Bipolar Disorder in Perinatal Women

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CASE VIGNETTE

“Ms Daphne” is a 23-year-old African-American female with a 5-year history of bipolar disorder. She is currently euthymic with no hospitalizations in the past 4 years. She does not smoke, drink alcohol, or use illicit drugs. She sees her outpatient psychiatrist every 3 months. Two months after her last appointment, she calls the clinic because she is now pregnant. She asks about risks of her psychotropic medications to the baby. She also asks about potential effects of the pregnancy on her mood. As her psychiatrist, how would you advise the patient on her risk of mood episodes in the perinatal period?

The prevalence of bipolar disorder in the general population is approximately 2% to 3%.¹ Women with bipolar disorder may have increased risk of mood episodes in the perinatal period (during pregnancy or within 1-year postpartum).^2,3 This increased risk may be due to associated hormonal and physiological changes, stress of childbirth and parenting, and/or overlap between peak reproductive years and bipolar disorder.² Bipolar disorder is also a risk factor for perinatal suicide, postpartum psychosis, and infanticide.⁴

The Current Study

Masters and colleagues⁵ systematically investigated the prevalence of bipolar disorder in perinatal women, and the prevalence and timing of bipolar-spectrum mood episodes in the perinatal period. The authors searched PubMed, Scopus, PsycINFO, CINAHL, Cochrane, and ClinicalTrials.gov for peer-reviewed articles in English. They included studies in perinatal adult women that detected bipolar disorder in the perinatal period using validated screening/diagnostic tools. Preexisting psychiatric disorders and psychotropic medications were permitted.

They excluded studies if psychiatric symptom assessment was secondary to an unrelated medical condition, assessments were conducted outside the perinatal period, and the prevalence of bipolar disorder was not reported.

The authors identified 4052 records and assessed 177 full-text articles. Twenty-two studies were included in the qualitative review and 12 in the meta-analysis. The authors divided study populations into 2 categories: 1) no psychiatric history preceding the perinatal period, and 2) bipolar disorder preceding the perinatal period. Studies with a history of “any mood disorder” were only included in the qualitative analysis.

They calculated pooled estimates and 95% confidence intervals using fixed effects models for: 1) overall bipolar disorder prevalence and bipolar-spectrum mood episode occurrence in women with no psychiatric history, and 2) bipolar-spectrum mood episode occurrence in women with bipolar disorder.

Among 22 observational studies, 14 were conducted in obstetric settings and 17 detected bipolar disorder using diagnostic instruments. Three studies were conducted in pregnant women, 9 in postpartum women, and 10 in both. Eleven studies (n=6325) reported the prevalence of bipolar disorder in women with no psychiatric history.

The pooled prevalence of bipolar disorder in women with no psychiatric history was 2.6% (95% CI 1.2-4.5%), with evidence for high heterogeneity (I2=91%). This estimate was higher in studies that used the MDQ (4.8%) versus diagnostic interviews (0.7%). The pooled prevalence of bipolar-spectrum mood episodes in these women (10 studies, n=4473) was 20% (95% CI 16-25%), with similar estimates in pregnancy (22%) and the postpartum (18%) occurrence in the perinatal period.

In women with a history of bipolar disorder (7 studies, n=2814), 55% (95% CI 39-70%) had at least 1 bipolar-spectrum mood episode occurrence during the perinatal period, also with similar estimates in pregnancy (51%) and the postpartum (55%). Six of 8 studies (n=4238) found higher rates of depressive episodes in women with (versus without) bipolar disorder. Women with (versus without) probable bipolar disorder were 6.5 times more likely to have a depressive episode.

Study Conclusions

The authors found a 3% pooled prevalence of bipolar disorder in the perinatal period among women with no psychiatric history, and 20% of women experienced a bipolar-spectrum mood episode during this period. Among women with a history of bipolar disorder, 55% experienced a bipolar-spectrum mood episode in the perinatal period. The primary study strength was the rigorous nature of this systematic review. Study limitations include high between-study heterogeneity, which was likely driven by differences in estimates in studies using diagnostic versus screening tools.

The Bottom Line

There is a high prevalence of bipolar-spectrum mood episode occurrence in women in the perinatal period. Bipolar disorder is exacerbated during pregnancy and postpartum, which is associated with adverse health outcomes. Screening for bipolar disorder and bipolar-spectrum mood episodes in the perinatal period is clearly warranted.

Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric Times^TM. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

References

1. Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68(3):241-251.

2. Sharma V, Pope CJ. Pregnancy and bipolar disorder: a systematic review. J Clin Psychiatry. 2012;73(11):1447-1455.

3. Freeman MP, Smith KW, Freeman SA, et al. The impact of reproductive events on the course of bipolar disorder in women. J Clin Psychiatry. 2002;63(4):284-287.

4. Rusner M, Berg M, Begley C. Bipolar disorder in pregnancy and childbirth: a systematic review of outcomes. BMC Pregnancy Childbirth. 2016;16(1):331.

5. Masters GA, Hugunin J, Xu L, et al. Prevalence of bipolar disorder in perinatal women: a systematic review and meta-analysis. J Clin Psychiatry. 2022;83(5):21r14045.