As more researchers are focusing their efforts on understanding and treating postpartum psychosis (PP), one of the major goals is to prevent relapse in women with risk factors for the disorder. While it would be ideal to eradicate PP altogether, preventing relapse in women who have known risk factors for PP (such as a diagnosis of bipolar disorder or a prior psychiatric episode in the postpartum period) is a step in the right direction. This study by Bergink et al. looked at prevention methods for women in these two high risk groups and developed a clinical algorithm for preventative, or prophylactic, treatment of PP.
The study included 70 women who were considered at high risk for PP due to a history of PP as defined as one or more episodes of psychosis, mania, or depression in the postpartum period of a prior pregnancy, or a diagnosis of bipolar disorder. 29 women had a history of PP only and 41 women had a diagnosis of bipolar disorder, including both women with and without episodes specifically in the 4 weeks following delivery.
For this study, Bergink and colleagues designed a Peripartum Prevention Program using the best evidence available to examine prophylactic options for women at high risk for PP. The program advised women who were being treated with a mood stabilizer at the time of enrollment to continue maintenance treatment throughout the pregnancy. Lithium monotherapy was the recommendation for mood stabilization during pregnancy, as the present literature indicates that this is the most efficacious method when weighing the benefits and potential risks of fetal medication exposure. For women who were medication-free at the time of their first evaluation, it was advised that lithium prophylaxis be started immediately postpartum. Another part of the program was emphasizing the importance of getting enough sleep. Each perinatal plan was individualized and involved all members of the participants’ care team. Participants received follow-up evaluations every 4-6 weeks during pregnancy and were followed for a minimum of 4 weeks after delivery.
One particularly interesting finding from this study was that the timing for the onset of PP was different between the two groups of at-risk women. Regardless of whether they were taking medication during pregnancy or not, none of the 29 women with a history of PP only relapsed during pregnancy. 13.8% of these women relapsed postpartum. On the other hand, 24.4% of the women with a diagnosis of bipolar disorder did experience a relapse during pregnancy. 22% of women with bipolar disorder relapsed in the postpartum, and most of these women had also experienced a relapse during pregnancy.
In the 29 women enrolled with a history of PP only, none took medication during pregnancy, and none relapsed during pregnancy. In the postpartum period, there were no relapses in women taking prophylaxis. However, the relapse rate for women not taking prophylaxis was 44.4%, which provides evidence for the efficacy of prophylaxis in the postpartum period for women who have experienced past episodes of PP.
75.6% of the 41 women with bipolar disorder enrolled in the study took medication during pregnancy. Of those women who took medication, the relapse rate during pregnancy was 19.4%. Among women who did not take medication during pregnancy, the relapse rate during pregnancy was higher, at 40%. Regardless of whether they were taking medication during pregnancy or not, 60% of women who relapsed during pregnancy also relapsed in the postpartum. Of those women who were stable during pregnancy, 83.9% used medication postpartum. This was overall successful with only 7.7% of those women experiencing relapse postpartum. In the women who stayed well throughout pregnancy and declined medication postpartum, 20% experienced relapse postpartum.
These results are notable as they indicate that there may be a difference in the two groups of women at risk—those with a history of PP only may have a particular vulnerability to episodes of psychosis that is restricted to the postpartum period, while those with a diagnosis of bipolar disorder (including women with and without history of PP) seem to be at risk for relapse both during pregnancy and after delivery. Additionally, this study showed that in women with bipolar disorder, maintaining lithium prophylaxis throughout pregnancy was effective in preventing relapse both during pregnancy and postpartum. Furthermore, lithium prophylaxis in the postpartum for both groups of at-risk women was shown to decrease rates of relapse.
While treatment plans should always be discussed extensively with clinicians and personalized for each patient, the treatment algorithm developed by Bergink et al. serves as a guideline for the prevention of PP relapse in women at high risk. For bipolar women, the recommendation is prophylaxis both during pregnancy and postpartum to maintain mood stability and prevent relapse. In contrast, women with a history of PP only should remain medication-free for the duration of their pregnancy to minimize any risk of fetal exposure, with prophylaxis starting immediately postpartum. These findings are an important step on the path to relapse prevention and better outcomes for women at risk for PP.
Research summary compiled by Nicola Roux.
Bergink, V., Bouvy, P., Vervoort, J., Koorengevel, K., Steegers, E., & Kushner, S. (2012). Prevention of Postpartum Psychosis and Mania in Women at High Risk. American Journal of Psychiatry, 169(6), 609-615.