Postpartum Management of Bipolar Disorder

International Society Bipolar Disorder

This morning I participated in a webinar sponsored by The International Society for Bipolar Disorders entitled, Postpartum Management of Bipolar Disorder: Challenges and Opportunities, led by Dr. Verinder Sharma. Bipolar disorder is commonly misdiagnosed as major depressive disorder, just as postpartum bipolar disorder is misdiagnosed as postpartum depressive disorder. Misdiagnosis of bipolar disorder has serious consequences. Reproductive events such as the birth of a child can trigger manic, hypomanic and mixed symptoms.

Studies vary as to the effect of pregnancy on bipolar disorder. For some women, pregnancy is associated with an improvement in symptoms. Childbirth and the postpartum period is a potent trigger of episodes of bipolar disorder. Psychiatric hospitalizations exponential rise during the one month postpartum period. Risk factors include being unmarried, perinatal death, and C-section. Both biological and psychosocial factors play a role. Later in life, menopause is associated with increased rapid cycling and more clinical visits for depressive symptoms.

The paradigm shift that is required is assessment by primary care providers throughout the lifecycle, including at the onset of menses (adolescence), pregnancy, post-partum, menopause, and other life stages.

Among women with prior psychiatric diagnoses, those with bipolar disorder are at highest risk in the postpartum period. 75% of cases of postpartum psychosis had onset within three days postpartum. 5% had an onset before delivery. Serious episodes of mania and psychosis commonly occur immediately after delivery. Care providers must identify these symptoms early on and pay attention to early signs and symptoms of an episode.

Different psychiatric diagnoses have greater or lesser risk postpartum. The highest relative risk is in bipolar disorder when compared to major depressive disorder and schizophrenia. Research studies clearly indicate that childbirth is a potent trigger of episodes of bipolar disorder. Schizophrenia is associated with the lowest relative risk for a postpartum onset.

For bipolar disorder type 1, postpartum symptoms of mania, hypomania, and mixed states are quite common. Once again, childbirth is a key and specific trigger for mania. For bipolar disorder type 2, in 20% of pregnancies there were mood episodes, with more depression and no psychosis. Co-morbidities include anxiety and major depressive disorder. Mania and psychosis had an earlier onset postpartum than depression. There is a higher risk of postpartum recurrences for bipolar disorder type 1 than bipolar disorder type 2.

Risk factors for increased postpartum relapse include: prenatal mood symptoms, younger age, unplanned pregnancy, primiparity (psychosis, mania, recurrent depression), history of prior postpartum mood episodes, family history of mood disorders or postpartum psychosis, lack of maintenance medication pre or post delivery, and prior psychiatric hospitalization.

Care providers must screen for symptoms of hypomania and mania because bipolar disorder is commonly misdiagnosed as major depressive disorder in postpartum. Treatment of bipolar disorder with antidepressants can trigger manic symptoms. 54% with of women diagnosed with postpartum depression had bipolar disorder, not major depressive disorder. 46% of women with postpartum bipolar disorder have co-morbid anxiety disorders (64% of which had OCD).

Postpartum hypomania common, with multiple studies showing 10-20% occurrence (Sharma 2009). There is an eight-fold increase in hypomania from pregnancy to postpartum. Childbirth is potent and unique trigger to bipolar disorder. (This point Sharma made repeatedly.) Often women were not diagnosed. There is not adequate awareness among clinicians. Clinicians are not asking the right questions, so they are not picking up symptoms of hypomania such as decreased sleep and racing thoughts.

The BRIDGE study of 2011 & 2012 found younger age of illness onset, high number of prior episodes, seasonality of mood episodes, hypo(mania) in 1st degree relatives, episodes of short duration, postpartum onset, psychotic symptoms, atypical features, and mixed depression. The conversion rate was 6.52% from major depressive disorder to bipolar disorder (11-18 fold higher) – the highest rate of conversion at any time during a woman’s life.

What is called for is screening and detection, universal screening during pregnancy and the postpartum period, at the first onset of depressive symptoms in the postpartum period, at early psychiatric contact (4 weeks postpartum). Treatment during pregnancy must be comprehensive, collaborative, and individualized. Follow-up must be both scheduled and as needed. Psycho-education is key. Clinicians must provide their patients with information about the disorder, the benefits of treatment, treatment options, expected results, the role of sleep deprivation as a trigger, and the effects of smoking, alcohol and drug use on fetal development.

Psychosis must be treated inpatient. Psychosis is a psychiatric emergency. The safety of the mother and her infant are paramount. Hospitalization provides a reduced level of stimulation to the mother.

Dr. Sharma’s conclusions: We can easily identify women at risk. The risk period is short. For bipolar type 1, the first is key. For bipolar type 2, the first two to three weeks.


19 responses to “Postpartum Management of Bipolar Disorder”

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  2. Unbelievable that even a psychiatrist dismissed your symptoms. Good for you that you got the help you needed. Screening is crucial, as is taking women seriously.

  3. Thank you for writing about such an incredibly important topic. Perinatal psychiatric care is so important. I can’t remember if I wrote about it in my blog, but when my little boy was a baby I went to a psychiatrist and told him that I was suicidal, I hadn’t slept for weeks (not to do with the baby), I believed that the police were looking for me, and all sorts of other stuff. The psychiatrist told me I just needed some sleep. That ALL new mothers got a bit down and tired sometimes.

    Luckily I did end up getting the help I needed, and I was up hospitalised for eight weeks, was having a psychotic mixed bipolar episode – and was told I was one of the worst cases the unit had seen. I think postnatal mental illness is often overlooked, or not taken seriously. Like you say, screening is so important for all women, and creating an environment where women feel they are allowed to ask for help as well. Thank you for sharing this information and fighting the fight.

  4. Agreed. Many woman (and men, for that matter) are not diagnosed, and perinatal mental health screenings are crucial. Honestly, mental health screening and referral should be integrated into all primary and preventive health functions for children, adolescents, men, and women.

  5. I was diagnosed with bipolar II during my first pregnancy, and after reading some of the studies, etc., I was terrified of what would happen in the postpartum period. (That’s also when my husband and I decided to change churches; we realized that our then-church wouldn’t have been there for us if something had gone wrong. But that’s a long story!) What was strange was how often my doctors minimized my fears. Admittedly, I wasn’t telling them everything I was feeling, but I was terribly frightened that I would become manic or psychotic or suicidal and have the baby with me. Fortunately, nothing bad happened. I was stable after that pregnancy.

    I hope that doctors take this seriously. At least some do, but many don’t. Anyone who is around pregnant/postpartum women needs to keep their eyes open for unusual behavior, etc., especially when the woman has a troubled mental health history.

  6. Kept telling myself I was doing the right thing. But I could feel myself slipping…it was scary. Been stable 14 yrs. now.

  7. Glad she is well now. I breastfed 27 months, until it became clear I was manic and had to take valproic acid.

  8. Thank you so much for sharing your story and for reblogging my summary of the webinar. Screening and follow-up is crucial!

  9. You are welcome. Dr. Sharma summarized many studies which I would love to provide links to once I have the time.

  10. Thanks, Kitt! Am planning to reblog this & I’m glad Mariska did too! :)))))))

  11. Dyane, I look forward to reading your book and your interview with Dr. Sharma once it is published. Happy Thanksgiving to you and your family.

  12. Thank you, Ellen. Happy Thanksgiving!

  13. Mom had a very rough time off meds when breastfeeding. Nuff said. But, she is glad she did it and all is well now. Thanks for the post.

  14. Thanks so much for sharing this! I’ve reblogged it on as I want as many women as possible to read this. Despite telling my obstetrician and maternity ward staff about my bipolar disorder (type 1) no-one knew what to do when I became acutely unwell – other than offering me a mild sleeping tablet. I begged for help, only to be told to “go home with your baby and everything will calm down eventually.” Two days later I ended up being taken in the back of a police divvy van to a psych ward. It’s so important that women with bipolar disorder realise the risks of becoming acutely unwell following childbirth – and that we have plans in place and our psychiatrist on stand-by. I did this following the birth of my subsequent two babies and remained well. I wish all maternity ward staff had the opportunity to read this blog as their ignorance is putting the lives of mums with bipolar disorder at risk.

  15. Reblogged this on bipolar mums and commented:
    This is one of the most useful things I have read regarding bipolar and pregnancy/childbirth. I wish I had read this before the birth of my first baby and highly recommend it to anyone who is pregnant or considering becoming pregnant. It’s possible to have a baby and not become unwell – but it takes preparation and having a support team at the ready.

  16. I totally forgot to subscribe to this webinar… Thanks for writting this great summary!

  17. This was a very interesting and helpful webinar.

    In 2015 I’ll be interviewing Dr. Sharma for my book “Birth of a New Brain – Healing from Postpartum Bipolar Disorder”. I’m so excited and honored he accepted my invitation, because he’s one of the world’s top experts in PPBD. (postpartum onset bipolar disorder)

    It was so validating for me to hear Dr. Sharma assert that postpartum hypomania and mania, which I experienced, is (as mentioned in the notes above) “quite common” but it’s “not often diagnosed” because there’ s “not much awareness”, which I’m on a major mission to improve as much as one passionate mama can. 😉

    Thanks for taking the time to present this wonderful summary, Kitt!

  18. Such a thoroughly helpful and informative and well written post– as always!! xx ellen

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