TREATMENT CHALLENGES OF BIPOLAR DISORDER DURING THE PERINATAL PERIOD
Keywords:
bipolar, pregnancy, perinatal, treatment, risk, factorsAbstract
Introduction: The perinatal period presents significant challenges for women with bipolar disorder (BD), who face heightened risks of affective episodes and postpartum psychosis.
This study aims to examine the course of BD during the perinatal period, assess associated risk factors, and evaluate therapeutic interventions.
Material and methods: This prospective cohort study included 23 women, diagnosed with BD (ICD-10), over the course of six months. Assessments included the Edinburgh Postnatal Depression Scale (EPDS), Young Mania Rating Scale (YMRS), clinical interviews, and a questionnaire on sociodemographic and risk factors. Patients received combined pharmacological and psychotherapeutic treatment.
Results: The EPDS scores showed a low likelihood of depression at baseline, 3, and 6 months (56.5%, 69.6%, 69.6%), with mean scores decreasing from baseline to three months and slightly increasing at six months (p = 0.81). The YMRS scale indicated a significant reduction in mania from baseline to six months (p = 0.038).
All participants reported risk factors, including history of affective episodes (95.6%), traumatic events, intimate-partner violence (34.8%), substance abuse (26.1%), and unplanned pregnancy (21.7%). There was no significant correlation between risk factors and depression (p >0.05).
Conclusion: The findings of the study confirm the increased risk of mood episodes in women with (BD) during the perinatal period. Continuous treatment and long- term monitoring play a vital role in reducing the incidence and severity of affective episodes. Identifying and managing risk factors is crucial for providing effective individualized care during this vulnerable period.
References
Doyle K, Heron J, Berrisford G, Whitmore J, Jones L, Wainscott G, et al. The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse. Eur Psychiatry 2012; 27(8): 563–569. doi:10.1016/j.eurpsy.2011.06.011.
Yonkers KA, Wisner KL, Stowe Z, Leibenluft E, Cohen L, Miller L, et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004; 161: 608–620. doi:10.1176/appi.ajp.161.4.608.
Grof P, Robbins W, Alda M, Berghoefer A, Vojtechovsky M, Nilsson A, et al. Protective effect of pregnancy in women with lithium-responsive bipolar disorder. J Affect Disord 2000; 61(1–2): 31–39. doi:10.1016/s0165-0327(99)00197-4.
Freeman MP, Smith KW, Freeman SA, Elroy SL, Kmetz GF. The impact of reproductive events on the course of bipolar disorder in women. J Clin Psychiatry 2002; 63(4): 284–287. doi:10.4088/jcp.v63n0403.
Masters GA, Hugunin J, Xu L, Ulbricht CM, Moore Simas TA, Ko JY, et al. Prevalence of bipolar disorder in perinatal women: A systematic review and meta-analysis. J Clin Psychiatry 2022; 83(5): 21r14045. doi:10.4088/JCP.21r14045.
Perry A, Gordon-Smith K, Di Florio A, Craddock N, Jones L, Jones I. Mood episodes in pregnancy and risk of postpartum recurrence in bipolar disorder: The Bipolar Disorder Research Network Pregnancy Study. J Affect Disord 2021; 294: 714–722. doi:10.1016/j.jad.2021.07.067.
Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis. J Womens Health (Larchmt) 2006; 15(3): 352–368. doi:10.1089/jwh.2006.15.352.
Spinelli MG. Postpartum psychosis: Detection of risk and management. Am J Psychiatry 2009; 166(4): 405–408. doi:10.1176/appi.ajp.2008.08121899.
Viguera AC, Nonacs R, Cohen LS, Tondo L, Murray A, Baldessarini RJ. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry 2000; 157(2): 179–184. doi:10.1176/appi.ajp.157.2.179.
Le Bas G, Youssef G, Macdonald JA, Teague S, Mattick R, Honan I, et al. The role of antenatal and postnatal maternal bonding in infant development. J Am Acad Child Adolesc Psychiatry 2022; 61(6): 820–829.e1. doi:10.1016/j.jaac.2021.08.024.
Arsova S, Hadzihamza K, Bajraktarov S, Isijanovski V. Treatment of depressive conditions in pregnancy. Maced J Med Sci 2018; 6(11): 2079–2089. doi:10.3889/oamjms.2018.433.
Arsova S, Hadzihamza K, Bajraktarov S. Systemic solutions for addressing early recognition and treatment of antenatal and postpartum/postnatal depression in Psychiatry Clinic in Skopje, North Macedonia. J Womens Health Dev 2020; 3(4): 8.
Arsova S, Haxhihamza K, Bajraktarov S, Gjorgovska B, Jovanovska V, Joksimovic M, et al. Recognizing perinatal depression during COVID-19 pandemic: Lessons learned and interventions taken to prevent suicide/infanticide. Int J Med Res Prof 2021; 7(6). doi:10.21276/ijmrp.2021.7.6.0XX.
Arsova S, Hadzihamza K, Bajraktarov S, Milutinovikj M, Kocoska S, Mitrovska S, et al. COVID-19 pandemic and postnatal depression, risk factors for postnatal depression. RAS Med Sci 2022; 2(3).
UNICEF. The influence of the COVID-19 pandemic on perinatal mental health among women in North Macedonia. 2022. Retrieved from: https://www.unicef.org/northmacedonia/reports/influence-covid-19-pandemic-perinatal-mental-health-women-north-macedonia
National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: Clinical management and service guidance (CG192). 2014. Available from: https://www.nice.org.uk/guidance/cg192
Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD, DEPRESsion Screening Data (DEPRESSD) EPDS Group. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ 2020; 371: m4022. doi:10.1136/bmj.m4022.
Young RC, et al. Young Mania Rating Scale. PsycTESTS Dataset 1978. doi:10.1037/t20936-000.
Akdeniz F, Vahip S, Pirildar S, Vahip I, Doganer I, Bulut I. Risk factors associated with childbearing-related episodes in women with bipolar disorder. Psychopathology 2003; 36(5): 234–238. doi:10.1159/000073448.
Viguera AC, Tondo L, et al. Episodes of mood disorders in 2,252 pregnancies and postpartum periods. Am J Psychiatry 2011; 168(11): 1179–1185. doi:10.1176/appi.ajp.2011.11010148.
Rusner M, Berg M, Begley C. Bipolar disorder in pregnancy and childbirth: A systematic review of outcomes. BMC Pregnancy Childbirth 2016; 16: 331. doi:10.1186/s12884-016-1127-1.
Di Florio A, Jones L, Forty L, Gordon-Smith K, Blackmore ER, Heron J, et al. Mood disorders and parity – a clue to the aetiology of the postpartum trigger. J Affect Disord 2014; 152–154: 334–339. doi:10.1016/j.jad.2013.09.034.
Dolman C, Jones IR, Howard LM. Women with bipolar disorder and pregnancy: factors influencing their decision-making. BJPsych Open 2016; 2(5): 294–300. doi:10.1192/bjpo.bp.116.003079.
Boden R, Lungren M, Brandt L, Reutfors J, Andersen M, Kieler H. Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: Population based cohort study. BMJ 2012; 345: e7085. doi:10.1136/bmj.e7085.
Di Florio A, Forty L, Gordon-Smith K, Heron J, Jones L, Craddock N, et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013; 70(2): 168–175. doi:10.1001/jamapsychiatry.2013.279.
Perry A, Gordon-Smith K, Lewis KJS, Di Florio A, Craddock N, Jones L, et al. Perinatal sleep disruption and postpartum psychosis in bipolar disorder: Findings from the UK BDRN Pregnancy Study. J Affect Disord 2024; 346: 21–27. doi:10.1016/j.jad.2023.11.005.
Huybrechts KF, Hernández-Díaz S, Patorno E, Desai RJ, Mogun H, Dejene SZ, et al. Antipsychotic use in pregnancy and the risk for congenital malformations. JAMA Psychiatry 2016; 73(9): 938–946. doi:10.1001/jamapsychiatry.2016.1520.
Viguera AC, Freeman MP, Góez-Mogollón L, Sosinsky AZ, McElheny SA, Church TR, et al. Reproductive safety of second-generation antipsychotics: Updated data from the Massachusetts General Hospital National Pregnancy Registry for Atypical Antipsychotics. J Clin Psychiatry 2021; 82(4): 20m13745. doi:10.4088/JCP.20m13745.
GOV.UK. Valproate: New safety and educational materials to support regulatory measures in men and women under 55 years of age. Accessed Nov 18, 2024. https://www.gov.uk/drug-safety-update/valproate.
Fornaro M, Maritan E, Ferranti R, Zaninotto L, Miola A, Anastasia A, et al. Lithium exposure during pregnancy and the postpartum period: A systematic review and meta-analysis of safety and efficacy outcomes. Am J Psychiatry 2020; 177(1): 76–92. doi:10.1176/appi.ajp.2019.19030228.
Vieira da Silva Magalhães P, Kapczinski F, Kauer-Sant’Anna M. Use of contraceptive methods among women treated for bipolar disorder. Arch Womens Ment Health 2009; 12: 183–185. doi:10.1007/s00737-009-0060-y.
Marengo E, Martino DJ, Igoa A, Scápola M, Fassi G, Baamonde MU, et al. Unplanned pregnancies and reproductive health among women with bipolar disorder. J Affect Disord 2015; 178: 201–205. doi:10.1016/j.jad.2015.02.033.
Halim N, Beard J, Mesic A, Patel A, Henderson D, Hibberd P. Intimate partner violence during pregnancy and perinatal mental disorders in low and lower middle income countries: A systematic review of literature, 1990–2017. Clin Psychol Rev 2018; 66: 117–135. doi:10.1016/j.cpr.2018.03.003.
Taylor CL, Stewart R, Ogden J, Broadbent M, Pasupathy D, Howard LM. The characteristics and health needs of pregnant women with schizophrenia compared with bipolar disorder and affective psychoses. BMC Psychiatry 2015; 15: 88. doi:10.1186/s12888-015-0451-8.
Taylor CL, Broadbent M, Khondoker M, Stewart RJ, Howard LM. Predictors of severe relapse in pregnant women with psychotic or bipolar disorders. J Psychiatr Res 2018; 104: 100–107. doi:10.1016/j.jpsychires.2018.06.019.
Babineau V, McCormack CA, Feng T, Lee S, Berry O, Knight BT, et al. Pregnant women with bipolar disorder who have a history of childhood maltreatment: Intergenerational effects of trauma on fetal neurodevelopment and birth outcomes. Bipolar Disord 2022; 24(6): 671–682. doi:10.1111/bdi.13207.
