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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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Carr C, Borges D, Lewis K, Heron J, Wilson S, Broome MR, Jones I, Di Florio A, Morales-Muñoz I. Sleep and Postpartum Psychosis: A Narrative Review of the Existing Literature. J Clin Med 2023; 12:7550. [PMID: 38137618 PMCID: PMC10744103 DOI: 10.3390/jcm12247550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Sleep problems are extremely common during the postpartum period. The role of sleep in the development of postpartum psychosis (PP) is, however, still under-researched. This narrative review aims to (1) provide a summary of the existing evidence for the associations between sleep problems and PP, (2) discuss the relevant risk factors associated with sleep problems and PP, and (3) suggest future lines of research in this area. Some of the existing literature suggests an association between sleep problems, specifically insomnia, sleep loss and sleep disruption during pregnancy and postpartum, and PP, with the most relevant risk factors including history of bipolar disorder and time of delivery. However, it is still unclear whether the previously mentioned sleep problems are a symptom of, or a trigger for PP. Thus, further research is needed to identify the specific role of sleep problems in PP, using longitudinal designs and more objective measures of sleep. This will allow appropriate detection, intervention and support for women experiencing and/or at risk for PP.
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Affiliation(s)
- Camilla Carr
- Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham B15 2TT, UK; (C.C.); (D.B.)
| | - Daniela Borges
- Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham B15 2TT, UK; (C.C.); (D.B.)
- Coventry and Warwickshire Partnership NHS Trust, Coventry CV6 6NY, UK
| | - Katie Lewis
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff CF24 4HQ, UK
| | - Jessica Heron
- Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham B15 2TT, UK; (C.C.); (D.B.)
- Action on Postpartum Psychosis, Swansea SA3 9BT, UK
| | - Sally Wilson
- Action on Postpartum Psychosis, Swansea SA3 9BT, UK
| | - Matthew R. Broome
- Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham B15 2TT, UK; (C.C.); (D.B.)
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham B4 6NH, UK
| | - Ian Jones
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff CF24 4HQ, UK
| | - Arianna Di Florio
- Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff CF24 4HQ, UK
| | - Isabel Morales-Muñoz
- Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham B15 2TT, UK; (C.C.); (D.B.)
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Sharma V, Sharkey KM, Palagini L, Mazmanian D, Thomson M. Preventing recurrence of postpartum depression by regulating sleep. Expert Rev Neurother 2023; 23:1-9. [PMID: 37462620 PMCID: PMC10527998 DOI: 10.1080/14737175.2023.2237194] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Women are at a high risk of recurrence of depression in the postpartum period. Given the circumscribed duration of the risk period and knowledge of its triggers, postpartum depression should be easily preventable. However, prophylactic drug studies have reported contradictory findings partly due to the heterogeneity of the disorder. Currently, there are no studies on the efficacy of psychotherapy in the prevention of postpartum depression in women with major depressive or bipolar disorder. AREAS COVERED This review evaluates the results of controlled medication and psychotherapeutic studies in the prevention of depression in women with major depressive disorder or bipolar disorder; it further suggests that the management of sleep loss/insomnia may be an effective strategy in the prevention of postpartum depression. EXPERT OPINION A thorough understanding of the clinical course of the antecedent mood disorder and historical treatment response is necessary before the implementation of strategies for the prevention of postpartum depression. Targeting disturbed and/or insufficient sleep - a common and early transdiagnostic symptom of peripartum psychiatric disorders - may be a more effective intervention for the prevention of postpartum depression and psychiatric comorbidities in some individuals than the traditional approach of antidepressant use.
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Affiliation(s)
- Verinder Sharma
- Department of Psychiatry, Western University, London, Ontario, Canada
- Department of Obstetrics & Gynecology, Western University, London, Ontario, Canada
- Parkwood Institute Mental Health, St. Joseph’s Health Care, London, Ontario, Canada
| | - Katherine M. Sharkey
- Department of Medicine, Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University Providence, Rhode Island
| | - Laura Palagini
- Department of Clinical and Experimental Medicine, Psychiatric Clinic, University of Pisa, Via Roma 67, 56100, Pisa, Italy
| | - 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, Jones L, Jones I. Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review. Brain Sci 2021; 11:brainsci11010047. [PMID: 33406713 PMCID: PMC7824357 DOI: 10.3390/brainsci11010047] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/18/2020] [Accepted: 12/27/2020] [Indexed: 11/16/2022] Open
Abstract
Postpartum psychoses are a severe form of postnatal mood disorders, affecting 1–2 in every 1000 deliveries. These episodes typically present as acute mania or depression with psychosis within the first few weeks of childbirth, which, as life-threatening psychiatric emergencies, can have a significant adverse impact on the mother, baby and wider family. The nosological status of postpartum psychosis remains contentious; however, evidence indicates most episodes to be manifestations of bipolar disorder and a vulnerability to a puerperal trigger. While childbirth appears to be a potent trigger of severe mood disorders, the precise mechanisms by which postpartum psychosis occurs are poorly understood. This review examines the current evidence with respect to potential aetiology and childbirth-related triggers of postpartum psychosis. Findings to date have implicated neurobiological factors, such as hormones, immunological dysregulation, circadian rhythm disruption and genetics, to be important in the pathogenesis of this disorder. Prediction models, informed by prospective cohort studies of high-risk women, are required to identify those at greatest risk of postpartum psychosis.
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Affiliation(s)
- Amy Perry
- Psychological Medicine, University of Worcester, Worcester WR2 6AJ, UK; (K.G.-S.); (L.J.)
- Correspondence:
| | - Katherine Gordon-Smith
- Psychological Medicine, University of Worcester, Worcester WR2 6AJ, UK; (K.G.-S.); (L.J.)
| | - Lisa Jones
- Psychological Medicine, University of Worcester, Worcester WR2 6AJ, UK; (K.G.-S.); (L.J.)
| | - Ian Jones
- National Centre for Mental Health, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff CF24 4HQ, UK;
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Reinstein SA, Deligiannidis KM. Acute Bipolar Psychosis Limited to the Course of an Ectopic Pregnancy. PSYCHOSOMATICS 2020; 61:799-803. [PMID: 32402409 DOI: 10.1016/j.psym.2020.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/29/2020] [Accepted: 03/31/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Sarah A Reinstein
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY; Department of Psychiatry, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
| | - Kristina M Deligiannidis
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY; Department of Obstetrics and Gynecology, Northwell Health, New Hyde Park, NY; Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY; Department of Psychiatry, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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González-Mesa E, Cuenca-Marín C, Suarez-Arana M, Tripiana-Serrano B, Ibrahim-Díez N, Gonzalez-Cazorla A, Blasco-Alonso M. Poor sleep quality is associated with perinatal depression. A systematic review of last decade scientific literature and meta-analysis. J Perinat Med 2019; 47:689-703. [PMID: 31393835 DOI: 10.1515/jpm-2019-0214] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/17/2019] [Indexed: 12/22/2022]
Abstract
Background Although pregnancy is frequently associated with mental states of happiness, hope and well-being, some physical and psychological changes can contribute to increased sleep disturbances and worsened sleep quality. Sleep quality has been linked to negative emotions, anxiety and depression. The main objective of this paper was to systematically review the impact of sleep during pregnancy on maternal mood, studying the association between objective and subjective measures of sleep quality and perinatal depression. Methods We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which included studies published between January 2008 and April 2019, and met the following criteria: (i) studies on pregnant women assessing the effects of sleep quality variables on perinatal mood disorders, (ii) studies published in English and (iii) full paper published in a peer-reviewed scientific journal with full-text format available. Results A total of 36 studies published in the last decade met the inclusion criteria for qualitative review and eight of them were suitable for meta-analysis. Both confirmed the negative effects of poor sleep on perinatal mood. However, qualitative analysis showed that unrepresentative samples and low participation rates falling below 80% biased some of the studies. The standard random-effects meta-analysis showed a pooled size effect [ln odds ratio (OR) 1.49 (95% confidence interval [CI] 1.19, 1.79)] for perinatal depression in cases of poor prenatal sleep quality, although heterogeneity was moderate to high [Q 16.05, P ≤ 0.025, H2 2.45 (95% CI 1.01, 13.70)]. Conclusion Poor sleep quality was associated with perinatal mood disturbances. The assessment of sleep quality along the pregnancy could be advisable with a view to offering preventative or therapeutic interventions when necessary.
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Affiliation(s)
- Ernesto González-Mesa
- Surgical Specialties, Biochemistry and Immunology Department, Malaga University School of Medicine, 32, Boulevard Louis Pasteur, 29071 Málaga, Spain
- Obstetrics and Gynecology at Malaga University Hospital, Málaga, Spain
| | | | | | | | | | - Ana Gonzalez-Cazorla
- Surgical Specialties, Biochemistry and Immunology Department, Malaga University School of Medicine, 32, Boulevard Louis Pasteur, 29071 Málaga, Spain
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Poels EMP, Bijma HH, Galbally M, Bergink V. Lithium during pregnancy and after delivery: a review. Int J Bipolar Disord 2018; 6:26. [PMID: 30506447 PMCID: PMC6274637 DOI: 10.1186/s40345-018-0135-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/10/2018] [Indexed: 12/16/2022] Open
Abstract
Lithium is an effective treatment in pregnancy and postpartum for the prevention of relapse in bipolar disorder. However, lithium has also been associated with risks during pregnancy for both the mother and the unborn child. Recent large studies have confirmed the association between first trimester lithium exposure and an increased risk of congenital malformations. Importantly, the risk estimates from these studies are lower than previously reported. Tapering of lithium during the first trimester could be considered but should be weighed against the risks of relapse. There seems to be no association between lithium use and pregnancy or delivery related outcomes, but more research is needed to be more conclusive. When lithium is prescribed during pregnancy, lithium blood levels should be monitored more frequently than outside of pregnancy and preferably weekly in the third trimester. We recommend a high-resolution ultrasound with fetal anomaly scanning at 20 weeks. Ideally, delivery should take place in a specialised hospital where psychiatric and obstetric care for the mother is provided and neonatal evaluation and monitoring of the child can take place immediately after birth. When lithium is discontinued during pregnancy, lithium could be restarted immediately after delivery as strategy for relapse prevention postpartum. Given the very high risk of relapse in the postpartum period, a high target therapeutic lithium level is recommended. Most clinical guidelines discourage breastfeeding in women treated with lithium. It is highly important that clinicians inform and advise women about the risks and benefits of remaining on lithium in pregnancy, if possible preconceptionally. In this narrative review we provide an up-to-date overview of the literature on lithium use during pregnancy and after delivery leading to clinical recommendations.
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Affiliation(s)
- Eline M P Poels
- Department of Psychiatry, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Hilmar H Bijma
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Megan Galbally
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Australia
| | - Veerle Bergink
- Department of Psychiatry, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands. .,Department of Psychiatry and Department of Obstetrics, Gynecology and Reproductive Science, The Blavatnik Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, Room L4-34, New York City, NY, 10029, USA.
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Lewis KJS, Di Florio A, Forty L, Gordon-Smith K, Perry A, Craddock N, Jones L, Jones I. Mania triggered by sleep loss and risk of postpartum psychosis in women with bipolar disorder. J Affect Disord 2018; 225:624-629. [PMID: 28889048 DOI: 10.1016/j.jad.2017.08.054] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/09/2017] [Accepted: 08/16/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Women with bipolar disorder are at high risk of affective psychoses following childbirth (i.e. "postpartum psychosis", PP) and there is a need to identify which factors underlie this increased risk. Vulnerability to mood dysregulation following sleep loss may influence risk of PP, as childbirth is typified by sleep disruption. We investigated whether a history of mood episodes triggered by sleep loss was associated with PP in women with bipolar disorder (BD). METHODS Participants were 870 parous women with BD recruited to the Bipolar Disorder Research Network. Lifetime diagnoses of BD and perinatal episodes were identified via interview and case notes. Information on whether mood episodes had been triggered by sleep loss was derived at interview. Rates of PP were compared between women who did and did not report mood episodes following sleep loss. RESULTS Women who reported sleep loss triggering episodes of mania were twice as likely to have experienced an episode of PP (OR = 2.09, 95% CI = 1.47-2.97, p < 0.001) compared to women who did not report this. There was no significant association between depression triggered by sleep loss and PP (p = 0.526). LIMITATIONS Data were cross-sectional therefore may be subject to recall bias. We also did not have objective data on sleep disruption that had occurred during the postpartum period or prior to mood episodes. CONCLUSIONS In clinical practice, a history of mania following sleep loss could be a marker of increased vulnerability to PP, and should be discussed with BD women who are pregnant or planning to conceive.
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Affiliation(s)
- Katie J S Lewis
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Road, CF24 4HQ Cardiff, UK
| | - Arianna Di Florio
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Road, CF24 4HQ Cardiff, UK
| | - Liz Forty
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Road, CF24 4HQ Cardiff, UK
| | | | - Amy Perry
- Institute of Health & Society, University of Worcester, Worcester, UK
| | - Nick Craddock
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Road, CF24 4HQ Cardiff, UK
| | - Lisa Jones
- Institute of Health & Society, University of Worcester, Worcester, UK
| | - Ian Jones
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Road, CF24 4HQ Cardiff, UK.
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Lewis KJS, Foster RG, Jones IR. Is sleep disruption a trigger for postpartum psychosis? Br J Psychiatry 2016; 208:409-11. [PMID: 27143002 DOI: 10.1192/bjp.bp.115.166314] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/21/2015] [Indexed: 01/29/2023]
Abstract
An episode of postpartum psychosis can be devastating for a woman and her family, and it is vital we understand the factors involved in the aetiology of this condition. Sleep and circadian rhythm disruption is a plausible candidate but further research is needed that builds on the latest advances in chronobiology and neuroscience.
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Affiliation(s)
- Katie J S Lewis
- Katie J. S. Lewis, BSc, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University; Russell G. Foster, BSc, PhD, FRS, Sleep and Circadian Neuroscience Institute, Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford; Ian R. Jones, MRCPsych, PhD, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Russell G Foster
- Katie J. S. Lewis, BSc, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University; Russell G. Foster, BSc, PhD, FRS, Sleep and Circadian Neuroscience Institute, Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford; Ian R. Jones, MRCPsych, PhD, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Ian R Jones
- Katie J. S. Lewis, BSc, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University; Russell G. Foster, BSc, PhD, FRS, Sleep and Circadian Neuroscience Institute, Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford; Ian R. Jones, MRCPsych, PhD, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
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Kulkarni J, Storch A, Baraniuk A, Gilbert H, Gavrilidis E, Worsley R. Antipsychotic use in pregnancy. Expert Opin Pharmacother 2015; 16:1335-45. [DOI: 10.1517/14656566.2015.1041501] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Lawson A, Murphy KE, Sloan E, Uleryk E, Dalfen A. The relationship between sleep and postpartum mental disorders: A systematic review. J Affect Disord 2015; 176:65-77. [PMID: 25702602 DOI: 10.1016/j.jad.2015.01.017] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 01/14/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postpartum mental disorders (e.g., anxiety, depression, psychosis) are serious conditions that affect approximately 10-15% of women after childbirth, and up to 40% of women at risk for these disorders. Research reveals an association between poor sleep quality/quantity and symptoms of anxiety, depression and psychosis. The aim of this systematic review was to evaluate the available evidence for the relationship between sleep and postpartum mental disorders. METHODS Searches included MEDLINE, EMBASE, and EBM Reviews - Cochrane Central Register of Controlled Trials, PsycINFO and EBSCOHost CINAHL through June 30, 2014. Manual searching was performed on reference lists of included articles. Published primary research in any language was included. RESULTS There were 3187 unique titles/abstracts and 44 full-text articles reviewed. Thirty-one studies were included. Evidence was found for the impact of self-reported poor sleep during pregnancy and the postpartum on the development of postpartum depression, with not enough evidence for either postpartum anxiety or psychosis. The evidence for objectively assessed sleep and the development of postpartum disorders was mixed. Among the 31 studies included, 1 was strong, 13 were moderate and 17 were weak. LIMITATIONS Research design, method of assessment, timing of assessment, recruitment strategies, representative adequacy of the samples and inclusion/exclusion criteria all varied widely. Many studies did not use tools validated for the perinatal population and had small sample sizes without power analysis. CONCLUSIONS Sleep interventions represent a potential low-cost, non-pharmacological prevention and treatment strategy for postpartum mental illness. Further high-quality research is needed on this topic area.
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Affiliation(s)
- Andrea Lawson
- Mount Sinai Hospital, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| | - Kellie E Murphy
- Mount Sinai Hospital, Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Eileen Sloan
- Mount Sinai Hospital, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Uleryk
- The Hospital for Sick Children, Library Sciences, Toronto, Ontario, Canada
| | - Ariel Dalfen
- Mount Sinai Hospital, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014; 384:1789-99. [PMID: 25455249 DOI: 10.1016/s0140-6736(14)61278-2] [Citation(s) in RCA: 294] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The perinatal period is associated with an increased risk of severe mental disorders. We summarise the evidence regarding the epidemiology, risk factors, and treatment of severe mental illness in relation to childbirth, focusing on bipolar disorder, affective psychosis, and schizophrenia. We discuss women with ongoing chronic conditions and those with the onset of new episodes of post-partum psychosis. Despite the importance of perinatal episodes, with suicide a leading cause of maternal death, few studies are available to guide the management of women with severe mental disorders in pregnancy and the post-partum period. However, general principles of management are discussed, including the need for an individual risk-benefit analysis for each woman.
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Affiliation(s)
- Ian Jones
- National Centre for Mental Health, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, UK.
| | - Prabha S Chandra
- National Institute of Mental Health and Neurosciences (NIMHNS), Bangalore, India
| | - Paola Dazzan
- Department of Psychosis Studies, Institute of Psychiatry, King's College London, UK
| | - Louise M Howard
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, UK
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Affiliation(s)
- Adib Essali
- Psychiatry Centre, Teshreen Hospital, Damascus, Syrian Arab Republic.
| | - Samer Alabed
- Department of Continuing Education, University of Oxford, Oxford, UK
| | - Aisha Guul
- Sunderland Royal Hospital, Sunderland, Tyne and Wear, UK
| | - Norah Essali
- Kalamoon University, Damascus, Syrian Arab Republic
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Abstract
BACKGROUND Postnatal psychosis is a worldwide life-threatening condition that affects one to two in every 1000 new mothers. It has an abrupt onset within a month of childbirth. Affected new mothers rapidly develop frank psychosis, cognitive impairment, and disorganised behaviours. Factors that increase the risk of postnatal psychosis include primiparous mothers who are single, women who are older, or with a past psychiatric history and family history of affective psychosis, prenatal depression and autoimmune thyroid dysfunction. The risk of a future postnatal recurrence is 25% to 57%. Preventive interventions for postnatal psychosis aim at identifying women with risk factors, early recognition of imminent psychosis through screening, and preventive drug therapy. Mood stabilisers, antipsychotic drugs and hormone therapy may be beneficial in the prevention of postnatal psychotic episodes in women at risk. OBJECTIVES To investigate the best available evidence for interventions aimed at preventing postnatal psychosis. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2012 using the search strategy of the Cochrane Schizophrenia Group. SELECTION CRITERIA All randomised controlled trials relevant to the prevention of postnatal psychosis. DATA COLLECTION AND ANALYSIS Two review authors inspected all citations to ensure reliable selection. If we had included relevant trials, we planned to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors would have independently extracted data. For homogenous dichotomous data, we planned to calculate the risk ratio (RR), 95% confidence interval (CI), and the number needed to treat to benefit/harm (NNTB/NNTH) on an intention-to-treat basis. MAIN RESULTS There are no included studies in this review. The electronic search produced three relevant references, among which we identified two old planned trials that seem never to have started, and one which we excluded a study because it was a report of a case series. AUTHORS' CONCLUSIONS This is not an empty review - it is a review full of unanswered questions. Despite growing interest in women's mental health, the literature in the area of postnatal psychosis is still very limited. It seems that clinicians have no choice but to continue with their current practices guided solely by varied clinical judgement. Women at risk of postnatal psychosis and their relatives are justified to be disappointed in the medical/research fraternity. A post hoc PubMed topic (not methodology-specific) search identified mainly case series. Policy makers have no trial-based evidence upon which to base their guidelines. Certainly, preventive interventions for postnatal psychosis are difficult to justify with confidence without well-designed, well-conducted, and well-reported randomised studies. Available publications suggest that such studies are possible and funders of research may wish to make this work a priority.
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Affiliation(s)
- Adib Essali
- Psychiatry Centre, Modern Psychiatry Hospital, Damascus, Syrian Arab Republic. .
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Immune system dysregulation in first-onset postpartum psychosis. Biol Psychiatry 2013; 73:1000-7. [PMID: 23270599 DOI: 10.1016/j.biopsych.2012.11.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 10/18/2012] [Accepted: 11/01/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Accumulating evidence suggests that dysregulation of the immune system represents an important vulnerability factor for mood disorders. Postpartum psychosis (PP) is a severe mood disorder occurring within 4 weeks after delivery, a period of heightened immune responsiveness and an altered endocrine set point. Therefore, the aim of this study was to examine immune activation in patients with first-onset PP at the level of monocytes, T cells, and serum cytokines/chemokines. METHODS We included 63 women admitted with first-onset PP. Control groups included healthy postpartum (n = 56) and nonpostpartum (n = 136) women. A quantitative-polymerase chain reaction monocyte gene expression analysis was performed with 43 genes previously identified as abnormally regulated in nonpostpartum mood disorder patients including the isoforms of the glucocorticoid receptor. Peripheral blood mononuclear cells percentages were measured by fluorescence-activated cell sorter analysis, whereas serum cytokines/chemokines were determined with a cytometric bead array. RESULTS In healthy women, postpartum T cell levels were significantly elevated compared with nonpostpartum. Patients with PP failed to show the normal postpartum T cell elevation. In contrast, these patients showed a significant elevation of monocyte levels and a significant upregulation of several immune-related monocyte genes compared with control subjects postpartum and nonpostpartum. Furthermore, the glucocorticoid receptor α/β gene expression ratio was decreased in monocytes of PP patients, strongly correlating with their immune activation. CONCLUSIONS This study demonstrates a robust dysregulation of the immuno-neuro-endocrine set point in PP, with a notable over-activation of the monocyte/macrophage arm of the immune system.
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