Bipolar Affective Disorder and Postpartum Psychosis, Royal ...
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The Perinatal Frame of
Mind.
Liz McDonald
Hon Consultant Perinatal Psychiatrist
Clinical Lead, Royal College of Psychiatrists
Visiting Lecturer, Tavistock and Portman NHS
Trust
RCOG October 2019
Bipolar Affective
Disorder and
Postpartum Psychosis,
what’s important in the
perinatal period?
Brunenell Exton, 1751: ‘Hysteric complaints after delivery’ Astruc 1761: ‘the hysteric passion or uterine suffocation’ Osiander, 1797: ‘….developed a delirium on the seventh day, in which she had to be restrained like a child in it’s cot’ Denman, 1801: Mania Lactea Esquirol, 1818: Puerperal insanity Marce, 1856: wider scope
Be aware….
The term ‘postnatal depression’
or ‘PND’ should not be used as
a generic term for all types of
psychiatric disorder in the
postnatal period as there is a
risk that other serious
disorders, particularly
Postpartum Psychosis, can be
missed
Confidential Enquiries into Maternal & Maternal
Deaths 2004
Psychosis: what do we mean? • Postpartum Psychosis • Bipolar Affective Disorder • Psychotic Depression • Schizophrenia • Schizoaffective Disorder
with increased risk?
Is childbirth associated
Admissions per week
10
15
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25
30
35
40
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55
60
0
5
pre_10…
pre_10…
pre_96w
pre_92w
pre_88w
pre_84w
pre_80w
pre_76w
pre_72w
pre_68w
pre_64w
pre_60w
pre_56w
pre_52w
pre_48w
pre_44w
Pregnan…
pre_36w
pre_32w
pre_28w
pre_24w
pre_20w
pre_16w
pre_12w
pre_8w
pre_4w
Childbirth
post_4w
post_8w
post_12w
post_16w
post_20w
post_24w
post_28w
post_32w
post_36w
Langan Martin et al, BMJ Open, 2016
post_40w
post_44w
post_48w
post_52w
post_56w
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post_64w
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post_72w
post_76w
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post_10…
post_10…
Childbirth is a potent trigger for severe
episodes
Di Florio et al, 2015
Working with maternity services
NICE APMH 2014:
At a pregnant woman’s first
contact with services, ask
about any past or present
severe mental illness,
previous or current
treatment, and any severe
postpartum mental illness
in a first degree relative
Page 7
We need to think about: • Diagnosis • First onset vs recurrence • Acute illness vs chronic symptoms • Role of pregnancy and childbirth • Effects on condition due due to parenting • Effects of condition on parenting • Effects on relationships: intimate, with infant and other children, with wide family, with social network and with health and other professionals • What factors modify course • Safeguarding
Postpartum psychosis
• 1-2 in 1000 births
• 50% is a first episode for the woman
• Onset: early weeks following
childbirth
• Duration: days, weeks (most common),
months
• Sudden and severe affective
psychosis, mood symptoms, loss of
contact with reality -delusional
ideas, hallucinations,
misinterpreting perceptions,
perplexity
• Treatment: psychiatric emergency,
medication, admission, keeping
infant safe• responds well to treatment • short-term prognosis generally very good (but recent retrospective study, 26% of women with post-partum psychosis reported ongoing symptoms a year after delivery). • greater than 50% risk of a severe recurrence after further pregnancies but are also at risk of further episodes not related to childbirth (69% of women with post-partum psychosis had at least one further non-puerperal affective episode) • support for partner and wider family throughout the episode of illness and into convalescence is important and needs to be planned for
• In order to support partners, services
need to be aware of and responsive to Hold in mind the
their experiences which may include loss experience of the father
and trauma, emotional responses (such
as feelings of guilt, regret and self-
and partner
blame), the multiple roles they are
managing, and the impact on the couple
relationship.
• …..barriers to care and unmet needs,
from a lack of awareness of PP and
delays in accessing appropriate
treatment, to a lack of support for, or
consideration of, partners.
• the impact of PP on partners is broad
and substantial and requires
consideration by healthcare
professionals in order to secure the best
clinical outcomes for all members of the
new family unit.
BMC Pregnancy Childbirth. 2018; 18: 414. Holford et al
2018Spectrum of Affective (Mood) Disorders
Mania
Depression
Unipolar Bipolar II Bipolar I
DepressionHigh risk of recurrence for women with bipolar disorder
Munk-Olsen et al 2009Bipolar disorder in women
• Comorbidity with medical disorders -
particularly thyroid disease, migraine,
obesity
• Hormonal changes eg puberty,
menstruation, menopause, childbirth
(DiFloria and Jones, 2011)
• PCOS
(Chen et al 2020)
• Gestational diabetes
• Ante-partum haemorrhage
• Placenta praevia
• Induction of labour and elective CS
(Boden et al 2012, Rusner et al 2016)
Exposure to medication not sole source of
risk.
Illness, behaviours associated with illness etcSevere postpartum episodes have a rapid
onset following delivery
100 100
90 90
80 80
70 70
60 60
50 50
40 40
30 30
20 20
Percent
Percent
10 10
0 0
1st week 2nd week 3rd week 4th week 6th week 1 2 3 4 5 6
Onset of pp by week Onset of pp in days
Heron, et al 2007Does the risk of admission differ
according to diagnosis?
30
25
20
15
10
5
0
UP BP Schiz
Relative Risk of admission in first postpartum month Munk-Olsen et al 2006Women with a previous post-partum psychosis
are at very high risk of relapse
1000
900
800
700
600
500
400
300
200
100
0
Pop BP previous PP
Episodes of PP per 1000 deliveriesDifferent risk profiles for women with
BP disorder and history of PP
2012Familiality in BPAD vulnerability to
postpartum episodes
100
90
80 77
70 65
% pregnancies
60
50
40 35 Chi-square = 15.77
30 23
p = 0.00007
20
10
0
Relative with PP No relative with PP
PP episode No PP episode
Jones and Craddock, Am J Psych 2001BPI BPII MDD
N 980 232 573
Narrow 33.3% 9.1% 0.3%
Mania / Mixed / affective
psychosis (6 weeks)
Intermediate 55.5% 40.1% 47.1%
Plus Depression (6 weeks)
Broad 69.4% 69.0% 67.4%
Any perinatal episode
(pregnancy or within 6 months)
DiFlorio et al, JAMA Psychiatry 2013Parity in BPAD women and risk of
postpartum psychosis
Bipolar I disorder (929 women, 1780 pregnancies).
proportion of pregnancies affected
0.4
0.3
0.2
0.1
1 2 3 4
order of pregnancy
Di Florio et al, 2015Parity in BPAD women and risk of
depression
Bipolar I disorder (929 women, 1780 pregnancies)
0.7
proportion of pregnancies affected
0.5
0.3
0.1
1 2 3 4
order of pregnancy
Di Florio et al,2015Women who reported sleep loss triggering episodes of mania were twice as likely to have experienced an
episode of PP (OR = 2.09, 95% CI = 1.47–2.97, p < 0.001) compared to women who did not report this. There
was no significant association between depression triggered by sleep loss and PP (p = 0.526).
Lewis et al 2018
100
90
80 no PND/PP
no PND/PP
70
60
50 PND
%
40
PND
30
20 PP
*
PP
10
0
YES NO
High Mood Usually Triggered by Sleep Loss
(n = 527)Childhood sexual abuse: associated with depression but not PPP in
BPAD
Perry et al 2016
NO ABUSE NO SEXUAL SEXUAL
ABUSE (N=134) ABUSE ABUSE
(N=480 (22%) (N=525) (N=89)
) (85%) (15%)
(78%)
P 157 38 (19%) 168 (86%) 27 (14%)
P (81%)
P 106 42 (28%) 118 (80%) 30 (20%)
N (72%)
D
Perry et al 2016
* p-valueThe individual woman Consider: • Mental health on entering pregnancy • Past history (number, timing and severity of episodes, response to medication) • Engagement with MH services
Relapse rates on stopping Lithium in pregnant,
postpartum and non-pregnant women
Pregnancy Postpartum
(Weeks 1–40) (Weeks 41–64)
100
90 (n=25)
80
% Remaining Stable
70
60 (n=42)
50
40 (n=59)
30
20 (n=20)
10 Nonpregnant Nonpregnant
Pregnant Postpartum
0
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64
Weeks at Risk Off Lithium
Viguera AC. Am J Psychiatry. 2000;157:179-184.Untreated outcome
Viguera et al.
Am J Psychiatry.
2007“Bashing my head against a brick wall” “I felt very much that they weren’t supportive of me trying to have a baby… I got a lot of negative information and just sort of negative vibes about it along the lines of ‘Well that will play havoc with your hormones and you’ll never cope” “It took us quite a long time to become proactive ...I think it would have been good...to have some hard facts from them, rather than... just sort of putting me off really”
Principles of managing women with BPAD and history of PPP in the
perinatal period
• Ensure ease of access to both maternity and mental
health care and prompt and effective treatment and care
• Understand the individual woman: who is she? what are
her concerns? Develop a rapport.
• What is her experience of illness, treatment and care,
pregnancy, parenthood?
• Preconception planning
Preconception Toolkit
www.healthylondon.org/resource/best-practice-toolkit-for-providing-family-
planning-advice-to-women-with-a-mental-illness/
Preconception Interventions and Resources for Women with Serious Mental
Illness: A Rapid Review. PHE 2020
• Think about the partner, family and infant
• Know her previous history and risks
• Multi-disciplinary and multi-agency pre-birth planning at
32/40 www.healthylondon.org/resource/pre-birth-planning-guidance-
for-perinatal-mental-health-services
• Communicate effectively with the woman, other teams
and agencies
• Signpost to resources for the woman and her partner eg
APP (Association for Post-partum Psychosis)You can also read
