To date, there has not been extensive literature addressing postpartum psychosis (PP) in relation to psychotic episodes outside of the postpartum period.
Rommel et. al began to address this gap in their May 2021 study that followed 106 women over four years following delivery in an attempt to locate possible clinical markers of psychosis or other psychiatric episodes beyond the postpartum period. They found that ~32% of these women experience recurrence of mood/psychotic episodes outside of the postpartum period. The team defined recurrence as “the occurrence of depression, (hypo)mania, psychosis or a mixed state episode fulfilling DSM-IV criteria, admission to hospital or a restart of medication.” The majority of these women were found to have a bipolar disorder diagnosis. The findings of this longitudinal study support the existing literature suggesting a link between bipolar disorder and postpartum psychosis. The authors point to how this connection represents two distinct diagnoses within the same spectrum. In fact, because postpartum psychosis is not registered in current classification systems such as the DSM-5, many women with the condition are diagnosed with bipolar disorder. Yet, existing literature suggests 43.5% of women with PP do not experience manic or psychotic recurrence outside the postpartum period.
This prospective study was designed to inform the community about recurrence of psychotic symptoms outside the postpartum period. The study took place at the Mother-Baby Unit (MBU) in the Department of Psychiatry in the Erasmus Medical Centre in Rotterdam, The Netherlands. Patients included in the study were between 18-45 years of age and experienced their first episode of mania or psychosis during the postpartum period up to 12 weeks after delivery. The researchers used the Structured Clinical Interview for DSM (SCID) and the Bipolar Affective Disorder Dimension Scale (BADDS) to assess participants. Approximately 76% of participants were treated with lithium, and 83% were treated with either typical or atypical antipsychotics during their MBU admission.
Participants were re-evaluated with the SCID four years postpartum and were categorized in two groups: 1) Women with recurrence of non-postpartum mood or psychotic episodes and 2) Women with no psychiatric episodes outside of the postpartum period. Group 1 included 34 women (32.1%) who experienced at least one non-postpartum episode during follow-up, and Group 2 included 72 women (67.9%) who did not experience recurrence during the four years. Two women (1.9%) experienced recurrence only following subsequent pregnancies, and both received a diagnosis of depression. Within Group 1, 14 women experienced (hypo)mania (13.2% of overall sample), 11 experienced depression/anxiety (10.4% of overall sample), and nine experienced a psychotic episode (8.5% of overall sample). The researchers did not find significant predictors of recurrence outside the postpartum period.
These results differ from a 2020 meta-analysis which found a 56.5% recurrence rate of mood/psychotic episodes outside the postpartum period. However, the meta-analysis followed patients 11 to 26 years postpartum rather than four years. The relatively lower relapse rates reported in the current study could also be attributed to the quality of healthcare for women in the treatment setting, the availability of preventative follow-up, and the high rate of continued medication use. The study supports the call for postpartum psychosis to be distinctly classified within the bipolar spectrum, given the majority of participants did not experience recurrence of mood episodes outside of the postpartum period as might be expected with a bipolar diagnosis.
The study also supports long-term monitoring for individuals who experience postpartum psychosis given the lack of biomarkers that predict who may be at risk for experiencing recurrence of mood or psychotic episodes. These important findings can inform effective clinical practices for treating individuals with postpartum psychosis with or without mood/psychotic disorders outside of the postpartum period.
Written by Margaret Gaw, Clinical Research Coordinator
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Rommel, A. S., Molenaar, N. M., Gilden, J., Kushner, S. A., Westerbeek, N. J., Kamperman, A. M., & Bergink, V. (2021). Long-term outcome of postpartum psychosis: a prospective clinical cohort study in 106 women. International journal of bipolar disorders, 9(1), 31. https://doi.org/10.1186/s40345-021-00236-2