A recent meta-analysis of relevant literature on postpartum psychosis (PP) examines the relationship between bipolar disorder, previous history of a postpartum psychotic episode, and the risk of relapse in the postpartum period. The authors reviewed 37 articles that describe a total of 5,700 deliveries. The results of the meta-analysis suggest that women with a diagnosis of bipolar disorder, women who have experienced an episode of PP in the past, and women who have both diagnoses are at significantly higher risk for a relapse in the postpartum period. The analysis also examines the effects of antipsychotic drugs during pregnancy or immediately following delivery as prophylactic treatment and shows that medication during pregnancy for women with bipolar disorder or initiation of medication directly after delivery for women with a history of PP is highly protective and minimizes the risk of an episode of psychosis in the postpartum period.
While rates of PP relapse in women with bipolar disorder, with a history of PP, or women with both diagnoses have been described in several studies, there is a high degree of variability in those reported rates. The meta-analysis performed by Wesseloo and colleagues aims to address this variability by aggregating data across studies. The meta-analysis not only reports on the rates of relapse for each group individually, but also compares rates between patients with bipolar disorder and patients with a history of PP. It additionally allows investigators to examine the affect of prophylactic medication either during pregnancy or directly after delivery on the rate of relapse.
37 studies were analyzed which included cohorts of women in the diagnosis groups described (bipolar disorder, history of PP, or both). From these studies, an overall postpartum relapse rate for PP was found to be 35%. In patients with a diagnosis of bipolar disorder, relapse risk was found to be 37%. Interestingly, in studies that made a distinction between bipolar I disorder and bipolar II disorder, there was no significant difference in relapse rate. In patients with a history of PP, the relapse rate was 31%. While there was not a significant difference between relapse rates between women with bipolar disorder and women with a history of PP, women with a history of PP were more likely to have a severe episode of PP, as characterized by an episode resulting in hospitalization, (29%) than women with a diagnosis of bipolar disorder (17%).
It is certainly concerning that such high rates of relapse of PP are observed for women with risk factors including a bipolar disorder diagnosis, a history of PP, or both. However, the good news is that prophylactic medication has been shown to be highly effective in maintaining mood stability during pregnancy and preventing relapse in the postpartum period. For women with bipolar disorder, there was not enough data to determine the efficacy of initiating prophylactic medication in the immediate postpartum period, but the data for medication use during pregnancy showed a greatly reduced rate of relapse for patients with bipolar disorder using medication during pregnancy (23%) when compared to women who did not use medication (66%). In women with a history of PP, the evidence suggests that initiation of prophylactic medication immediately after delivery after a medication-free pregnancy is an effective strategy. It is important to weigh the costs and benefits and consult a clinician with knowledge about using psychiatric medications during pregnancy to find the most effective and safe prophylactic pharmacotherapy.
This meta-analysis provides useful insights into the risk of relapse of PP observed for women with a bipolar disorder diagnosis, a history of PP, or both. There is a need for more research on postpartum psychosis, and particularly on the effects of prophylactic medication during pregnancy and immediately postpartum. Steps for relapse prevention include exploring pharmacotherapy options with providers, having a specific obstetric birth plan in place, intervention starting at the earliest observation of symptoms, and establishing practices that will maximize sleep, allow women to maintain a stable circadian rhythm and reduce the amount of stress they are experiencing, and support maternal-newborn bonding.
Research summary compiled by Nicola Roux.
Wesseloo, R., Kamperman, A., Munk-Olsen, T., Pop, V., Kushner, S., & Bergink, V. (2016). Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. American Journal of Psychiatry, 173(2), 117-127.