Advancing Equity in Maternal Mental Health: Clinical Perspectives on Postpartum Psychosis in Underserved Populations

For too many Black and Brown mothers, the postpartum period can shift from a time of joy to a life-threatening psychiatric crisis, one that is too often overlooked until it is too late. The period after a child is born is considered an extremely vulnerable time. The natural decline in one's endogenous hormones makes the patient susceptible to a myriad of psychological fluctuations, especially if there are already pre-existing mental health conditions. Postpartum psychosis (PPP) is a rare but severe psychiatric emergency that typically emerges within days to weeks after childbirth, characterized by hallucinations, delusions, disorganized thought, and high risk for suicide or infanticide (Raza & Raza, 2023). Although not as common as other disorders that fall within the Perinatal Mood and Anxiety Disorder (PMAD) umbrella, its impact is devastating for the patient and the families involved.

PPP is a rare but severe psychiatric disorder, affecting approximately 1 to 2 per 1,000 births worldwide (Perry et al., 2021). Within days to weeks after childbirth, affected mothers may develop acute psychiatric symptoms; hallucinations, delusional thinking, and severe mood instability, that sharply differentiate PPP from more common PMADs (Raza & Raza, 2023). Postpartum psychosis often occurs in women with bipolar disorder, may represent the first onset of the illness, and carries a 50–80% risk of recurrence within the bipolar spectrum (Friedman, Reed, & Ross, 2023). Because of its rapid onset and life-threatening potential, postpartum psychosis requires immediate recognition and intervention to prevent devastating outcomes for both mother and infant.

Healthcare disparities and Social Determinants of Health (SDOH) are crucial for clinicians to consider when addressing the crisis affecting the communities they serve. Ignoring the systemic implications of our healthcare system and disregarding cultural competence when working with marginalized communities hinders the opportunities for improved patient outcomes. Despite the severity of postpartum psychosis, women from Black, Brown, and underserved communities encounter disproportionate barriers to recognition and treatment, shaped by social determinants of health, gaps in culturally competent care, and the pervasive effects of implicit bias. In a prospective study, Lafferty et al. (2024) found that unmet social needs were strongly associated with increased risk of adverse mental health among postpartum patients in underserved communities, underscoring the structural inequities that place these women at heightened risk.

At the provider level, insufficient cultural competence compounds these challenges. In a qualitative study of perinatal service providers, DeRoche et al. (2023) reported widespread recognition of gaps in training, resources, and systemic supports necessary to deliver equitable and culturally responsive mental health care. Furthermore, implicit bias directly affects screening and treatment engagement. Holcomb et al. (2025) demonstrated that when social determinants and cultural context are not adequately considered, screening efforts become less effective and women from racially and ethnically diverse backgrounds are less likely to be referred for appropriate care.

Postpartum psychosis is a psychiatric emergency that requires immediate inpatient care to protect both mother and infant. First-line treatment includes antipsychotic medication and mood stabilizers such as lithium, with electroconvulsive therapy reserved for severe or resistant cases (Jairaj et al., 2023). The most critical steps for providers are rapid recognition, prompt referral to psychiatric services, and ensuring treatment plans are explained in a culturally responsive way. Early action is essential to prevent harm and improve recovery.

The most powerful tool we have as providers is education, both for ourselves and for the patients and caregivers we serve. Without adequate knowledge, we cannot equip families with the holistic support they need to navigate postpartum psychosis. As clinicians, we carry a responsibility to remain aware of available resources and to guide patients toward them. Clinical implications include expanding provider training in culturally competent care, collaborating with stakeholders to address implicit bias, and integrating behavioral health experts into perinatal settings to strengthen interdisciplinary collaboration. By prioritizing education and equity, we can ensure that all women, particularly those from underserved Black and Brown communities, receive timely, compassionate, and effective care during this vulnerable period.

References

DeRoche C, Hooykaas A, Ou C, Charlebois J, King K. Examining the gaps in perinatal mental health care: A qualitative study of the perceptions of perinatal service providers in Canada. Front Glob Womens Health. 2023 Mar 15;4:1027409. doi: 10.3389/fgwh.2023.1027409. PMID: 37009091; PMCID: PMC10050873.

Raza SK, Raza S. Postpartum Psychosis. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544304/

Friedman SH, Reed E, Ross NE. Postpartum Psychosis. Curr Psychiatry Rep. 2023 Feb;25(2):65-72. doi: 10.1007/s11920-022-01406-4. Epub 2023 Jan 13. PMID: 36637712; PMCID: PMC9838449.

Holcomb LA, Maldonado L, Nietert PJ, Hayes MA, Witcraft SM, Newman RB, Brady KT, McRae-Clark AL, Gray KM, Guille C. Examining the role of social determinants of health in maternal mental health screening and treatment engagement during the perinatal period. Biol Sex Differ. 2025 Feb 12;16(1):11. doi: 10.1186/s13293-025-00687-7. PMID: 39939867; PMCID: PMC11823023.

Lafferty AK, Duryea E, Martin R, Moseley L, Lopez M, McIntire DD, Spong CY, Nelson DB. A Prospective Study of Social Needs Associated with Mental Health among Postpartum Patients Living in Underserved Communities. Am J Perinatol. 2024 May;41(S 01):e2396-e2402. doi: 10.1055/a-2113-2739. Epub 2023 Jun 20. PMID: 37339676.

Perry A, Gordon-Smith K, Jones L, Jones I. Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review. Brain Sci. 2021 Jan 4;11(1):47. doi: 10.3390/brainsci11010047. PMID: 33406713; PMCID: PMC7824357.