Screening for bipolar disorder during pregnancy and the postpartum period

Maternal and paternal postpartum early mood and bonding

BACKGROUND

Whereas the maternal 'blues' has been widely researched, comparatively less is known about the "highs" following childbirth, and the relation between mothers and fathers' mood in this early period. We aimed to investigate the association between maternal 'blues' and 'highs' with paternal postpartum mood (here described as 'lows' and 'highs') in the early postpartum and their associations with the quality of child bonding.

METHODS

Women and their cohabitating male partners, fathers of the index child (N = 98 couples), attending an obstetric hospital unit completed questionnaires on mood, bonding and socio-demographics between the 3rd and the 5th postpartum day. We used generalised estimating equations to analyse the data.

RESULTS

The 'blues' scores were higher in mothers, whereas 'highs' and bonding were higher in fathers. Maternal 'blues' were significantly correlated with paternal 'lows' (rs = .23, p < .05) and maternal 'highs' were also associated with paternal 'highs' (rs = .22, p < .05). Parental 'highs' were significantly associated with better baby bonding (B = .13, p = .02).

CONCLUSIONS

Our study demonstrates moderate associations between both 'blues/lows' and 'highs' in mothers and fathers shortly after the birth of the child. Associations between mood, particularly 'highs', and bonding were similar for mothers and fathers. Greater consideration of 'blues/lows' and 'highs' in both parents is needed to promote adjustment in the postpartum period.

Validated tools to identify common mental disorders in the perinatal period: A systematic review of systematic reviews

BACKGROUND

Uncertainty remains regarding the validity of screening tools to detect common mental disorders (CMDs) during perinatal periods. This umbrella review aims to provide an up-to-date summary of psychometric properties of tools for the identification of perinatal CMDs.

METHODS

Reviews were identified via Ovid MEDLINE, PsychINFO, EMBASE, Global Health and Cochrane Database of Systematic Reviews electronic databases with no date or language restriction. Pooled sensitivity and specificity estimates and ranges were extracted and summarised using forest plots. Quality assessment was conducted using Measurement Tool to Assess Systematic Reviews (AMSTAR-2).

RESULTS

Of 7,891 papers identified, 31 reviews met inclusion criteria. 76 screening tools were identified; most frequently validated were Edinburgh Postnatal Depression Scale (EPDS) (n = 28 reviews), Beck's Depression Inventory (BDI) (n = 13 reviews) and Patient Health Questionnaire (PHQ) (n = 12 reviews). Forest plots demonstrated a pattern of decreasing sensitivity and increasing specificity with increasing cut-off scores. Sub-group analysis of data extracted from low quality reviews demonstrated wider 95% CIs and overall lower specificity. Validity also varied according to ethnicity, socio-economic background and age.

LIMITATIONS

Despite a low Covered Corrected Area (CCA) score the primary studies included within reviews overlapped; therefore we were unable perform meta-analysis.

CONCLUSIONS

The evidence suggests that the EPDS, PHQ and BDI are useful across a range of diverse settings but the context of tool application is a key factor determining validity. This review highlights that utilizing screening tools in clinical practice is complex and requires careful consideration of the population, context, and health system it will be used in.

Postpartum Depression: Current Status and Possible Identification Using Biomarkers

Postpartum depression (PPD) is a serious health issue that can affect about 15% of the female population within after giving birth. It often conveys significant negative consequences to the offsprings. The symptoms and risk factors are somewhat similar to those found in non-postpartum depression. The main difference resides in the fact that PPD is triggered by postpartum specific factors, including especially biological changes in the hormone levels. Patients are usually diagnosed using a questionnaire onsite or in a clinic. Treatment of PPD often involves psychotherapy and antidepressant medications. In recent years, there have been more researches on the identification of biological markers for PPD. In this review, we will focus on the current research status of PPD, with an emphasis on the recent progress made on the identification of PPD biomarkers.

Indirect psychiatric consultation for perinatal bipolar disorder: A scoping review

OBJECTIVE

To synthesize the literature and develop guidance on supports needed for primary care and perinatal providers in screening, initial management, triage, and bridging treatment for perinatal bipolar disorder.

METHODS

We conducted a scoping review by searching six electronic databases using keywords related to perinatal bipolar disorder. We summarized descriptive statistics on settings and extracted information on care approaches. We synthesized the literature on indirect care models and extracted data on screening, follow-up, referrals, and management.

RESULTS

1169 articles were retrieved. 51 articles were included after review. Most papers were reviews. Fewer addressed care in obstetric (n = 20, 39%), primary care (n = 10, 20%), and pediatric settings (n = 2, 4%). Most papers (n = 30, 59%) discussed using screening instruments for bipolar disorder. Articles were mixed on recommendations for bipolar disorder screening.

CONCLUSIONS

Varied strategies for structured assessment exist and are influenced by practice setting. There remains uncertainty about optimal strategies for screening and management of perinatal bipolar disorder. We recommend screening for bipolar disorder in the perinatal period in select circumstances (with depression screening, known bipolar disorder risk factors, and prior to starting antidepressants). If specialty mental health care is unavailable, we recommend enhancing usual care through integrated care strategies such as indirect consultation.

Positive screening rates for bipolar disorder in pregnant and postpartum women and associated risk factors

OBJECTIVE

Bipolar disorder affects 2-8% of pregnant and postpartum women; untreated illness is associated with poor outcomes. This study aimed to describe bipolar disorder screening rates in obstetric settings and associated characteristics.

METHOD

Women were recruited during pregnancy through three months postpartum from 14 obstetric clinics in Massachusetts. The Mood Disorder Questionnaire (MDQ) was used to screen for bipolar disorder; a subset previously diagnosed with bipolar was also examined. Differences in characteristics by screening outcome were tested using chi-square and t-tests.

RESULTS

Of 574 participating women, 18.8% screened positive for bipolar disorder. Compared to those with negative, those with positive bipolar screens had 18.5-times the prevalence of positive substance use screens (11.1% vs. 0.6%, p < 0.001) and 3.4-times reported feeling they were not receiving adequate psychiatric help (24.0 vs. 7.0%, p < 0.001). Less than half of those with positive bipolar screens (42.0%) and 61.3% with pre-existing bipolar reported receiving current psychiatric care.

CONCLUSIONS

Almost one in five perinatal women screened positive for bipolar disorder. Positive screenings were associated with comorbid substance use and low treatment rates. This study highlights the importance of screening for bipolar disorder during the perinatal period and the need for systematic approaches to ensure adequate assessment and follow-up.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT02760004.

Postpartum psychiatric disorders

Pregnancy is a complex and vulnerable period that presents a number of challenges to women, including the development of postpartum psychiatric disorders (PPDs). These disorders can include postpartum depression and anxiety, which are relatively common, and the rare but more severe postpartum psychosis. In addition, other PPDs can include obsessive-compulsive disorder, post-traumatic stress disorder and eating disorders. The aetiology of PPDs is a complex interaction of psychological, social and biological factors, in addition to genetic and environmental factors. The goals of treating postpartum mental illness are reducing maternal symptoms and supporting maternal-child and family functioning. Women and their families should receive psychoeducation about the illness, including evidence-based discussions about the risks and benefits of each treatment option. Developing effective strategies in global settings that allow the delivery of targeted therapies to women with different clinical phenotypes and severities of PPDs is essential.

Bipolar Disorder in Pregnancy and Postpartum: Principles of Management

Pregnancy and postpartum represent times of increased vulnerability for women with bipolar disorder, yet this condition remains under-diagnosed and under-treated. As 50 % of pregnancies are unplanned, the risks associated with the illness and the potential risks associated with treatment should be considered when a woman of reproductive age first presents for evaluation. This article reviews the epidemiology of perinatal bipolar disorder, screening recommendations, and treatment with pharmacotherapy and electroconvulsive therapy (ECT). An overview of the data in pregnancy and lactation is presented for lithium, lamotrigine, valproic acid, newer antipsychotics, and ECT. General principles of management include close monitoring in pregnancy and postpartum, careful adjustment of the treatment regimen to attenuate the risk of relapse, and avoidance of valproic acid when possible. Thoughtful consideration of these issues will minimize the risks to the mother and baby.

DOES SCREENING WITH THE MDQ AND EPDS IMPROVE IDENTIFICATION OF BIPOLAR DISORDER IN AN OBSTETRICAL SAMPLE?

BACKGROUND

Women with bipolar disorder (BD) are at high risk for postpartum affective episodes and psychosis. Although validated screening tools are available for postpartum unipolar depression, few screening tools for hypomania/mania exist. Screening tools for BD in the postpartum period are essential for improving detection and planning appropriate treatment. We evaluated whether adding the Mood Disorders Questionnaire (MDQ) to the Edinburgh Postnatal Depression Scale (EPDS) increased the identification of BD in the early postpartum period.

METHODS

Women (N = 1,279) who delivered a live infant and screened positive on the EPDS and/or MDQ at 4-6 weeks postbirth were invited to undergo an in-home Structured Clinical Interview for DSM-IV (SCID).

RESULTS

Positive EPDS and/or MDQ screens occurred in 12% of the sample (n = 155). In home SCID diagnostic interviews were completed in 93 (60%) of the mothers with positive screens. BD was the primary diagnosis in 37% (n = 34). Women with BD screened positive on the EPDS and/or MDQ as follows: EPDS+/MDQ+ (n = 14), EPDS+/MDQ- (n = 17), and EPDS-/MDQ+ (n = 3). The MDQ identified 50% (17/34) of the women with BD and 6 additional cases of BD when the MDQ question regarding how impaired the mother perceived herself was excluded from the screen criterion.

CONCLUSION

Addition of the MDQ to the EPDS improved the distinction of unipolar depression from bipolar depression at the level of screening in 50% of women with traditional MDQ scoring and by nearly 70% when the MDQ was scored without the impairment criterion.

Instruments that prospectively predict bipolar disorder - A systematic review

BACKGROUND

Identification of earlier stages of Bipolar Disorder (BD), even prior to the first manic episode, may help develop interventions to prevent or delay the onset of BD. However, reliable and valid instruments are necessary to ascertain such earlier stages of BD. The aim of the current review was to identify instruments that had predictive validity and utility for BD for use in early intervention (EI) settings for the prevention of BD.

METHODS

We undertook a systematic examination of studies that examined participants without BD I or II at baseline and prospectively explored the predictive abilities of instruments for BD onset over a period of 6 months or more. The instruments and the studies were rated with respect to their relative validity and utility predicting onset of BD for prevention or early intervention. Odds ratios and area under the curve (AUC) values were derived when not reported.

RESULTS

Six studies were included, identifying five instruments that examined sub-threshold symptoms, family history, temperament and behavioral regulation. Though none of the identified instruments had been examined in high-quality replicated studies for predicting BD, two instruments, namely the Child Behavioral Checklist - Pediatric BD phenotype (CBCL-PBD) and the General Behavioral Inventory - Revised (GBI-R), had greater levels of validity and utility.

LIMITATION

Non-inclusion of studies and instruments that incidentally identified BD on follow-up limited the breadth of the review.

CONCLUSION

Instruments that test domains such as subthreshold symptoms, behavioral regulation, family history, and temperament hold promise in predicting BD onset.

Screening for bipolar spectrum disorders: A comprehensive meta-analysis of accuracy studies

BACKGROUND

Bipolar spectrum disorders are frequently under-recognized and/or misdiagnosed in various settings. Several influential publications recommend the routine screening of bipolar disorder. A systematic review and meta-analysis of accuracy studies for the bipolar spectrum diagnostic scale (BSDS), the hypomania checklist (HCL-32) and the mood disorder questionnaire (MDQ) were performed.

METHODS

The Pubmed, EMBASE, Cochrane, PsycINFO and SCOPUS databases were searched. Studies were included if the accuracy properties of the screening measures were determined against a DSM or ICD-10 structured diagnostic interview. The QUADAS-2 tool was used to rate bias.

RESULTS

Fifty three original studies met inclusion criteria (N=21,542). At recommended cutoffs, summary sensitivities were 81%, 66% and 69%, while specificities were 67%, 79% and 86% for the HCL-32, MDQ, and BSDS in psychiatric services, respectively. The HCL-32 was more accurate than the MDQ for the detection of type II bipolar disorder in mental health care centers (P=0.018). At a cutoff of 7, the MDQ had a summary sensitivity of 43% and a summary specificity of 95% for detection of bipolar disorder in primary care or general population settings.

LIMITATIONS

Most studies were performed in mental health care settings. Several included studies had a high risk of bias.

CONCLUSIONS

Although accuracy properties of the three screening instruments did not consistently differ in mental health care services, the HCL-32 was more accurate than the MDQ for the detection of type II BD. More studies in other settings (for example, in primary care) are necessary.

Clinical correlates of perinatal bipolar disorder in an interdisciplinary obstetrical hospital setting

BACKGROUND

Pregnancy and the postpartum period can be destabilizing for women with bipolar disorder (BD), and treatment decisions particularly complex. Yet, to date, relatively little research has focused on perinatal BD.

METHOD

Following IRB approval, trained raters reviewed clinical records of 334 women who had sought treatment at a specialized partial hospitalization program serving perinatal women, including demographic, clinical, and treatment history information as noted in each patient׳s chart by treating providers.

RESULTS

Slightly over 10% of the perinatal sample was diagnosed with Bipolar I, Bipolar II, or Bipolar NOS Disorder. In addition, 26% of the sample, regardless of diagnostic status, reported recent, abnormally elevated mood persisting 4 or more days. Compared to women with other Axis I disorders, women with a BD diagnosis were more likely to report a substance abuse history, prior suicide attempts, and more extensive psychiatric histories, including greater use of pharmacotherapy. Pregnant women with BD were more likely to take psychotropic medications prenatally, and postpartum women with BD reported higher rates of birth complications and difficulty breastfeeding.

LIMITATIONS

This research is limited by use of retrospective data, and utilization of self-report and clinician diagnosis, rather than structured interviews.

CONCLUSION

Even in the context of a partial hospital sample with high levels of symptoms and impairment, the clinical features of perinatal women with BD stand out as markedly more severe in comparison to those of women seeking care for other perinatal psychiatric conditions. Risk for suicide, substance abuse, and difficulties in the mother-child relationship are concerns.

Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings

IMPORTANCE

The period prevalence of depression among women is 21.9% during the first postpartum year; however, questions remain about the value of screening for depression.

OBJECTIVES

To screen for depression in postpartum women and evaluate positive screen findings to determine the timing of episode onset, rate and intensity of self-harm ideation, and primary and secondary DSM-IV disorders to inform treatment and policy decisions.

DESIGN

Sequential case series of women who recently gave birth.

SETTING

Urban academic women's hospital.

PARTICIPANTS

During the maternity hospitalization, women were offered screening at 4 to 6 weeks post partum by telephone. Screen-positive women were invited to undergo psychiatric evaluations in their homes.

MAIN OUTCOMES AND MEASURES

A positive screen finding was an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or higher. Self-harm ideation was assessed on EPDS item 10: "The thought of harming myself has occurred to me" (yes, quite often; sometimes; hardly ever; never). Screen-positive women underwent evaluation with the Structured Clinical Interview for DSM-IV for Axis I primary and secondary diagnoses.

RESULTS

Ten thousand mothers underwent screening, with positive findings in 1396 (14.0%); of these, 826 (59.2%) completed the home visits and 147 (10.5%) completed a telephone diagnostic interview. Screen-positive women were more likely to be younger, African American, publicly insured, single, and less well educated. More episodes began post partum (40.1%), followed by during pregnancy (33.4%) and before pregnancy (26.5%). In this population, 19.3% had self-harm ideation. All mothers with the highest intensity of self-harm ideation were identified with the EPDS score of 10 or higher. The most common primary diagnoses were unipolar depressive disorders (68.5%), and almost two-thirds had comorbid anxiety disorders. A striking 22.6% had bipolar disorders.

CONCLUSIONS AND RELEVANCE

The most common diagnosis in screen-positive women was major depressive disorder with comorbid generalized anxiety disorder. Strategies to differentiate women with bipolar from unipolar disorders are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00282776.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013

The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second-line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not-recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third-line options.

Identifying features of bipolarity in patients with first-episode postpartum depression: findings from the international BRIDGE study

OBJECTIVES

The aims of this study were to assess rates of bipolar spectrum disorders in women experiencing their first episode of postpartum depression, and to find out features indicative of bipolarity in these patients.

METHODS

As part of the international BRIDGE study designed to detect hypo/mania in patients with a major depressive episode, 52 (5.85%) were found to experience a first episode of postpartum (FEPP) depression, whereas 833 (94.13%) had a first episode of nonpostpartum (FENPP) depression. Hypo/mania was assessed using varying definitions of bipolarity, and the two groups compared on sociodemographic, family history and clinical characteristics.

RESULTS

Compared to FENPP depressive patients, women with FEPP depression had higher rates of bipolar disorders, with more hypo/mania in first degree relatives. Psychotic symptoms, atypical features, mixed depression, younger age at onset, high number of prior episodes, episodes of short duration, switches on antidepressants, seasonality of mood episodes as well as mood episodes with free intervals were found to be more frequent in FEPP depressives.

LIMITATIONS

The following are the limitations of this study: centres not randomly selected, recall bias, cross-sectional design, and limited training of participating psychiatrists.

CONCLUSIONS

This study confirms, in women experiencing a first depressive episode, high rates (15 to 50%) of bipolar disorders during the postpartum period and is the first to systematically assess and demonstrate the higher prevalence of identifying features of bipolarity in FEPP versus FENPP depression. Early recognition of bipolarity in these patients may help prevent the harmful consequences of this illness.

Screening for postpartum bipolar disorder: validation of the Mood Disorder Questionnaire

BACKGROUND

Despite the prevalent nature of postpartum depression in women with bipolar disorder, there are currently no screening instruments designed specifically for bipolar disorder in the postpartum period.

METHODS

Women with histories of major depressive disorder or bipolar disorder (type I or II) attending an outpatient perinatal clinic were administered the Mood Disorder Questionnaire during the first month after delivery. An experienced research coordinator, blind to the Mood Disorder Questionnaire results, conducted a face to face diagnostic interview using the Structured Clinical Interview for DSM-IV.

RESULTS

A total of 57 women with bipolar disorder (30 with bipolar II disorder and 27 with bipolar I disorder) and 68 women with major depressive disorder completed the Mood Disorder Questionnaire between two to four weeks after delivery. The traditional scoring criteria yielded a sensitivity of 75.44% [95%CI: 62.24%-85.87%] and a specificity of 86.76% [95%CI: 76.36%-93.77%]. The optimal cut-off score was eight or more endorsed symptoms without the supplementary questions (a sensitivity of 87.72% [95% CI: 76.32%-94.92%] and a specificity of 85.29% [95%CI: 74.61%-92.72%]).

CONCLUSIONS

The Mood Disorder Questionnaire with alternate scoring is a useful screening instrument for bipolar disorder in the postpartum period.

Childbirth and mental disorders

This review approaches the topic of childbirth and mental illness using a model of perinatal health which takes into consideration the multiple determinants of health, approached from a lifespan perspective. The paper seeks to answer four broad questions using this model and available literature: (1) What is the relationship between childbirth and mental disorders? (2) How common are mental disorders during childbearing, and what is the perinatal course of illness? (3) What are the effects of mental illness during childbearing on foetal and infant developmental outcomes? (4) How do you approach the detection and treatment of mental disorders during the perinatal period?