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Sharma V, Wood KN, Weaver B, Mazmanian D, Thomson M. Occurrence of postpartum manic or mixed episodes in women with bipolar I disorder: A systematic review and meta-analysis. Bipolar Disord 2024; 26:240-248. [PMID: 38258551 DOI: 10.1111/bdi.13405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Accurate information on the frequency and prevalence of manic or mixed episodes is important for therapeutic, prognostic, and safety concerns. We aimed to estimate the risk of relapse of manic and mixed episodes after delivery in women with bipolar I disorder or schizoaffective disorder-bipolar type. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search in PubMed, PsycINFO, Embase, and Cochrane databases was carried out on November 17, 2022, using the terms ((bipolar disorder) OR (manic depressive illness)) AND (mania)) AND (postpartum)) AND (recurrence)) AND (relapse). The search was updated on March 29, 2023. Case studies and qualitative analyses were excluded. Twelve studies reporting on 3595 deliveries in 2183 women were included in the quantitative analysis. RESULTS The overall pooled estimate of postpartum relapse risk was 39% (95% CI = 29, 49; Q(11) = 211.08, p < 0.001; I2 = 96.31%). Among those who had a relapse, the pooled estimate of risk for manic and mixed episodes was 38% (95% CI = 28, 50; Q(11) = 101.17, p < 0.001; I2 = 91.06%). Using data from the nine studies that reported the percentage of medication use during pregnancy, we estimated a meta-regression model with the percent medication use as a continuous explanatory variable. The estimated prevalence of relapse was 58.1% (95% CI, 9.6 to 39.3 to 76.8) for studies with no medication use and 25.9% (95% CI, 10.5-41.3) for studies with 100% medication use. The difference between the two prevalence estimates was statistically significant, z = -2.099, p = 0.0359. CONCLUSIONS Our findings suggest an overall pooled estimate of postpartum relapse risk of 39%, while the pooled estimate of risk for manic and mixed episodes was 38%. These findings highlight the need to educate patients with bipolar I disorder, and their healthcare professionals about the high risk of relapse of manic or mixed episodes after delivery.
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Affiliation(s)
- Verinder Sharma
- Department of Psychiatry, Western University, London, Ontario, Canada
- Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada
- Parkwood Institute Mental Health, St. Joseph's Health Care, London, Ontario, Canada
| | - Katelyn N Wood
- Parkwood Institute Mental Health, St. Joseph's Health Care, London, Ontario, Canada
| | - Bruce Weaver
- Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada
| | - Dwight Mazmanian
- Department of Psychology, Lakehead University, Thunder Bay, Ontario, Canada
| | - Michael Thomson
- Department of Psychiatry, Western University, London, Ontario, Canada
- Parkwood Institute Mental Health, St. Joseph's Health Care, London, Ontario, Canada
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Perry A, Gordon-Smith K, Lewis KJS, Di Florio A, Craddock N, Jones L, Jones I. Perinatal sleep disruption and postpartum psychosis in bipolar disorder: Findings from the UK BDRN Pregnancy Study. J Affect Disord 2024; 346:21-27. [PMID: 37940050 DOI: 10.1016/j.jad.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Women with bipolar disorder (BD) are at high risk of postpartum psychosis (PP). The factors that increase risk of PP among women with BD are not fully understood. Here, we examine whether sleep disruption in the perinatal period (poor sleep quality in late pregnancy and sleep deprivation related to childbirth) is associated with PP in a longitudinal study of pregnant women with BD. METHODS Participants were 76 pregnant women with lifetime DSM-5 bipolar I disorder or schizoaffective-BD, followed from week 12 of pregnancy to 12 weeks postpartum. Demographics and lifetime psychopathology were assessed at baseline via semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry). Psychopathology and sleep disruption within the current perinatal period were assessed in the third trimester and at 12 weeks postpartum. Data were supplemented by clinician questionnaires and case-note review. RESULTS After controlling for prophylactic use of mood stabilising medication, the loss of at least one complete night of sleep across labour/delivery was associated with five times the odds of experiencing PP compared to no or less than one night of sleep loss across labour/delivery (OR 5.19, 95 % CI 1.45-18.54; p = 0.011). Sleep quality in late pregnancy was not associated with PP, and perinatal sleep disruption was not associated with postpartum depression. LIMITATIONS Lack of objective measures of sleep factors. CONCLUSIONS In the context of other aetiological factors, severe sleep loss associated with childbirth/the immediate postpartum may act as a final trigger of PP. These findings could have important clinical implications for risk prediction and prevention of PP.
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Affiliation(s)
- A Perry
- Psychological Medicine, University of Worcester, UK
| | | | - K J S Lewis
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK; Department of Psychiatry, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, United States of America
| | - A Di Florio
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK
| | - N Craddock
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK
| | - L Jones
- Psychological Medicine, University of Worcester, UK
| | - I Jones
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK
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Hasser C, Ameresekere M, Girgis C, Knapp J, Shah R. Striking the Balance: Bipolar Disorder in the Perinatal Period. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:3-15. [PMID: 38694148 PMCID: PMC11058914 DOI: 10.1176/appi.focus.20230020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
The authors reviewed the literature, published between 2018 and 2023, on treating bipolar disorder in the perinatal period in order to summarize current treatment perspectives. Mood episodes occur during pregnancy and there are high rates of both initial onset and recurrence in the postpartum period. Bipolar disorder itself is associated with higher risks of adverse pregnancy outcomes, including gestational hypertension, hemorrhage, cesarean delivery, and small for gestational age infants. A general principle of perinatal treatment includes maintaining psychiatric stability of the pregnant person while reducing medication exposure risk to the fetus. A variety of factors can compromise psychiatric stability, including rapid discontinuation of stabilizing medications, decreased efficacy due to physiologic changes of pregnancy, and exacerbation of underlying psychiatric illness. Psychosocial interventions include optimizing sleep, increasing support, and reducing stress. The American College of Obstetricians and Gynecologists recommends against discontinuing or withholding medications solely due to pregnancy or lactation status. Individualized treatment involves a discussion of the risks of undertreated bipolar disorder weighed against the risks of individual medication choice based on available evidence regarding congenital malformations, adverse neonatal and obstetrical events, and neurodevelopmental outcomes. Valproate is not a first-line treatment due to higher risks. Data are lacking on safety for many newer medications. The authors review current safety data regarding lithium, lamotrigine, and antipsychotics, which are the most commonly used treatments for managing bipolar disorder in the perinatal period. Due to physiologic changes during pregnancy, frequent therapeutic drug monitoring and dose adjustments are required.
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Affiliation(s)
- Caitlin Hasser
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Maithri Ameresekere
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Christina Girgis
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Jacquelyn Knapp
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Riva Shah
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
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Alcantarilla L, López-Castro M, Betriu M, Torres A, Garcia C, Solé E, Gelabert E, Roca-Lecumberri A. Risk factors for relapse or recurrence in women with bipolar disorder and recurrent major depressive disorder in the perinatal period: a systematic review. Arch Womens Ment Health 2023; 26:737-754. [PMID: 37718376 DOI: 10.1007/s00737-023-01370-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 09/08/2023] [Indexed: 09/19/2023]
Abstract
It is well known that the perinatal period supposes a considerable risk of relapse for women with bipolar disorder (BD) and recurrent major depressive disorder (rMDD), with the consequences that this entails. Therefore, the authors sought to provide a critical appraisal of the evidence related to specific risk factors for this population with the aim of improving the prevention of relapses during pregnancy and postpartum. The authors conducted a systematic review assessing 18 original studies that provided data on risk factors for relapse or recurrence of BD and/or rMDD in the perinatal period (pregnancy and postpartum). Recurrences of BD and rMDD are more frequent in the postpartum period than in pregnancy, with the first 4-6 weeks postpartum being especially complicated. In addition, women with BD type I are at higher risk than those with BD type II and rMDD, and the most frequent presentation of perinatal episodes of both disorders is a major depressive episode. Other risk factors consistently repeated were early age of onset of illnesses, severity criteria, primiparity, abrupt discontinuation of treatment, and personal or family history of perinatal affective episodes. This review shows that there are common and different risk factors according to the type of disorder and to perinatal timing (pregnancy or postpartum) that should be known for an adequate prevention of relapses.
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Affiliation(s)
- Laura Alcantarilla
- Perinatal Mental Health Unit CLINIC_BCN, Hospital Clínic de Barcelona, Barcelona, Spain
- Psychiatry Service, Hospital de Sagunto, Valencia, Spain
| | - María López-Castro
- Perinatal Mental Health Unit CLINIC_BCN, Hospital Clínic de Barcelona, Barcelona, Spain
- Psychiatry Service, Sant Pau's Biomedical Research Institute (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Maria Betriu
- Perinatal Mental Health Unit CLINIC_BCN, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Torres
- Perinatal Mental Health Unit CLINIC_BCN, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Cristina Garcia
- Perinatal Mental Health Unit CLINIC_BCN, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Eva Solé
- Perinatal Mental Health Unit CLINIC_BCN, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Estel Gelabert
- Department of Clinical Psychology and Health, Autonomous University of Barcelona, Barcelona, Spain
| | - Alba Roca-Lecumberri
- Perinatal Mental Health Unit CLINIC_BCN, Hospital Clínic de Barcelona, Barcelona, Spain.
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Uguz F, Sharma V, Boyce P, Clark CT, Galbally M, Koukopoulos A, Marsh W, Stevens A, Viguera A. Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors. J Clin Psychopharmacol 2023; 43:434-452. [PMID: 37683233 DOI: 10.1097/jcp.0000000000001740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
ABSTRACT Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.
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Affiliation(s)
- Faruk Uguz
- From the Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Verinder Sharma
- Schulich School of Medicine and Dentistry, The University of Western Ontario; Lawson Health Research Institute; Parkwood Institute Mental Health, Perinatal Mental Health Clinic, London Health Sciences Center, London, Ontario, Canada
| | - Philip Boyce
- Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Crystal T Clark
- Department of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Megan Galbally
- Department of Psychiatry, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Alexia Koukopoulos
- University Hospital Policlinico Umberto I, La Sapienza University of Rome; Centro Lucio Bini, Rome, Italy
| | - Wendy Marsh
- Department of Psychiatry, University of Massachusetts Medical School/UMass Memorial Medical Center, Worcester, MA.
| | - Anja Stevens
- Centre for Bipolar Disorders, Dimence Group, Deventer, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Psychiatry, the Netherlands
| | - Adele Viguera
- Cleveland Clinic, Cleveland Clinic Neurological Institute, Cleveland, OH
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Abstract
PURPOSE OF REVIEW Postpartum psychosis is a psychiatric emergency that can affect the health and life of mothers, infants, and families. Postpartum psychosis (PPP) is distinct from non-postpartum psychosis in many ways, and it is crucial to study and understand PPP to identify, treat, and possibly prevent this condition. We therefore sought to review the latest research findings about PPP with the intention of updating readers about the latest evidence base. RECENT FINDINGS Multiple physiologic pathways have been implicated in the development of PPP, and further understanding these pathways may allow for early detection and treatment. Risk assessment and treatment should include consideration of the woman patient but also the mother-infant dyad and the larger family. It is our hope that this review of research updates in postpartum psychosis may inform clinical practice and promote specialized, evidence-based diagnosis, risk assessment, and treatment.
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Affiliation(s)
| | - Eric Reed
- grid.67105.350000 0001 2164 3847Case Western Reserve University, 10254 Euclid Avenue, Cleveland, OH 44106 USA
| | - Nina E. Ross
- grid.67105.350000 0001 2164 3847Case Western Reserve University, 10254 Euclid Avenue, Cleveland, OH 44106 USA
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Sharma V, Mazmanian D, Palagini L, Bramante A. Postpartum psychosis: Revisiting the phenomenology, nosology, and treatment. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2022. [DOI: 10.1016/j.jadr.2022.100378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Efficacy and Safety of Transcranial Electric Stimulation during the Perinatal Period: A Systematic Literature Review and Three Case Reports. J Clin Med 2022; 11:jcm11144048. [PMID: 35887812 PMCID: PMC9318834 DOI: 10.3390/jcm11144048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: The perinatal period is an at-risk period for the emergence or decompensation of psychiatric disorders. Transcranial electrical stimulation (tES) is an effective and safe treatment for many psychiatric disorders. Given the reluctance to use pharmacological treatments during pregnancy or breastfeeding, tES may be an interesting treatment to consider. Our study aims to evaluate the efficacy and safety of tES in the perinatal period through a systematic literature review followed by three original case reports. Method: Following PRISMA guidelines, a systematic review of MEDLINE and ScienceDirect was undertaken to identify studies on tES on women during the perinatal period. The initial research was conducted until 31 December 2021 and search terms included: tDCS, transcranial direct current stimulation, tACS, transcranial alternating current stimulation, tRNS, transcranial random noise stimulation, pregnancy, perinatal, postnatal, and postpartum. Results: Seven studies reporting on 33 women during the perinatal period met the eligibility criteria. No serious adverse effects for the mother or child were reported. Data were limited to the use of tES during pregnancy in patients with schizophrenia or unipolar depression. In addition, we reported three original case reports illustrating the efficacy and safety of tDCS: in a pregnant woman with bipolar depression, in a pregnant woman with post-traumatic stress disorder (sham tDCS), and in a breastfeeding woman with postpartum depression. Conclusions: The results are encouraging, making tES a potentially safe and effective treatment in the perinatal period. Larger studies are needed to confirm these initial results, and any adverse effects on the mother or child should be reported. In addition, research perspectives on the medico-economic benefits of tES, and its realization at home, are to be investigated in the future.
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Postpartum Relapse in Patients with Bipolar Disorder. J Clin Med 2022; 11:jcm11143979. [PMID: 35887743 PMCID: PMC9319395 DOI: 10.3390/jcm11143979] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/03/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022] Open
Abstract
Pregnancy and postpartum are vital times of greater vulnerability to suffer a decompensation of bipolar disorder (BD). Methods: A systematic literature search was performed on public electronic medical databases, following PRISMA guidelines. Studies were included if they reported postpartum relapse in patients diagnosed with BD according to Diagnosis Statistical Manual (DSM) or International Classification Disease (ICD) criteria. Results: Sixteen articles describing 6064 deliveries of 3977 women were included in the quantitative analyses. The overall risk of postpartum relapse was 36.77%. The methodology of the studies, the diagnostic criteria, the discrimination between BD type I and II, and the origin of the sample were very heterogeneous. Conclusions: the rate of postpartum bipolar relapse is very high, as it is considered to be a critical period. It is especially important to detect decompensation in this period and to evaluate mood-stabilizing treatment, given the high risk of relapse concentrated in a short period.
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