Women With Bipolar Disorder Are At Increased Risk Of Suicide After Delivery

Postpartum psychosis, or mania after childbirth, is remarkably common among women with bipolar disorder. If ignored, as it usually is, it can lead to an increased risk of suicide and infanticide, according to a latest review by Dr Katherine Wisner and co from Northwestern Medicine, Stanford University and Erasmus Medical Center in the Netherlands.

The review was a collective effort of a team of researchers who delved into epidemiological and genetic data that triggers postpartum psychosis among women with bipolar disorders and found the issue to be shockingly understudied, let alone addressed and resolved. The review was published in American Journal of Psychiatry, September edition.

Postpartum psychosis, medically known as puerperal psychosis, is a severely debilitating mental disorder that has an erratic onset. With a potential to begin anywhere from between a few days to few weeks post-delivery, it constitutes a psychiatric emergency that needs prompt attention.

It is coupled with life-threatening symptoms such as mania, hallucinations and delusions, which mandate institutionalization in most of the women to prevent further mental deterioration, and most importantly, to keep the newborn safe and alive.

As the researchers dug deep down the old publications, data, clinical trials and studies generated by epidemiology over the last few years, they found the incidence of postpartum psychosis to be surprisingly low at 0.25-0.6 per 1,000 births.

A finding which speaks volumes of the limited global exploration of the issue by the researchers. Other mental disorders that affect women post-delivery have been extensively studied and explored. One such example is postpartum depression, which ubiquitously affects women from all races and ethnicities, and has grabbed its fair share of attention translating into the development of appropriate remedies.

While the low incidence of postpartum psychosis may come across as a medical relief, it remains a concern for women with active or resolved bipolar disorder because the latter is 100% risk factor for the former.

Dr Katherine Wisner and co found that initial episode of psychosis progressed to full-blown disease in as many as 20-50% of the women who recently gave birth. Other women, who successfully cruised through the postpartum period, were not risk-free though. They were seen to develop the disorder later in life.

Why Are Women At Increased Risk Of Postpartum Psychiatric Disorders?

Women undergo several physiological changes after birth. All of their hormones and chemicals that surged throughout the 9 (more or less) months of their pregnancy suddenly take a deep dip precipitating diseases in genetically susceptible women.

Almost 85% of the women experience mood disturbances during postpartum period, usually within first weeks of giving birth. These symptoms, termed postpartum blues, are mild and transient and go away on their own but can aggravate in around 10-15% of women and lead to serious psychiatric disorders such as depression and psychosis.

Postpartum psychosis is rare, accounting for 1-2 per 1,000 women after childbirth. Women with postpartum psychosis become a pendulum between rapidly shifting elated and depressed mood. A confused and disoriented mother is a risk – both for herself and her infant. Most of her delusions and (auditory) hallucinations are centered on her child which can make her harm herself or her child.

Lithium remains the mainstay of treatment in bipolar disorder. Several studies have indicated that lithium prophylaxis can dramatically reduce the risk of postpartum psychosis but some healthcare providers are not convinced and insist on practicing caution. They believe exposing a breastfeeding woman to lithium means exposing the infant to a highly unsafe drug.

Is Lithium Safe In Women With Postpartum Psychosis?

Lithium belongs to pregnancy category D drugs which makes it a really hazardous drug since it can elicit birth defects and malformations in the fetus such as heart anomalies (Ebstein’s anomaly). The Food and Drug Administration (FDA) has recommended the drug to be used in pregnancy only when there are no alternatives.

But we are talking about post-birth treatment. Some studies, albeit small, have shown a prophylactic use of lithium to not negatively affect the baby. Why its judicious use should not be encouraged then, Wisner questions who is a psychiatrist, a professor of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine and the lead author of the study.

“This is a really serious disorder, and no one likes to treat women with medication during pregnancy or breastfeeding, but there’s certainly very high risk in not treating as well, such as the risk for suicide,” Wisner said.

She goes on to say, “People think that once you’re pregnant, you’re not entitled to your body, but what happens to the mother happens to the fetus — a mentally healthy mom is critical for fetal and infant development,” Wisner said. “And these women often experience good responses with lithium treatment.”

Wisner and colleagues stress that the risks should not keep the doctors from giving the drug to women in need. In fact, she believes that as soon as the baby comes out, lithium should go in.

True there are concerns about the safety of lithium but American Academy of Pediatrics (APA) has provided a complete guidance to physicians about drugs that can be secreted in milk. As per APA, lithium can be taken by women with postpartum psychosis but careful and vigilant monitoring of blood levels should be ensured in both mother and baby.

The review highlights another issue – a separation of the mentally-sick mother from her child. In the United States, mothers with psychiatric disorders are generally admitted to hospitals where visitation of the child is not allowed until they (mothers) are convalescent or have fully recovered.

This practice makes it impossible for mothers to breastfeed and care for the younglings. Wisner and co recommend the government set up mother-baby joint care at psychiatric hospitals throughout the country where mothers and babies are admitted and treated together.

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