Risk of puerperal and non-puerperal recurrence of illness following bipolar affective puerperal (post-partum) psychosis

Is sex important? Gender differences in bipolar disorder

Sex is clearly important in unipolar mood disorder with compelling evidence that depression is approximately twice as common in women than in men. In the case of bipolar disorder, however, it is widely perceived that the reported equal rate of illness in men and women reflects no important gender distinctions. In this paper we review the literature on gender differences in bipolar illness and attempt to summarize what is known and what requires further study. Despite the uncertainties that remain some conclusions can be drawn. Most studies, but not all, report an almost equal gender ratio in the prevalence of bipolar disorder but the majority of studies do report an increased risk in women of bipolar II/hypomania, rapid cycling and mixed episodes. Important gender distinctions are also found in patterns of co-morbidity. No consistent gender differences have been found in a number of variables including rates of depressive episodes, age and polarity of onset, symptoms, severity of the illness, response to treatment and suicidal behaviour. Unsurprisingly, however, perhaps the major distinction between men and women with bipolar disorder is the impact that reproductive life events, particularly childbirth, have on women with this diagnosis.

Oestradiol and psychosis: clinical findings and biological mechanisms

Female sex steroids easily access the central nervous system and modulate a number of intracerebral processes via their specific receptors. Oestradiol is the biologically dominant female sex steroid and has been implicated in the aetiology and course of psychotic illnesses. There is evidence for interaction between oestradiol and several neurobiological systems that have been implicated in the pathogenesis of psychotic illnesses. Clinical studies have indicated that psychosis, and in particular schizophrenia, is associated with reduced ovarian function and that this may be inherent to the illness itself. In schizophrenia several studies have suggested a therapeutic effect of oestradiol and selective oestrogen modulators although research is still at an early stage. In bipolar disorder, the relationship between childbirth and first onsets or recurrences is one of the most reproducible findings in psychiatric research. Whether or not the rapid fall of oestrogens is the mediating mechanism is not yet clear but preliminary oestrogen treatment studies commenced immediately after childbirth are promising. Outside the perinatal context, tamoxifen, a selective oestrogen receptor modulator, has shown strong antimanic effects although further studies are necessary to test an effect in larger samples. Hormonal treatments should not yet be used in standard care but could be considered in women with treatment resistant psychoses.

Assessment and treatment of bipolar II postpartum depression: a review

OBJECTIVE

This paper critically reviews the current literature on the detection, diagnosis, and treatment of bipolar II postpartum depression.

METHOD

A Pub-Med search (1998-2009), using the search terms 'postpartum depression', 'postpartum depression AND screening/detection/diagnosis/treatment', 'bipolar I AND postpartum depression', 'bipolar II AND postpartum depression', 'postpartum hypomania', and 'postpartum hypomania AND screening', was carried out. The reference lists of articles identified were also searched to select other relevant publications.

RESULTS

Brief hypomanic symptoms occur in the early puerperium in approximately 15% of women. Despite preliminary evidence that postpartum depression in some patients may be a manifestation of bipolar II disorder or bipolar disorder NOS, there are no screening instruments to differentiate unipolar from bipolar depression arising in pregnancy or the postpartum. Also lacking are evidence-based treatment options specifically targeted to treat bipolar II postpartum depression.

CONCLUSIONS

Research into postpartum mood disorders has focused primarily on major depressive disorder, bipolar I disorder, and puerperal psychosis, and has largely ignored the study of bipolarity beyond bipolar I disorder. The clinical and research implications of the misdiagnosis of bipolar II depression as major depressive disorder in the postpartum period are discussed.

Bipolar affective disorder in the postnatal period: investigating the role of sleep

OBJECTIVES

Psychotic disorders have a high rate of relapse in the postpartum period for reasons that are unclear, but may be related to changes in sleep patterns that occur during pregnancy and after birth. Understanding of the influence of sleep on postpartum psychosis presentation is limited. The aim of the current study was to investigate changes in sleep/wake activity during pregnancy and the postpartum period in women with a history of psychosis.

METHODS

Women with a history of bipolar disorder and/or postpartum psychosis (HxW) were recruited (n = 23) together with a control population (CtW) (n = 15). Data on demographic and psychosocial factors, mental health status, and sleep/wake activity were collected at seven timepoints-the last week of each trimester of pregnancy and four times during the postpartum (weeks 1, 4, and 8, and at month 6). Longitudinal data were analysed using an HLM version 6 repeated-measures multilevel model.

RESULTS

No significant differences were noted in sleep/wake activity between HxW and CtW. None of the HxW who were taking a mood stabilizer during their pregnancy, including at delivery, relapsed during the study. Of those taking an antidepressant or antipsychotic, or no medication, 3 relapsed within the first six months and 2 within the first two months. HxW were more likely to report a poor partner relationship than CtW.

CONCLUSION

Results suggest that during the perinatal period, there is no difference in sleep/wake activity in women with a history of a psychotic disorder. Use of mood stabilizer during pregnancy and at delivery appears important in preventing psychotic relapse in the postpartum.

Differentiation and clinical implications of postpartum depression and postpartum psychosis

Postpartum depression and postpartum psychosis are serious mood disorders encountered by nurses working in a variety of settings. Postpartum depression refers to a nonpsychotic depressive episode, while postpartum psychosis refers to a manic or affective psychotic episode linked temporally with childbirth. The nursing profession plays a crucial role in the early identification and treatment of these postpartum mood disorders. This article explains the classification, clinical presentation, epidemiology, management, and long-term outcomes of postpartum depression and postpartum psychosis.

Lifetime physical and sexual abuse and the risk for depression symptoms in the first 8 months after birth

Despite the growing body of evidence on the significance of postpartum depression, little research has explored the contribution of lifetime or current abuse to postpartum depression. One hundred-thirty-nine women were assessed during their third trimester of pregnancy and followed for 2, 4, 6, and 8 months postpartum for abuse status and depression symptoms. Predictors of postpartum depression were also assessed. Few women reported current abuse experiences, although 37% reported having lifetime physical or sexual abuse or both. Women with a lifetime history of abuse were 3.6-8.4 times more likely to experience postpartum depression than their nonabused peers at each measurement time. This effect steadily increases during the first 6 months after birth and decreases at the 8th month. These findings extend recent reports of the chronicity of abuse and have implications for care providers. The standard of care for abuse assessments may need to be expanded to include consideration of lifetime physical and sexual abuse experiences of pregnant and postpartum women.

Evidence-based guidelines for treating bipolar disorder: revised second edition--recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. The second version, like the first, is based explicitly on the available evidence and presented, like previous Clinical Practice guidelines, as recommendations to aid clinical decision making for practitioners: they may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed but selective qualitative review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in treatment of episodes, relapse prevention and stopping treatment.

Psychotic illness in first-time mothers with no previous psychiatric hospitalizations: a population-based study

BACKGROUND

Psychotic illness following childbirth is a relatively rare but severe condition with unexplained etiology. The aim of this study was to investigate the impact of maternal background characteristics and obstetric factors on the risk of postpartum psychosis, specifically among mothers with no previous psychiatric hospitalizations.

METHODS AND FINDINGS

We investigated incidence rates and potential maternal and obstetric risk factors of psychoses after childbirth in a national cohort of women who were first-time mothers from 1983 through 2000 (n = 745,596). Proportional hazard regression models were used to estimate relative risks of psychoses during and after the first 90 d postpartum, among mothers without any previous psychiatric hospitalization and among all mothers. Within 90 d after delivery, 892 women (1.2 per 1,000 births; 4.84 per 1,000 person-years) were hospitalized due to psychoses and 436 of these (0.6 per 1,000 births; 2.38 per 1,000 person-years) had not previously been hospitalized for any psychiatric disorder. During follow-up after the 90 d postpartum period, the corresponding incidence rates per 1,000 person-years were reduced to 0.65 for all women and 0.49 for women not previously hospitalized. During (but not after) the first 90 d postpartum the risk of psychoses among women without any previous psychiatric hospitalization was independently affected by: maternal age (35 y or older versus 19 y or younger; hazard ratio 2.4, 95% confidence interval [CI] 1.2 to 4.7); high birth weight (> or = 4,500 g; hazard ratio 0.3, 95% CI 0.1 to 1.0); and diabetes (hazard ratio 0).

CONCLUSIONS

The incidence of psychotic illness peaks immediately following a first childbirth, and almost 50% of the cases are women without any previous psychiatric hospitalization. High maternal age increases the risk while diabetes and high birth weight are associated with reduced risk of first-onset psychoses, distinctly during the postpartum period.

Prise en charge des femmes souffrant d'un trouble bipolaire de la conception au post-partum

Any plans for pregnancy must be discussed in detail with women with bipolar disorders. They must be informed about the risks related to it and the need for some precautions. Because of the risk of relapse during pregnancy, the risk/benefit ratio of maintaining or starting prophylactic treatment should be assessed, taking into account family history and frequency of recurrences. Lithium may be used during pregnancy under close monitoring. Most anticonvulsants are contraindicated because of their teratogenicity. During the post-partum period, prophylaxis is required in most cases because of the high risk of relapse. If no prophylaxis was given during pregnancy, it must be started quickly after delivery to be effective when the risk is at its highest, i.e., during the first two weeks after delivery. Women with bipolar disorders should be advised against breast-feeding to avoid exposure of the infant to psychotropic medication. Because breast-feeding can be stressful and causes sleep deprivation, it may increase the risk of relapse. Second-generation antipsychotic agents should not be used during pregnancy or breast-feeding because inadequate information is currently available about their safety.

The use of electroconvulsive therapy in postpartum affective disorders

Postpartum affective disorders continue to be a major health issue for women. There is a general belief that electroconvulsive therapy (ECT) is effective in treating severe or treatment-refractory postpartum affective illnesses, but evidence to support this assertion is lacking. In this case series, we present 5 cases of women with postpartum depression and psychosis, all of whom had failed prior pharmacological therapy. All 5 women had a significant response within 3 to 6 treatments with ECT. Our findings suggest that ECT is overall an effective treatment of postpartum illnesses. In addition to being an excellent choice for women who have failed prior medication trials, ECT may also be considered for women whose severity of illness necessitates rapid symptom resolution.

[Clinical approach and epidemiological aspects of mood and anxiety disorders during pregnancy and postpartum. Review and synthesis]

The aim of this article is to review clinical and epidemiological data on pre- and postnatal anxious and depressive disorders. To this end, we systematically analysed definitions, prevalence, risk factors and obstetrical consequences of perinatal disorders, as reported in seminal as well as more recent publications. We report and discuss the most consensual results about anxious and depressive disorders of pregnancy and the postpartum, with special emphasis on maternity blues, postpartum depression and postpartum psychosis. Reviewed data confirm that the perinatal period is a time of high risk for the onset or exacerbation of several anxious or depressive disorders, which are likely to impede the normal progress of pregnancy or the child's development. The potential severity of bipolar disorders and puerperal psychosis is highlighted by the fact that they heavily contribute to maternal mortality. The specificity of perinatal disorders, their impact on public health, the extensive research and mounting knowledge in that field, provide ample justification for the recognition of perinatal psychiatry as a distinct branch of psychiatry.

Postpartum depression, an autoimmune disease?

Medical conditions with known etiology and typical peripartal/postpartal disease exacerbations are now, without exception, considered autoimmune in etiology. Postpartum psychiatric conditions, and especially postpartum depression, currently, however, are still not understood in their etiology. This paper suggests that the typical postpartum flare pattern, and other clinical characteristics, point towards an autoimmune etiology for (postpartum) depression. The high prevalence of (postpartum) depression led to its designation as a major public health problem. A better understanding of etiology and pathophysiology would greatly advance the, currently still inaccurate, diagnosis of the condition, and improve approaches towards prevention and treatment.

A review of postpartum psychosis

OBJECTIVE

The objective is to provide an overview of the clinical features, prognosis, differential diagnosis, evaluation, and treatment of postpartum psychosis.

METHODS

The authors searched Medline (1966-2005), PsycInfo (1974-2005), Toxnet, and PubMed databases using the key words postpartum psychosis, depression, bipolar disorder, schizophrenia, organic psychosis, pharmacotherapy, psychotherapy, and electroconvulsive therapy. A clinical case is used to facilitate the discussion.

RESULTS

The onset of puerperal psychosis occurs in the first 1-4 weeks after childbirth. The data suggest that postpartum psychosis is an overt presentation of bipolar disorder that is timed to coincide with tremendous hormonal shifts after delivery. The patient develops frank psychosis, cognitive impairment, and grossly disorganized behavior that represent a complete change from previous functioning. These perturbations, in combination with lapsed insight into her illness and symptoms, can lead to devastating consequences in which the safety and well-being of the affected mother and her offspring are jeopardized. Therefore, careful and repeated assessment of the mothers' symptoms, safety, and functional capacity is imperative. Treatment is dictated by the underlying diagnosis, bipolar disorder, and guided by the symptom acuity, patient's response to past treatments, drug tolerability, and breastfeeding preference. The somatic therapies include antimanic agents, atypical antipsychotic medications, and ECT. Estrogen prophylaxis remains purely investigational.

CONCLUSIONS

The rapid and accurate diagnosis of postpartum psychosis is essential to expedite appropriate treatment and to allow for quick, full recovery, prevention of future episodes, and reduction of risk to the mother and her children and family.

Clinical characteristics of perinatal psychiatric patients: a chart review study

Although postpartum depression and other perinatal disorders have been the subject of increased research attention, important questions remain regarding women who actively seek psychiatric treatment during pregnancy and the postpartum period. In this study, we examined clinical records of 500 perinatal psychiatric patients who received treatment in a psychiatric day hospital (N = 398) or outpatient behavioral health clinic (N = 102). Patients' presenting diagnoses, psychiatric history, treatment course, and depressive symptoms were recorded. The majority of women had major depression as their primary diagnosis, with an average Edinburgh Postnatal Depression Scale score of over 20. Many depressed patients were diagnosed with comorbid anxiety and substance abuse disorders. Although most women were willing to take psychotropic medications, a sizable minority were not, particularly those who were breast-feeding. For more than a third of the sample, the treatment sought while pregnant or postpartum represented their first contact with the mental health system. Treatment implications are discussed.

Obstetric variables associated with bipolar affective puerperal psychosis

BACKGROUND

Previous cross-sectional studies have highlighted a number of obstetric variables that may be associated with the development of broadly defined puerperal (post-partum) psychosis. These include: (a) primiparity, (b) pregnancy complications, (c) delivery complications, (d) Caesarean section, (e) female baby and (f) shorter gestation period.

AIMS

To examine these risk factors in women with well-characterised bipolar affective puerperal psychosis.

METHOD

A sample of 129 women with bipolar affective puerperal psychosis were investigated using a design that takes advantage of within-subject comparisons of affected and unaffected deliveries.

RESULTS

Two of the variables studied were independently associated with an episode of puerperal psychosis: primiparity (odds ratio=3.76, P < 0.001) and delivery complications (odds ratio=2.68, P=0.022).

CONCLUSIONS

This study provides further evidence of the association between primiparity and puerperal psychosis and suggests that complications during delivery may be associated with a severe post-partum episode.

Bipolar disorder and childbirth: the importance of recognising risk

In October 2003 the report was published of an inquiry into the death of a psychiatric colleague that raised a number of important questions – not least regarding our management of women with bipolar disorder in pregnancy and the postpartum period (North East London Strategic Health Authority, 2003). Dr Daksha Emson took the life of herself and her 3-month-old daughter, Freya. This tragedy took place during a psychotic episode triggered by childbirth and was a consequence of her history of bipolar affective disorder. Sadly, the case of Dr Emson is far from unique. The Confidential Enquiries into Maternal Deaths (2001) found that suicide had become the leading cause of maternal mortality in the UK, accounting for 28% of maternal deaths (Oates, 2003a). The majority of the women who died by suicide suffered an abrupt onset of a severe psychotic illness within days of childbirth – a ‘puerperal psychosis', to use the traditional nosological label. For some women an episode of puerperal psychosis will be the first experience of severe mental illness, but a significant proportion of women will have had previous episodes. In the Confidential Enquiries into Maternal Deaths (2001), for example, 46% of the women who killed themselves (the majority by violent means) had previously been in contact with psychiatric services – and half of these had had a previous admission with a severe episode of illness following childbirth (Oates, 2003b). In many maternal suicides, therefore, the occurrence of an episode of severe post-partum psychiatric illness is an eminently predictable event. Although some women in the report were in contact with psychiatric services, none had received a detailed risk assessment, none had a formal management plan, and none was under close surveillance in the puerperium. It is also worth noting that none of the women in the cases of maternal suicide reported in the Confidential Enquiries was under the care of a mother and baby unit or perinatal psychiatric service (Oates, 2003a). The report on maternal deaths in 2000–2002 has now been published (Confidential Enquiries into Maternal Deaths, 2004) and, sadly, the findings are similar.