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Early intervention key for postpartum women at risk for bipolar disorder

Implementing prevention programs and other interventions during and after pregnancy may decrease the number and severity of manic episodes in women at high risk for bipolar disorder, according to a personal view published in Lancet Psychiatry.

“No large-scale research on the prevention of bipolar disorder in women who have recently given birth (up to 4 weeks postpartum) has been done, despite childbirth being among the most potent and specific triggers of hypomania or mania,” Verinder Sharma, MBBS, from the departments of psychiatry and obstetrics and gynecology at Western University, and the Parkwood Institute, London, Ontario, Canada, and colleagues wrote.

In this personal view, Sharma and colleagues reported the clinical characteristics of women at risk for bipolar disorder after childbirth and management recommendation as well as prevision and early intervention opportunities.

Characteristics

Mood symptoms are a common occurrence after childbirth, but may be an indication of postpartum episodes of hypomania or mania, according to the researchers.

In the perinatal period, bipolar disorder risk factors may include history of bipolar disorder in a first-degree family member and subthreshold manic symptoms without family history of bipolar disorder. After childbirth, women should be considered high-risk when they experience their first onset of a major depressive episode, have major depressive disorder with mixed or psychotic features, have a history of bipolar disorder in a first-degree family member and have subsyndromal hypomanic episodes.

“The postpartum period is ideally suited for primary and secondary prevention of bipolar disorder,” Sharma and colleagues wrote. “Women are routinely under the care of health professionals during and after pregnancy. 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.”

Identification, intervention

Close clinical monitoring, especially during the third trimester, is important, according to the investigators. Women at risk for bipolar disorder should be referred for psychiatric evaluation and follow-up, according to investigators. After giving birth, clinical monitoring of women without a history of psychiatric illness should include observing for depression, hypomania, anxiety, irritability, aggressiveness and sleep disturbance.

“Women at risk of developing bipolar disorder who wish to have children should be referred for preconception counseling, ideally at least 3 months before planning pregnancy, or as soon as possible after discovering they are pregnant,” Sharma and colleagues wrote. “Psychoeducation should emphasize the need for regular psychiatric care to enable early detection of prodromal and early symptoms, and rapid implementation of prevention and early intervention strategies.”

Some other strategies for prevention and early intervention in women included:

• optimizing sleep;
• ensuring social support;
• lifestyle management;
• considering low-dose benzodiazepines or atypical neuroleptics;
• psychotherapy for more severe major depressive episodes; and
• treatment with quetiapine, lamotrigine or lurasidone for those having a severe major depressive episode and at high risk of switching to bipolar disorder.

“Evidence from other high-risk populations and on bipolar disorder in general can inform prevention strategies for women who are at risk of developing bipolar disorder after childbirth,” they researchers concluded. “However, the potential risks of identification (eg, false positives and perceived stigma and labeling) and early intervention (eg, anxiety about a diagnosis and side-effects of psychotropic medication) need to be carefully balanced against the possible benefits to the patient.” – by Savannah Demko

Disclosure: Sharma reports numerous relevant financial disclosures; please see the study for all authors’ relevant financial disclosures.