The perinatal period is a critical time to screen and treat psychiatric illness among reproductive-aged women. The consequences of untreated mental illness in the perinatal period are profound and wide-reaching, ranging from the loss of interpersonal and financial resources to maternal and infant mortality and morbidity. Growing attention has been paid to perinatal mood and anxiety disorders (PMADs), such as postpartum depression and postpartum anxiety; however, it may be time for clinicians to turn toward more nuanced approaches to perinatal mental health care that incorporate screening for bipolar disorder and bipolar-spectrum mood episodes along with major depressive disorder (MDD). In fact, assessing for postpartum depression without also screening for (hypo)mania may result in misidentification of postpartum mental illness.
Previous studies have shown that among women with bipolar disorder (BD), there is a higher risk for postpartum psychosis. However, much less is known regarding unipolar depression versus bipolar disorder in women presenting with depressive symptoms. A recent review and meta-analysis is a critical look into the prevalence of bipolar disorder in the perinatal period. For this review, the authors identified articles in English that included populations of perinatal women (pregnant or within the first year postpartum) who were 18 years or older and who had completed a screening or diagnostic tool for bipolar disorder. The analysis included 22 studies as part of the qualitative review and 12 for the meta-analysis.
The study found that upwards of 20% of women with no history of psychiatric illness experience their first bipolar-spectrum mood episode (including depression, hypomania/mania, or mixed mood) during the perinatal period. In women with no known psychiatric illness before pregnancy, the pooled prevalence of BD was 2.6%. Conversely, for women with previously diagnosed BD, 54.9% were found to have at least one bipolar-spectrum mood episode during the perinatal period.
The authors highlight several questions these striking findings raise: “Does this then mean that the peripartum period confers about a 7-fold increased risk for precipitating a first lifetime presentation of bipolar disorder? Or, that an astonishingly high 1 in 5 depressed pregnant or postpartum women may actually manifest signs of bipolar disorder? Or, that the vast majority of women with preexisting bipolar disorder may have gone unrecognized or altogether undiagnosed prior to pregnancy and delivery?”
We do not yet have answers to those questions; however, this vital review sheds light on the high prevalence of mood episodes in the often vulnerable and complex peripartum period. Furthermore, this work highlights the need for further research into the existing screening and treatment pathways and options for identifying underrecognized perinatal mood disorders like BD. For women with previously diagnosed BD, evidence-based clinical care that involves continued treatment with medications and therapy is often critical. There continues to be research on mood stabilizers taken during the perinatal period such as lamotrigine and lithium. However, there has not been published literature analyzing the longitudinal course and treatment of perinatal patients with depressive symptoms who might actually have BD.
Amidst this important review about the prevalence of BD, it is important to consider the diagnostic confusion of MDD versus BD especially given the DSM-5 construct of MDD with mixed features. Rather than the distinct and opposite poles of depression and mania, it may be beneficial to turn toward a clinical continuum that reflects the spectrum within mood disorders. Furthermore, it is vital to dissect how much the prevalence of BD from this review represents treated versus untreated conditions and the class of medication patients may be taking. Ultimately, this review should alert clinicians to the prevalence of depression alongside (hypo)mania in peripartum mental health screening and treatment – while highlighting caveats related to the accuracy of diagnosing perinatal mood disorders and the significant need for further research to understand the phenomenology of psychiatric disorders in the peripartum.
Masters GA, Hugunin J, Xu L, Ulbricht CM, Moore Simas TA, Ko JY, Byatt N. Prevalence of Bipolar Disorder in Perinatal Women: A Systematic Review and Meta-Analysis. J Clin Psychiatry. 2022 Jul 13;83(5):21r14045. doi: 10.4088/JCP.21r14045. PMID: 35830616. https://pubmed.ncbi.nlm.nih.gov/35830616/
Freeman MP, Goldberg JF. The Pursuit to Recognize Bipolar Disorder in Pregnant and Postpartum Women. J Clin Psychiatry. 2022 Jul 13;83(5):22ed14399. doi: 10.4088/JCP.22ed14399. PMID: 35830617. https://pubmed.ncbi.nlm.nih.gov/35830617/