Teresa Twomey: On The Big Bad Wolf of Postpartum Mood Disorders

Dear Moms:

You probably know the story of the Three Little Pigs. You may even know the song: "Who's afraid of the big bad wolf, big bad wolf, big bad wolf? Who's afraid of the big, bad wolf? Tra la la la la."

In the story, three little pigs leave their mother's home to build homes of their own. Two of the pigs do not pay any attention to the threat of the big bad wolf. One of those builds a house of hay and the other a house of twigs. But the third pig prepares by building a house of brick. As you know, when the wolf comes to "huff and puff," the houses of the first two fall down but the one with bricks stands strong. When playing "three little pigs" as children, the child with the house of bricks sings "Not me, not me, not me" in response to the phrase "Who's afraid of the big bad wolf?" It is a metaphor for preparing to face adversity.

In the world of postpartum mood disorders (PPMDs), postpartum psychosis is the "big bad wolf". Fortunately, this wolf only comes knocking at the door of about 1 or 2 out of 1000 (yes, one thousand) new moms. That means this disorder is "rare" in one sense — but it does happen. To give a comparison, it occurs at about the same rate as Downs Syndrome.

In some versions of the Three Little Pigs, those whose houses are destroyed are killed by the wolf. In other versions they escape to the home of their sibling with the brick house. With postpartum psychosis cases, approximately 10% have or come very close to having tragic outcomes, where someone is "killed by the wolf". The other 90% escape that fate.

Fortunately, there are "bricks" to build a house against the big bad wolf of postpartum psychosis. The first set of bricks the foundation, is knowledge of self. The woman should know what puts women in a high-risk category and whether she's in it. Some women may already know they are high risk. Others may be but just aren't aware of it, so they assume they are safe. That is building a house of hay, counting on the wolf not coming around. It is best to have a formal assessment of risk for perinatal mood and anxiety disorders, not simply to assume that no previous diagnosis of a mental illness equals zero risk.

The second set of bricks is knowledge about postpartum psychosis. Women who plan to have children, their partners and their families should be familiar with the symptoms of postpartum psychosis should know what to do if they occur. (And if she is high risk, to learn about possible steps for prevention and early intervention.) Those who simply assume they do not need to know about postpartum psychosis because they do not have risk factors or because they are not like "those women" who get postpartum psychosis are building houses of twigs, counting on the wolf staying away from their door. Although there certainly are indications that some women are at greater risk, such as bipolar disorder or a history of previous psychotic episodes, postpartum psychosis can happen to any new mom — even happy, successful women with no history of mood disorders.

A third set of bricks is knowledgeable practitioners. You want to be sure that your doctors and other medical providers are fully informed about postpartum mood disorders, including postpartum psychosis. Do any of your doctors assess patients for risk of mood disorders or do they just rely on patients to self-report? Do your doctors plan to assess you postpartum, or will they only act if and when it's obvious to them that you are having a problem? Are they trained to identify these illnesses? (For example, ask whether they know the difference between how a patient presents with postpartum OCD versus one with postpartum psychosis.) What would your doctor do or recommend in the event you did have postpartum psychosis or another PPMD? These are important questions, as your healthcare practitioners are your source of effective treatment should an illness arise.

There are no guarantees that the wolf won't come to your door. But there are plenty of steps to take to prepare against that possibility, and effective treatments if it does occur. If you are low risk, and you've got your house built full of bricks of knowledge, you might sing "Who's afraid of the big bad wolf, the big bad wolfe, the big bad wolf? Who's afraid of the big, bad wolf? NOT ME, NOT ME , NOT ME!"

Teresa Twomey is a survivor of postpartum psychosis and the author of the book"Understanding Postpartum Psychosis:A Temporary Madness". She also serves co-coordinator for the state of Connecticut for Postpartum Support International.

About Katherine Stone

is the founder of Postpartum Progress. She has been named a WebMD Health Hero, one of the fiercest women in America by More magazine, and one of the top 20 Social Media Moms by Working Mother magazine. She is a survivor of postpartum OCD.

Tell Us What You Think


  1. I LOVE this metaphor.
    Awesome! Thanks for sharing such invaluable tips on how to best prepare for the big bad wolf.

  2. Katherine Stone/Post says:

    Thank you for your candor. Postpartum psychosis is so important to understand. We need more people like you who can talk about it openly and serve as examples of the fact that it is fully treatable. Glad you were a part of this day!
    — Katherine

  3. I think prevention is key, so I love these practical suggestions. And knowledge really is power – if we can inform our family, friends and healthcare providers, I think we all stand a better chance of either preventing some of this stuff, or at least lessening the severity. I am excited to check out your book.

  4. Awareness & preparation are key. If only more women knew that this was a possibility, I really think this could be more easily identified and treated before tragedy strikes.

  5. Great analogy Teresa! One that communicates effectively the foolishness of keeping yourself ignorant of PPP assuming you and no one you know will ever get it.
    To carry on with your analogy, in working with women you have developed PPP, I have yet to meet one that regrets having built their house with bricks (having had prior knowledge of the symptoms of PPP) but I do know many women (including myself) who lament that we had our houses built with hay.

  6. Nice blog and excellent post i really appreciate on hard work.