Postpartum Psychiatric Episode Predicts Bipolar Disorder

Fran Lowry

December 09, 2011

December 9, 2011 — Women who experience a psychiatric episode in the immediate postpartum period appear to have an increased risk of developing bipolar affective disorder, according to the results of a new study.

In a large Danish cohort study, women who experienced the onset of psychiatric symptoms within 14 days after delivery had a more than 4-fold increased risk of converting to bipolar disorder than women who did not experience such symptoms, Trine Munk-Olsen, PhD, from Aarhus University, Aarhus, Denmark, and colleagues reported.

Dr. Munk-Olsen told Medscape Medical News that there is a well-established link between childbirth and bipolar affective disorders and that she and others have documented this link in several studies.

She and her team conducted the present study because, despite this knowledge, many women who experience a psychiatric disorder in the immediate postpartum period do not receive a specific diagnosis of bipolar disorder.

"For this reason, we were interested in following women with non-bipolar postpartum psychiatric episodes over time to study if they, at a later stage, convert to a bipolar diagnosis," Dr. Munk-Olsen said.

The findings were published online on December 5 in the Archives of General Psychiatry.

Implications for DSM-5?

Dr. Munk-Olsen and her team conducted a cohort study drawing information from the entire Danish population using different registries as data sources covering a study period from 1973 to 2007.

They identified all women (n = 120,378) who had a first-time psychiatric episode with any type of diagnosis, excluding bipolar affective disorder, and followed them over time.

"By doing this, we identified how many women were readmitted at a later stage in their lives and diagnosed specifically with bipolar affective disorder diagnoses," she explained.

Of these women, a total of 3062 were readmitted or had an outpatient contact with bipolar affective disorder diagnoses.

The study found that a postpartum onset of symptoms 0 to 14 days after giving birth predicted subsequent conversion to bipolar disorder, with a relative risk (RR) of 4.26 (95% confidence interval [CI], 3.11 - 5.85).

Fifteen years after the initial psychiatric contact, approximately 14% of the women who had their first treatment at a psychiatric facility within the first month after delivery converted to a bipolar affective diagnosis.

In comparison, after 15 years, approximately 5% of women with later postpartum onset of psychiatric symptoms (31 - 365 days postpartum) and 4% of women who experienced their first psychiatric episode at a time not related to childbirth had converted to bipolar disorder.

The study also showed that postpartum inpatient admissions were associated with a 2-fold increased risk for conversion to bipolar disorder than did outpatient visits (RR = 2.16; 95% CI, 1.27 - 3.66).

"We hope that our study will be considered in the current debate regarding revisions of both the DSM [Diagnostic and Statistical Manual of Mental Disorders] and ICD [International Classification of Diseases] classification systems," Dr. Munk-Olsen said.

"We also believe our results provide evidence that a postpartum psychiatric episode is a marker which raises the possibility of both a current and a subsequent bipolar diagnosis, which most importantly has both diagnostic and prognostic implications," she added.

Need for Careful Evaluation

Shari I. Lusskin, MD, director of reproductive psychiatry at New York University Langone Medical Center and Mt Sinai Medical Center, New York City, told Medscape Medical News that this association has long been known, but that this study adds scientific "proof" to what clinicians know clinically.

"Women who develop their first episode of psychiatric illness in the first month after having a baby have an elevated risk of developing bipolar disorder. The relative risk is highest for those who require inpatient treatment and for those who become symptomatic in the first 2 weeks postpartum," Dr. Lusskin said.

For her, the take-home message is that women with postpartum mental illness, including postpartum depression, "should be carefully evaluated for personal and family risk factors for bipolar disorder before they are given an antidepressant."

"The big problem is people don’t appreciate that whenever you put a person on an antidepressant, there is a risk of converting them into a manic or hypermanic state if they have an underlying bipolar disorder, and by putting somebody on an antidepressant, you may unmask their bipolar disorder faster.

"So you really want to screen for bipolar disorder whenever you see a patient for depression. Clinicians tend not to do this, or they don’t do it enough," Dr. Lusskin said.

Dr. Munk-Olsen and Dr. Lusskin have disclosed no relevant financial relationships.

Arch Gen Psychiatry. Published online December 5, 2011. Abstract


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