Elsevier

The Lancet Psychiatry

Volume 6, Issue 9, September 2019, Pages 786-792
The Lancet Psychiatry

Personal View
Childbirth and prevention of bipolar disorder: an opportunity for change

https://doi.org/10.1016/S2215-0366(19)30092-6Get rights and content

Summary

The recent conceptualisation of bipolar disorder as a neuroprogressive illness has highlighted the potential importance of prevention and early intervention in high-risk populations. Undiagnosed bipolar disorder early in the disease course is associated with adverse clinical outcomes and impaired functioning for patients, which in turn has economic consequences. Despite the mounting evidence that childbirth is one of the most potent and specific triggers of manic symptoms, studies are not available on the effectiveness of targeted interventions in the prevention of bipolar disorder in women who have recently given birth. In this Personal View, we describe the clinical characteristics of women at risk of developing bipolar disorder after childbirth, before discussing opportunities for prevention and early intervention and outlining challenges in the assessment and management of women at risk of transitioning to bipolar disorder after childbirth. Existing evidence, although scarce, supports a clinical staging model by which at-risk women are managed with a variety of behavioural and pharmacological interventions aimed at preventing bipolar disorder. Close monitoring and early intervention might reduce the risk of hypomanic or manic symptoms in women at risk of developing bipolar disorder after childbirth; however, the potential benefits of early identification and intervention need to be carefully balanced against the additional risks for affected women.

Introduction

Bipolar disorder is a common chronic illness that in the most recent global survey in 2011 affected 2·4% of the world's population.1 As the fourth leading cause of disability worldwide among young people,2 bipolar disorder generally begins in late adolescence or early adulthood, and is associated with notable morbidity and mortality.3 Receiving the correct diagnosis of bipolar disorder often takes several years.4, 5 Not identifying and appropriately managing cases of bipolar disorder early in the disease course can be associated with adverse clinical and functional consequences for patients, and economic consequences for individuals and society.5 The recent conceptualisation of bipolar disorder as a neuroprogressive illness has highlighted the potentially important role of prevention and early intervention in high-risk populations.6 More specifically, early intervention strategies might prevent or attenuate the cognitive and structural brain changes seen in the later stages of the disorder.6, 7, 8 Thus, by optimising recognition and treatment, early intervention programmes might help to minimise neuroprogression and eliminate the deleterious consequences associated with misdiagnosis or delayed diagnosis of bipolar disorder.9 As the majority of individuals with bipolar disorder begin to show symptoms in late adolescence, studies on early intervention strategies have primarily focused on adolescents.10, 11, 12 However, no large-scale research on the prevention of bipolar disorder in women who have recently given birth (up to 4 weeks post partum) has been done, despite childbirth being among the most potent and specific triggers of hypomania or mania.13 Why childbirth is such a potent trigger is not completely understood, but might be related to puerperal hormonal and genetic factors that activate disease pathways.14 In a substantial subgroup of women, we postulate that manic or hypomanic episodes indicative of bipolar disorder could occur for the first time after childbirth. Puerperal psychosis (defined as brief psychotic disorder, or a psychotic episode in the context of major depressive disorder, bipolar I disorder or bipolar II disorder),15 a rare but serious complication of childbirth, can be the first manifestation of bipolar disorder in some women.16, 17 Furthermore, some evidence exists that women with bipolar disorder are at an increased risk of psychiatric hospitalisation immediately after delivery.18, 19, 20 The risk of maternal suicide and infanticide in women with puerperal psychosis also increases after childbirth.16, 21, 22 Additionally, bipolar disorder might have a negative effect on mother–child interactions and child development.23 Thus, implementation of prevention programmes during and after pregnancy might reduce the number and severity of episodes in women at high risk of developing bipolar disorder, which would benefit not only the mother, but also her child and family, and ultimately society. In this Personal View, we describe the clinical characteristics of women at risk of developing bipolar disorder after childbirth, and discuss opportunities in this context for prevention and early intervention. We also outline challenges in the assessment and management of women at risk of transitioning to bipolar disorder after childbirth.

Section snippets

Clinical characteristics of at-risk women

Research evidence has accumulated in relation to clinical characteristics associated with the risk of first onset of hypomania or mania in the perinatal period. The high-risk population showing these characteristics includes women with a history of bipolar disorder in a first-degree family member24 or of puerperal psychosis in a first-degree family member, who have: (1) no previous history of psychiatric illness, including no history of subthreshold symptoms of hypomania, mania, or depression;25

Why is the post-partum period an opportune time for prevention?

The post-partum period is ideally suited for primary and secondary prevention (defined in the appendix) of bipolar disorder. Women are routinely under the care of health professionals during and after pregnancy.40 Some of the putative risk factors of bipolar disorder such as sleep loss, substance use, and use of antidepressants or psychostimulants can be easily targeted. Of note, mood symptoms are a common occurrence after childbirth. The relatively short duration of the risk period for

Identification and monitoring

Women at risk of developing bipolar disorder who wish to have children should be referred for preconception counselling, ideally at least 3 months before planning pregnancy, or as soon as possible after discovering they are pregnant.3 Psychoeducation should emphasise the need for regular psychiatric care to enable early detection of prodromal and early symptoms, and rapid implementation of prevention and early intervention strategies. If possible, either the woman's partner or another family

Prevention and early intervention

Strategies for prevention or early intervention in women at risk of developing bipolar disorder are outlined in panel 1. The suggested strategies are intended for use by psychiatrists, obstetricians, and primary care providers. The selection of prevention strategies for a given individual should take into consideration the clinical status of the patient, including life circumstances, existing risk factors and stressors, current psychotropic drug use (eg, antidepressants in women with major

Challenges

The implementation of prevention and early intervention strategies in mothers showing first onset of hypomania or mania after recently giving birth is challenging for several reasons. First, mood symptoms are common and occur in the majority of women—the so-called baby blues. Second, unlike the availability of screening tools for physical illnesses, such as the Framingham Risk Score for estimation of risk for coronary artery disease,70 few such instruments are available to assess the risk for

Conclusion

Mood symptoms are common after childbirth and might be a harbinger of post-partum episodes of hypomania or mania. The risk for first onset of hypomania or mania during the puerperium is greatly increased, and higher than in any other period in a woman's life. Because of the universality of sleep disruption around childbirth and the purported role of sleep deprivation as a trigger for bipolar disorder, the post-partum period presents a unique opportunity for early detection and prevention of

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