Bipolar disorder in the perinatal period
Bipolar disorder, which used to be called manic depression, involves both periods of feeling low (depressed) and high (mania). While the cause is unknown, it is clear that bipolar disorder is frequently inherited and often linked to stressful life events.
Women who have a history of bipolar disorder in their family may have a first episode during pregnancy or in the postnatal period. Women who have had bipolar disorder or puerperal psychosis before have a high risk of relapse at this time.
Women experiencing bipolar disorder during the perinatal period may focus their fears and depressive concerns on the pregnancy, the wellbeing of the baby or feelings of inadequacy as a parent. Comprehensive mental health assessment and involvement of a psychiatrist are necessary in the care of women experiencing symptoms of bipolar disorder.
Medications and continued monitoring are required to treat and manage this biological condition.
Symptoms of bipolar disorder
Symptoms of bipolar disorder during pregnancy or in the postnatal period are the same as those at other times. Whether the woman is in a depressed or manic phase, her ability to care for her baby will be significantly affected and she may be at risk of suicide or harming herself or her baby.
Some women with bipolar disorder have symptoms of psychosis. These include seeing or hearing things/people that are not there (hallucinations), feeling everyone is against them (paranoia) and having beliefs that are not based on reality (delusions).
Common symptoms of depression and mania associated with bipolar disorder
| Common behaviour associated with depression | Common behaviour associated with mania |
|---|---|
| Moodiness that is out of character | Increased energy |
| Increased irritability and frustration | Irritability |
| Finding it hard to make minor personal criticisms | Over-activity |
| Spending less time with friends and family | Increased spending |
| Loss of interest in food, sex, exercise or other pleasurable activities | Being reckless or taking unnecessary risks (e.g. driving fast or dangerously) |
| Being awake throughout the night | Increased sex drive |
| Increased alcohol and drug use | Racing thoughts |
| Staying home from work or school | Rapid speech |
| Increased physical symptoms (e.g. fatigue or pain) | Decreased sleep |
| Slowing down of thoughts and actions | Grandiose ideas |
| Hallucinations and/ or delusions (psychosis) | Hallucinations and/ or delusions (psychosis) |
| Suicidal thoughts or thoughts of harming baby |
Assessment of bipolar disorder
When assessing women for bipolar disorder in the perinatal period, a diagnosis is based on accepted diagnostic criteria (DSM-V or ICD-10).
Appropriate response to assessments is likely to involve referral for specialist mental health assessment. Urgent referral is needed when a woman has severe symptoms or suicidal thinking.
A woman with severe symptoms is likely to require admission into a psychiatric hospital setting, especially if she may be at risk of harming herself or her baby. Hospital admission facilitates stabilisation of symptoms and initiation of medications with ongoing monitoring by health professionals. Admission to a psychiatric setting with a mother and baby unit is preferable where available, so mother and baby can stay together.
Following discharge from hospital, ongoing support and monitoring of mother and baby by a specialist mental health professional is required.
Management of bipolar disorder
Management of bipolar disorder in the perinatal period requires medications to stabilise symptoms and reduce the likelihood of relapse. Assessment and monitoring of the mother–infant interaction is a key part of care of both mother and infant.
Medications
Advice should be sought from a psychiatrist before medications are prescribed, changed or ceased, and the potential risks and benefits to the woman and foetus/baby should be considered. Medication should not be ceased suddenly.
The choice of medications will depend on the range of symptoms. Mood stabilisers are used to treat manic episodes and psychotic symptoms and help reduce relapse. Antipsychotics and antidepressants may also be of benefit.
Medications during pregnancy
In pregnancy or planning pregnancy, women taking mood stabilising drugs should be advised to supplement with high dose folate preconception and in the first trimester (to reduce the small increased risk of birth defects with these drugs) and consult with a psychiatrist.
Sodium valproate and clozapine should not be prescribed to women planning pregnancy or during pregnancy without consulting a psychiatrist.
Lithium is associated with a very small increased risk of birth defects and consultation with a psychiatrist is advised.
Medications during breastfeeding
Given the need for medication and maximising sleep in women with bipolar disorder, the advantages and disadvantages of breastfeeding for mother and baby need to be discussed with the woman and her partner.
Sodium valproate and clozapine should not be used without consultation with a psychiatrist.
Lithium should be used cautiously. Advice should be sought from a psychiatrist if breastfeeding and it is important to ensure close monitoring of the baby by a specialist (e.g. neonatologist/paediatrician).
A woman’s physical activity levels and diet need to be considered if she is taking antipsychotics in the postnatal period, due to their association with weight gain.
Electroconvulsive therapy (ECT)
ECT may be used to treat acute mania, psychosis and severe depression during pregnancy or following the birth. If ECT is used during pregnancy, close monitoring by a psychiatrist, obstetrician and specialist obstetric anaesthetist is required.
Psychological therapies
Psychological therapies, such as cognitive behaviour therapy (CBT) or interpersonal psychotherapy (IPT), can assist women to develop effective coping strategies as they recover. Mother–infant therapy can be useful in promoting mother-infant bonding. Counselling/support is also recommended for the partner and key support people.
Key points to remember
Some things to remember about assessing and managing bipolar disorder in the perinatal period are:
- The possibility of bipolar disorder should be considered in women with current or past symptoms of mania, whether or not they have had a depressive episode, especially if the woman has a personal/family history of bipolar disorder.
- Comprehensive mental health assessment should be arranged for women with recurrent or new onset of bipolar disorder, suicidal thinking or if there is risk of harm to the woman, infant or other children in her care.
- Monitoring for relapse is required when women choose to discontinue medication during the perinatal period.
- It is important to discuss and review medication when a woman is planning a pregnancy, when a pregnancy is confirmed and following the birth.
- Assessment should be made for side effects and/or lack of initial response shortly after treatment is initiated.
- Minimising stress and maximising sleep are vital. Where possible, it is beneficial for women to draw on support from family members, friends, the community and/or health services, including in-home support or respite services. As the woman recovers, a routine that allows both parents to have quality time, both as a couple and individually, can be helpful.