Postpartum Relapse in Patients with Bipolar Disorder: Comparison
View Latest Version
Please note this is a comparison between Version 2 by Dean Liu and Version 3 by Dean Liu.

Pregnancy and postpartum are vital times of greater vulnerability to suffer a decompensation of bipolar disorder (BD).

  • bipolar disorder
  • postpartum
  • treatment
  • management
  • relapse
  • prevention

1. Introduction

Bipolar Disorder (BD) is a severe affective mood disorder characterized by a wide range of lifelong mood changes, varying between depressive, hypomanic, or manic, with or without mixed features [1][2]. Because of the average age of onset of BD, many women will face their reproductive desires with the threat of the risks inherent to this pathology. Pregnancy is a critical period, both physiologically and emotionally, with an increased likelihood of relapse. Although much uncertainty still remains about the risk of mood episodes during pregnancy [3], women with a history of BD are at high risk for postpartum relapse [4].
Postpartum is a period of high risk for the appearance and recurrence of psychiatric disorders, particularly depression, mania, and psychoses [5]. In a classical population-based cohort, patients with BD had a postpartum risk of psychiatric admission due to relapse of 16%, much higher than that of other mental disorders (3% for patients with schizophrenia and 2% for patients with major depressive disorder) [6]. Munk-Olsen et al. [7] analyzed the risk of perinatal psychiatric readmission in a population of more than 28,000 women with preexisting mental illness, finding a higher relative risk of relapse during the early postpartum period for BD patients (relative risk = 37.2, 95% CI = 13.6, 102.0) compared to schizophrenia patients (relative risk = 4.6, 95% CI = 2.5, 8.5) or other psychiatric disorders (relative risk = 3.0, 95% CI = 1.9, 4.7). The period of highest risk of hospitalization for relapse in women with BD was between days 10 and 19 postpartum.
Episodes of hypomania, mania, or depression may occur in the context of BD or develop for the first time after childbirth. Although not as prevalent as the baby blues, elation and associated hypomanic symptoms (generally referred to as the “highs”) are also common after childbirth [8]. It is important to detect these “highs”, even if they do not have a functional impact, because these postpartum hypomanic symptoms may be associated with subsequent depression [8].
Childbirth can also be the trigger for bipolar depression. Of all women diagnosed with postpartum depression, 54% met the diagnostic criteria for BD, but only 10% of those had a previous diagnosis [9], which suggests the need for screening. These depressions usually have diurnal variations in mood, hypersomnia, hyperphagia, distractibility, and irritability. Therefore, BD depression should be considered postpartum in women with atypical depressive symptoms, with a family history of BD, or who do not respond to antidepressant treatment [10]. When these patients are being treated with antidepressants, they may present mixed features, in which the probability of suicide is higher, so close monitoring is required [11].
Significant hormonal changes and physiological changes after childbirth can act as a trigger for relapse in these patients [12]. In many cases, the psychopharmacological treatment of the patient is suspended during pregnancy, due to the teratogenic risk, which depends on the characteristics of the drug and the time of exposure [13].
Underestimation of relapse risk could lead to ineffective prevention strategies and delayed referral for specialized perinatal care, could impair quality of life, and could cause a higher rate of acute hospitalization and suicide [14][15]. The relevance of this issue transcends into the planning of subsequent pregnancies. Women with first-onset postpartum mania or psychosis are less likely to have more children, and, furthermore, women with BD are known to have lower fertility rates compared to the general population [16]. The likelihood of obstetric complications (such as gestational hypertension and antepartum hemorrhage, labor induction, cesarean section) and complications to the fetus (low birth weight, increased risk of malformations, increased neonatal morbidity) is also higher in this population [17].

2. Clinical Characteristics

The most important clinical variable analyzed is the type of BD. Considering the data from the 13 studies that differentiated between type I and II BD [15][18][19][20][21][22][23][24][25][26][27][28][29], the weighted mean percentage of patients with BD type I was 69.83%. One of the studies included segregated the results into two different types of category: BD type I/schizoaffective BD and BD type II/BD not otherwise specified, and related disorders [28]. The studies generally analyze very heterogeneous clinical factors, although there are some common variables among the studies that are of interest, such as the age of onset of the illness [18][19][20][21][22][23][24][25][26][30], family history of affective disorder [21][23][24][26][27], duration of the illness [22][24][26][28][30], presence of episodes in the past [23][24][26][28], previous perinatal episodes (depending on the article, researchers will speak specifically of late pregnancy, postpartum, and/or puerperium) [15][21][22][25][27][28][29], rapid cycling [23][26][29], the use of prophylaxis with mood-stabilizers and/or antipsychotics in the perinatal period [15][19][21][23][25][27][28][29][31], alcohol abuse [26][29], previous suicide attempts [20][21][26][29], or the number of hospitalizations [21][25][27][29].

3. Subtype Episode

Studies generally differentiate between manic and depressive episodes, although some differentiate specific categories of hypomanic [20][21][22][24][26] and/or mixed features (24–26,30,35). When the type of episode was specified, four studies coincided in pointing out the existence of a greater probability of suffering episodes of postpartum psychosis/mania in women with a previous diagnosis of BD I [18][20][23][28]. Considering all types of BD, depression was the most prevalent form of postpartum morbidity [20][22][26].

4. Pregnancy and Childbirth

The most studied clinical factor related to pregnancy was the number of pregnancies per woman. Most studies include, in their sample, women with a variable number of pregnancies, with only one study limiting the sample to primiparous women [32]. A postpartum relapse in the first pregnancy usually leads to a decreased likelihood of having more children [33] and to an increased risk of new episodes in subsequent pregnancies [20][23].

5. Factors Associated with Postpartum Relapse

5.1. Sociodemographic Factors

On the association between sociodemographic factors and postpartum relapse, most studies agree that there is no greater prevalence of specific characteristics in relapse episodes. There are only very few works venturing to make points in this regard, such as those who claim that the risk of relapse is more likely in women with a younger age at delivery [21] or with a smaller number of children and a higher academic level [22].

5.2. Clinical Factors

Most studies point out that risk of relapse is more prevalent in perinatal episodes having a lower-than-average age at the onset of the disease [22][23][24][30], having a longer duration of the episode [24][26], having suffered previous episodes of the disease in the past, having a family history of BD [21][23][24], or having had psychiatric hospital admissions in the period prior to pregnancy, especially if there have been several and/or recent episodes [32]. The risk of relapse was found to be higher during the postpartum period than during pregnancy in women diagnosed with BD [22][23][25], presenting similar risk patterns for a perinatal episode in the two diagnostic groups (type I and II) [22][28]. One study points out that this risk is even higher after live birth compared to miscarriage and induced abortion [23], although the chosen method of delivery could not predict the risk of relapse [18][30]. A situation of particular risk occurs when, during the period of pregnancy, no treatment is received [20]. If researchers add to this that the rate of postpartum relapse in women with BD was higher when they experienced previous episodes during pregnancy [15][22][28] or during first gestation [19][20], perinatal prophylaxis in BD becomes essential to reduce the risk of relapse [15][19][31]. Other predictors of postpartum relapse, such as obstetric complications during pregnancy [30], unplanned pregnancies, or poor disease remission during gestation, have also been reported [21].

References

  1. Grande, I.; Berk, M.; Birmaher, B.; Vieta, E. Bipolar disorder. Lancet 2016, 387, 1561–1572.
  2. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; APA: Washington, DC, USA, 2013; Available online: https://www.psychiatry.org/psychiatrists/practice/dsm (accessed on 10 May 2022).
  3. Salim, M.; Sharma, V.; Anderson, K.K. Recurrence of bipolar disorder during pregnancy: A systematic review. Arch. Womens Ment. Health 2018, 21, 475–479.
  4. Wesseloo, R.; Kamperman, A.M.; Munk-Olsen, T.; Pop, V.J.; Kushner, S.A.; Bergink, V. Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. Am. J. Psychiatry 2016, 173, 117–127.
  5. Leibenluft, E. Women with bipolar illness: Clinical and research issues. Am. J. Psychiatry 1996, 153, 163–173.
  6. Kendell, R.E.; Chalmers, J.C.; Platz, C. Epidemiology of puerperal psychoses. Br. J. Psychiatry 1987, 150, 662–673.
  7. Munk-Olsen, T.; Laursen, T.M.; Mendelson, T.; Pedersen, C.B.; Mors, O.; Mortensen, P.B. Risks and predictors of readmission for a mental disorder during the postpartum period. Arch. Gen. Psychiatry 2009, 66, 189–195.
  8. Sharma, V.; Singh, P.; Baczynski, C.; Khan, M. A closer look at the nosological status of the highs (hypomanic symptoms) in the postpartum period. Arch. Womens Ment. Health 2021, 24, 55–62.
  9. Sharma, V.; Khan, M.; Corpse, C.; Sharma, P. Missed bipolarity and psychiatric comorbidity in women with postpartum depression. Bipolar Disord. 2008, 10, 742–747.
  10. Kelly, E.; Sharma, V. Diagnosis and treatment of postpartum bipolar depression. Expert. Rev. Neurother. 2010, 10, 1045–1051.
  11. Quevedo, L.; da Silva, R.A.; Coelho, F.; Pinheiro, K.A.T.; Horta, B.L.; Kapczinski, F.; Pinheiro, R.T. Risk of suicide and mixed episode in men in the postpartum period. J. Affect. Disord. 2011, 132, 243–246.
  12. Jones, I.; Chandra, P.S.; Dazzan, P.; Howard, L.M. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014, 384, 1789–1799.
  13. Raffi, E.R.; Nonacs, R.; Cohen, L.S. Safety of Psychotropic Medications During Pregnancy. Clin. Perinatol. 2019, 46, 215–234.
  14. Appleby, L.; Mortensen, P.B.; Faragher, E.B. Suicide and other causes of mortality after post-partum psychiatric admission. Br. J. Psychiatry 1998, 173, 209–211.
  15. Bergink, V.; Bouvy, P.F.; Vervoort, J.S.P.; Koorengevel, K.M.; Steegers, E.A.P.; Kushner, S.A. Prevention of postpartum psychosis and mania in women at high risk. Am. J. Psychiatry 2012, 169, 609–615.
  16. Laursen, T.M.; Munk-Olsen, T. Reproductive patterns in psychotic patients. Schizophr. Res. 2010, 121, 234–240.
  17. Rusner, M.; Berg, M.; Begley, C. Bipolar disorder in pregnancy and childbirth: A systematic review of outcomes. BMC Pregnancy Childbirth 2016, 16, 331.
  18. Di Florio, A.; Jones, L.; Forty, L.; Gordon-Smith, K.; Blackmore, E.R.; Heron, J.; Craddock, N.; Jones, I. Mood disorders and parity—A clue to the aetiology of the postpartum trigger. J. Affect. Disord. 2014, 152–154, 334–339.
  19. Grof, P.; Robbins, W.; Alda, M.; Berghoefer, A.; Vojtechovsky, M.; Nilsson, A.; Robertson, C. Protective effect of pregnancy in women with lithium-responsive bipolar disorder. J. Affect. Disord. 2000, 61, 31–39.
  20. Maina, G.; Rosso, G.; Aguglia, A.; Bogetto, F. Recurrence rates of bipolar disorder during the postpartum period: A study on 276 medication-free Italian women. Arch. Womens Ment. Health 2014, 17, 367–372.
  21. Doyle, K.; Heron, J.; Berrisford, G.; Whitmore, J.; Jones, L.; Wainscott, G.; Oyebode, F. The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse. Eur. Psychiatry 2012, 27, 563–569.
  22. Viguera, A.C.; Tondo, L.; Koukopoulos, A.E.; Reginaldi, D.; Lepri, B.; Baldessarini, R.J. Episodes of mood disorders in 2252 pregnancies and postpartum periods. Am. J. Psychiatry 2011, 168, 1179–1185.
  23. Gilden, J.; Poels, E.M.P.; Lambrichts, S.; Vreeker, A.; Boks, M.P.M.; Ophoff, R.A.; Kahn, R.S.; Kamperman, A.M.; Bergink, V. Bipolar episodes after reproductive events in women with bipolar I disorder, A study of 919 pregnancies. J. Affect. Disord. 2021, 295, 72–79.
  24. Uguz, F.; Kirkas, A. Olanzapine and quetiapine in the prevention of a new mood episode in women with bipolar disorder during the postpartum period: A retrospective cohort study. Braz. J. Psychiatry 2021, 43, 617–620.
  25. Sharma, V.; Sommerdyk, C.; Xie, B.; Campbell, K. Pharmacotherapy of bipolar II disorder during and after pregnancy. Curr. Drug Saf. 2013, 8, 246–252.
  26. Colom, F.; Cruz, N.; Pacchiarotti, I.; Mazzarini, L.; Goikolea, J.M.; Popova, E.; Torrent, C.; Vieta, E. Postpartum bipolar episodes are not distinct from spontaneous episodes: Implications for DSM-V. J. Affect. Disord. 2010, 126, 61–64.
  27. Sharma, V.; Smith, A.; Mazmanian, D. Olanzapine in the prevention of postpartum psychosis and mood episodes in bipolar disorder. Bipolar Disord. 2006, 8, 400–404.
  28. Perry, A.; Gordon-Smith, K.; Di Florio, A.; Craddock, N.; Jones, L.; Jones, I. Mood episodes in pregnancy and risk of postpartum recurrence in bipolar disorder: The Bipolar Disorder Research Network Pregnancy Study. J. Affect. Disord. 2021, 294, 714–722.
  29. Wisner, K.L.; Hanusa, B.H.; Peindl, K.S.; Perel, J.M. Prevention of postpartum episodes in women with bipolar disorder. Biol. Psychiatry 2004, 56, 592–596.
  30. Akdeniz, F.; Vahip, S.; Pirildar, S.; Vahip, I.; Doganer, I.; Bulut, I. Risk factors associated with childbearing-related episodes in women with bipolar disorder. Psychopathology 2003, 36, 234–238.
  31. Cohen, L.S.; Sichel, D.A.; Robertson, L.M.; Heckscher, E.; Rosenbaum, J.F. Postpartum prophylaxis for women with bipolar disorder. Am. J. Psychiatry 1995, 152, 1641–1645.
  32. Harlow, B.L.; Vitonis, A.F.; Sparen, P.; Cnattingius, S.; Joffe, H.; Hultman, C.M. Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch. Gen. Psychiatry 2007, 64, 42–48.
  33. Liu, X.; Plana-Ripoll, O.; Ingstrup, K.G.; Agerbo, E.; Skjærven, R.; Munk-Olsen, T. Postpartum psychiatric disorders and subsequent live birth: A population-based cohort study in Denmark. Hum. Reprod. 2020, 35, 958–967.
More
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)
Video Production Service
Feedback