Working with me

I'm a licensed clinical psychologist, a certified perinatal mental health specialist, and helping moms tell scary but harmless thoughts apart from real warning signs is a regular part of my week. When a mom needs a psychiatrist or a higher level of care, I help her get there and I'm happy to coordinate with her doctors. I see moms in Austin or on video, and babies are always welcome in my office.

The first step is a free 15-minute call. Tell me what has been going on, and I will tell you honestly what I think would help.

Book a free 15-minute call