Bipolar Disorder in the Postpartum Period: Management Strategies and Future Directions

Post-partum depression: From clinical understanding to preclinical assessments

Post-partum depression (PPD) with varying clinical manifestations affecting new parents remains underdiagnosed and poorly treated. This minireview revisits the pharmacotherapy, and relevant etiological basis, capable of advancing preclinical research frameworks. Maternal tasks accompanied by numerous behavioral readouts demand modeling different paradigms that reflect the complex and heterogenous nature of PPD. Hence, effective PPD-like characterization in animals towards the discovery of pharmacological intervention demands research that deepens our understanding of the roles of hormonal and non-hormonal components and mediators of this psychiatric disorder.

A Comprehensive Review on Postpartum Depression

One of the most common psychological effects following childbirth is postpartum depression. Postpartum depression (PPD) has a significant negative impact on the child's emotional, mental as well as intellectual development if left untreated, which can later have long-term complications. Later in life, it also results in the mother developing obsessive-compulsive disorder and anxiety. Many psychological risk factors are linked with PPD. The pathophysiology of the development of PPD is explained by different models like biological, psychological, integrated, and evolutionary models, which relate the result of the condition with particular conditions and factors. This article also explains the role of methyldopa as a medication used during pregnancy and the postpartum phase with the development of PPD. There are different mechanisms by which methyldopa causes depression. The large-scale screening of the condition can be done by Edinburgh Postnatal Depression Scale (EPDS). The diagnosis can be made by clinical assessment, simple self-report instruments, and questionnaires provided to mothers. Currently, there has not been any specific treatment for PPD, but selective serotonin reuptake inhibitors (SSRIs) like sertraline are effective in acute management. Venlafaxine and desvenlafaxine are serotonin-norepinephrine reuptake inhibitors used for the relief of symptoms. The SSRI and tricyclic antidepressants (TCA) used in combination have a prophylactic role in PPD. Nowadays, women prefer psychological therapies, complementary health practices, and neuromodulatory interventions like electroconvulsive therapy more than previous pharmacological treatments of depression. Allopregnanolone drug made into sterile solution brexanolone leads to a rapid decline of PPD symptoms. PPD is a common and severe disorder that affects many mothers following childbirth but is ignored and not given much importance. Later it affects the child's psychological and intellectual abilities and mother-child bonding. We can easily prevent it by early diagnosis and timely care and management of the mother. Understanding the underlying pathophysiology would also go a long way in preventing and managing the disorder.

Advancing health through research: A scoping review of and model for adjunctive psychosocial interventions to improve outcomes for perinatal women with bipolar disorder

BACKGROUND

We aimed to identify randomized clinical trials (RCTs) which evaluated the efficacy of adjunctive psychosocial interventions to improve outcomes during the perinatal period for women with bipolar disorder (BD).

METHODS

We scanned the literature to identify RCTs evaluating the efficacy of adjunctive psychosocial therapies or interventions provided during the perinatal period to women with BD. We searched from 1946 to July 2020 using Embase, Ovid Medline, PsycINFO, and Scopus. We then searched for future, current, and recently completed RCTs described on www.ClinicalTrials.gov.

RESULTS

This scoping review (1946 - July 2020) revealed no published RCTs for this population. The findings expose an important gap in research and knowledge, as well as a health disparity.

CONCLUSION

We heuristically tied a mechanistic stress reduction model to relevant findings. The initial hypotheses are informed by effective stress reducing psychosocial interventions for: a) people with BD outside the perinatal period and b) perinatal women with major depressive disorder (MDD may improve the health of perinatal women with BD). We hypothesize that the perinatal trajectory of health for women with BD will improve by adding psychosocial interventions or therapies to treatment as usual. We propose maternal stress reduction as a potential mediator/mechanism.

LIMITATIONS

Findings reported are limited to the methods of a scoping review. Reproductive status tends to be a missing variable; we highlight the need for its inclusion. Interdisciplinary, collaborative research to improve the treatment outcome for perinatal women with BD is warranted and ripe for advancement.

Clinical characteristics of bipolar disorders with postpartum depressive onset

BACKGROUND

Postpartum period is associated with an increased risk of bipolar disorder diagnosis and relapse, mainly major depressive episode. Onset during this period might be associated with specific characteristics.

AIM

To compare the socio-demographic and clinical characteristics of parous women presenting with bipolar disorder and an index depressive episode occurring during or outside the postpartum period.

METHODS

Using the multicenter cohort FACE-BD (FondaMental Academic Centers of Expertise for Bipolar Disorders), we considered all women who started their BD with a major depressive episode and have at least one child. We compared two groups depending on the onset: in or outside the postpartum period.

RESULTS

Among the 759 women who started BD with a major depressive episode, 93 (12.2%) had a postpartum onset, and 666 (87.8%) had not. Women who started BD in the postpartum period with a major depressive episode have a more stable family life, more children, an older age at onset, more Bipolar 2 disorder, less history of suicide attempts, less depressive episodes and more mood stabilizer treatments as compared to those who started with a major depressive episode outside the postpartum period. The multivariable logistic regression showed that women with an onset in the postpartum period had significantly more children, less lifetime depressive episodes and a lower rate of history of suicide attempts as compared to women with an onset outside the postpartum period.

DISCUSSION

Our results suggest that women starting their BD with postpartum depression have a more favorable course of BD, especially less history of suicide attempt and less lifetime depressive episodes.

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.

Bipolar Disorder in the Menopausal Transition

PURPOSE OF REVIEW

We review recent data on bipolar disorder in menopausal-aged women, particularly in women undergoing the menopausal transition (MT). We discuss evidence on the severity of symptoms in bipolar women during the MT. Moreover, we address two factors in bipolar disorder and menopausal research: standardized menopausal staging and women's conceptualization of their menopausal and bipolar symptoms.

RECENT FINDINGS

While there are few studies within the last 5 years on bipolar women undergoing the MT, new evidence suggest that mood symptoms in women worsen with progression through the MT. Consistent use of the standardized menopausal staging system can facilitate understanding of the timing of worsening symptoms. Moreover, whether women conceptualize their symptoms as arising from their MT or bipolar disorder can influence whether they seek hormonal therapy or psychiatric treatment, respectively. The MT is a potential time for mood instability in vulnerable women, which can manifest as first-onset development of bipolar disorder or increased symptom severity in women with pre-existing bipolar disorder. Adoption of a standardized menopausal staging may offer novel frameworks for understanding of the role of the MT in bipolar disorder.

"What if I get ill?" perinatal concerns and preparations in primi- and multiparous women with bipolar disorder

Background

Women with bipolar disorder have a high risk of illness relapse postpartum, including psychosis. The aim of the study was to explore how perinatal women with bipolar disorder relate to the risk. What are their concerns? How do they prepare for the dual demands of mood episodes and motherhood?

Methods

A qualitative study was conducted. To ensure rich insight into the research questions, 13 primiparous and 13 multiparous women with bipolar disorder (I or II), were individually interviewed in pregnancy or early postpartum. Thematic analysis was applied.

Results

Across parity, concerns for illness relapse included concerns for depression and psychosis. Primiparous women worried about “the unknown” in relation to postpartum reactions. Overall, the most significant concerns were the impact of mood episodes on mothering and on the partner. Concerns regarding the infant were maternal medication, mood episodes affecting the child, and heredity. Resources and preparations included: support from the partner, the family, and health services; adjustment of daily life; and mental strategies. Women were aware of the postpartum risk, but their levels of personal concern varied between low, moderate and high. Women with low level of concern for illness relapse had made the least deliberations and preparations. A subgroup of women with high level of concern also had limited resources and preparations.

Conclusions

The findings highlight the importance of including a psychological and psychosocial focus in perinatal prevention planning and counselling. Even if women with BD are informed about the increased risk of illness relapse postpartum, they relate to it differently. Their level of personal concern impacts their perinatal deliberations and preparations, which in turn may impact postpartum adjustment. When counselling these women, it is important to assess their personal risk recognition, perinatal concerns and available resources and preparations, and support them accordingly. Extra attention should be given to women with a low level of concern, and women with a high level of concern who have limited resources and preparations. These women represent particularly vulnerable subgroups that are critical to identify and offer comprehensive follow-up.

Psychoactive drug exposure during breastfeeding: a critical need for preclinical behavioral testing

Breastfeeding women are excluded from clinical trials of psychoactive drugs because of ethical concerns. Animal testing, which often is predictive of adverse effects in humans, represents the only avenue available for assessing drug safety for human offspring exposed to drugs during lactation. I determined whether behavioral outcomes for children exposed during breastfeeding to antidepressants, anxiolytics, antipsychotics, anti-seizure medications, analgesics, sedatives, and marijuana can be predicted by rodent studies of offspring exposed to drugs during lactation. Animal data were available for only 10 of 80 CNS-active drugs canvassed. Behavioral deficits in adolescence or adulthood in rats and mice after various drug exposures during lactation included reductions in sexual behavior, increased anxiety, hyperactivity, and impaired learning and memory. Whether similar adverse effects will emerge in adulthood in children exposed to drugs during breastfeeding is unknown. Rodent research has the potential to forecast impairments in breastfed children long before information emerges from post-marketing reports and should be prioritized during preclinical drug evaluation by the FDA for new drugs and for drugs currently prescribed off-label for lactating women.

Is parity status associated with bipolar disorder clinical features, severity or evolution?

OBJECTIVE

To assess prospectively the association of the number of past pregnancies on the evolution of bipolar disorder (BD).

METHODS

Data were drawn from the 2 waves of the National Epidemiologic Study of Alcohol and Related Conditions (NESARC), a representative sample of the US population of 34,653 participants. All women diagnosed with BD were included. The number of children and BD's characteristics, i.e. BD type, age of onset, hospitalization and suicide attempt, and lifetime psychiatrics comorbidity were assessed at wave 1. Mood episode and BD's characteristics were also assessed at wave 2.

RESULTS

In the sample of 1190 women with BD, 27% had no child, 17% had one, 25% had two 31% had three children or more. Women with at least two children were more likely to have BD I, to report hypomania and suicide attempt during the follow-up than women without child. Parity was not associated with other characteristics of BD, nor with the severity and course of the illness.

LIMITATIONS

Not provide information on pregnancies not ending to a delivery.

CONCLUSION

Parity is associated with a higher incidence of hypomania and suicide attempt during a 3-years follow-up in women with BD.

Postpartum depression: bipolar or unipolar? Analysis of 434 Polish postpartum women

Objective

To assess the prevalence of soft bipolar features in a sample of women with postpartum depressive symptoms, as well as to compare the sociodemographic and obstetric characteristics of subjects with bipolar or unipolar postpartum depressive symptomatology.

Methods

Four hundred and thirty-four participants were enrolled in this cross-sectional study. Postpartum depression (PPD) symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), while the Mood Disorder Questionnaire (MDQ) was used to screen for bipolarity features.

Results

Of the 434 participants, 66 (15.2%) scored ≥ 13 points on the EPDS, thus fulfilling the screening criteria, and 103 scored ≥ 7 points on the MDQ. In comparison with non-depressed subjects, the women who scored positively on the EPDS were significantly more likely to exhibit symptoms of bipolar spectrum disorders (38 vs. 21%; chi-square test, p = 0.015). Women with bipolar PPD symptomatology were significantly younger than those exhibiting unipolar PPD symptoms (31.0±4.8 years vs. 28.5±4.1 years; t-test, p = 0.03). The groups did not differ in terms of obstetric characteristics.

Conclusion

Our findings suggest that patients with PPD symptomatology may be more likely to exhibit soft bipolarity features as compared with non-depressed women.

Bipolar II disorder as a risk factor for postpartum depression

OBJECTIVES

There is evidence for a bipolar diathesis in postpartum depression (PPD) and women presenting with a first PPD frequently receive a diagnosis of bipolar type II disorder (BD-II). However formal evidence for an association between BD-II and PPD has not yet been reported. In the present study we tested a potential association between BD-II and PPD.

METHODS

Parous women with a diagnosis of bipolar type I disorder (BD-I) (n=93), BD-II (n=36) or major depressive disorder (MDD) (n=444) were considered in the present study. All women were retrospectively evaluated for history of PPD (DSM-IV criteria) and other clinical and socio-demographic features.

RESULTS

Women with a history of PDD (n=139, 24%) were younger, younger at illness onset and had more family history for BD compared to women without history of PPD (n=436, 75.9%). Half of BD-II women reported PPD (50%), compared to less than one-third of BD-I and MDD women (respectively 27.5% and 21.6%) (p=0.004).

LIMITATIONS

Limitations include the retrospective assessment of PPD and no available data about the timing of postpartum episodes, illness onset or psychiatric care before or after childbirth, and the number of postpartum episodes.

CONCLUSIONS

BD-II may confer a remarkable risk for PPD, which may be even higher than that of women affected by BD-I disorder. Careful monitoring of BD-II women during the pregnancy and postpartum period, as well as assessment of bipolar features in women with a PPD without a current diagnosis of BD are recommended.

Second-Generation Antipsychotics During the Lactation Period: A Comparative Systematic Review on Infant Safety

OBJECTIVE

This review examined the safety of second-generation antipsychotics (SGAs) in exposed breastfed infants.

METHODS

PubMed was searched for English language reports between January 1, 1990, to June 30, 2015, by using combinations of the key words breastfeeding, lactation, postpartum period, puerperium, antipsychotics, second-generation antipsychotics, olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole, amisulpride, clozapine, asenapine, lurasidone, and iloperidone. Case reports, case series, and prospective or cross-sectional studies including relevant data such as relative infant dose (RID), milk-to-plasma ratio (M/P ratio), infant drug plasma levels, and adverse events were identified.

RESULTS

A total of 37 relevant reports were examined. These reports included a total of 206 infants exposed to olanzapine (n = 170), quetiapine (n = 14), risperidone/paliperidone (n = 8), clozapine (n = 6), aripiprazole (n = 4), ziprasidone (n = 2), and amisulpride (n = 2). Approximately half of the available data on the M/P ratio, RID, and infant drug plasma levels included olanzapine. Relatively adequate reports suggest that olanzapine has low RID values. Limited reports suggest low RID values for quetiapine and ziprasidone, moderate RID values for risperidone/paliperidone and aripiprazole, and high RID values for amisulpride. Antipsychotic levels were undetectable in the plasma of most of the exposed infants. Other than clozapine, adverse events were rarely reported in infants exposed to SGAs.

CONCLUSIONS

The current data suggest that SGAs seem to be relatively safe in the exposed breastfed infants for short-term usage. However, additional studies, in particular for antipsychotics other than olanzapine, examining short-term and especially long-term effects of SGAs on the breastfed infants are required.