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.