Amy Perry

Affective instability, childhood trauma and major affective disorders.

BACKGROUND Affective instability (AI), childhood trauma, and mental illness are linked, but evidence in affective disorders is limited, despite both AI and childhood trauma being associated with poorer outcomes. Aims were to compare AI levels in bipolar disorder I (BPI) and II (BPII), and major depressive disorder recurrent (MDDR), and to examine the association of AI and childhood trauma within each diagnostic group. METHODS AI, measured using the Affective Lability Scale (ALS), was compared between people with DSM-IV BPI (n=923), BPII (n=363) and MDDR (n=207) accounting for confounders and current mood. Regression modelling was used to examine the association between AI and childhood traumas in each diagnostic group. RESULTS ALS scores in descending order were BPII, BPI, MDDR, and differences between groups were significant (p<0.05). Within the BPI group any childhood abuse (p=0.021), childhood physical abuse (p=0.003) and the death of a close friend in childhood (p=0.002) were significantly associated with higher ALS score but no association was found between childhood trauma and AI in BPII and MDDR. LIMITATIONS The ALS is a self-report scale and is subject to retrospective recall bias. CONCLUSIONS AI is an important dimension in bipolar disorder independent of current mood state. There is a strong link between childhood traumatic events and AI levels in BPI and this may be one way in which exposure and disorder are linked. Clinical interventions targeting AI in people who have suffered significant childhood trauma could potentially change the clinical course of bipolar disorder.

Gambling problems in bipolar disorder in the UK: prevalence and distribution

Background North American studies show bipolar disorder is associated with elevated rates of problem gambling; however, little is known about rates in the different presentations of bipolar illness. Aims To determine the prevalence and distribution of problem gambling in people with bipolar disorder in the UK. Method The Problem Gambling Severity Index was used to measure gambling problems in 635 participants with bipolar disorder. Results Moderate to severe gambling problems were four times higher in people with bipolar disorder than in the general population, and were associated with type 2 disorder (OR = 1.74, P = 0.036), history of suicidal ideation or attempt (OR = 3.44, P = 0.02) and rapid cycling (OR = 2.63, P = 0.008). Conclusions Approximately 1 in 10 patients with bipolar disorder may be at moderate to severe risk of problem gambling, possibly associated with suicidal behaviour and a rapid cycling course. Elevated rates of gambling problems in type 2 disorder highlight the probable significance of modest but unstable mood disturbance in the development and maintenance of such problems.

Adverse childhood life events and postpartum psychosis in bipolar disorder

BACKGROUND Women with bipolar disorder are at increased risk of postpartum psychosis. Adverse childhood life events have been associated with depression in the postpartum period, but have been little studied in relation to postpartum psychosis. In this study we investigated whether adverse childhood life events are associated with postpartum psychosis in a large sample of women with bipolar I disorder. METHODS Participants were 432 parous women with DSM-IV bipolar I disorder recruited into the Bipolar Disorder Research Network (www.BDRN.org). Diagnoses and lifetime psychopathology, including perinatal episodes, were obtained via a semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry; Wing et al., 1990) and case-notes. Adverse childhood life events were assessed via self-report and case-notes, and compared between women with postpartum psychosis (n=208) and those without a lifetime history of perinatal mood episodes (n=224). RESULTS There was no significant difference in the rate of any adverse childhood life event, including childhood sexual abuse, or in the total number of adverse childhood life events between women who experienced postpartum psychosis and those without a lifetime history of perinatal mood episodes, even after controlling for demographic and clinical differences between the groups. LIMITATIONS Adverse childhood life events were assessed in adulthood and therefore may be subject to recall errors. CONCLUSIONS We found no evidence for an association between adverse childhood life events and the occurrence of postpartum psychosis. Our data suggest that, unlike postpartum depression, childhood adversity does not play a significant role in the triggering of postpartum psychosis in women with bipolar disorder.

Stratification of the risk of bipolar disorder recurrences in pregnancy and postpartum

Background Pregnancy and childbirth are a period of high risk for women with bipolar disorder and involve difficult decisions particularly about continuing or stopping medications. Aims To explore what clinical predictors may help to individualise the risk of perinatal recurrence in women with bipolar disorder. Method Information was gathered retrospectively by semi-structured interview, questionnaires and case-note review from 887 women with bipolar disorder who have had children. Clinical predictors were selected using backwards stepwise logistic regression, conditional permutation random forests and reinforcement learning trees. Results Previous perinatal history of affective psychosis or depression was the most significant predictor of a perinatal recurrence (odds ratio (OR) = 8.5, 95% CI 5.04–14.82 and OR = 3.6, 95% CI 2.55–5.07 respectively) but even parous women with bipolar disorder without a previous perinatal mood episode were at risk following a subsequent pregnancy, with 7% developing postpartum psychosis. Conclusions Previous perinatal history of affective psychosis or depression is the most important predictor of perinatal recurrence in women with bipolar disorder and can be used to individualise risk assessments. Declaration of interest None.

A Visual Timeline Tool for Tracking Mood and Medication Perinatally in Affective Disorders

Women with bipolar disorder are at particularly high risk of relapse following childbirth with almost one in five experiencing an episode of postpartum psychosis following delivery (Di Florio et al. 2013; Wesseloo et al. 2016). Factors which increase risk for severe postpartum relapse in women with bipolar disorder are poorly understood. The majority of previous research has traditionally employed retrospective methods of assessment, and/or has only measured a limited range of potential risk factors. High-quality studies investigating risk factors prospectively in pregnant women with bipolar disorder are rare, and have predominantly focused on the role of medication use in postnatal relapse (Viguera et al. 2007). We are currently conducting a large-scale prospective pregnancy study to investigate factors which influence risk for severe postpartum mood episodes in women with bipolar disorder (UK Bipolar Disorder Research Network, www.BDRN.org). Women are recruited systematically through specialist perinatal psychiatry services nationwide, or non-systematically via national patient support charities. Lifetime and current psychopathology is assessed during pregnancy using a semistructured interview (Schedules for Clinical Assessment in Neuropsychiatry; Wing et al. 1990), and a follow-up SCAN interview is conducted at 12-week postpartum to assess psychopathology during the perinatal period. These data are combined with further information obtained at 12-week postpartum from clinician questionnaires and medical case records to determine both the occurrence of episodes of illness and medication use across the whole perinatal period. Data are also gathered on a wide range of potential risk and protective factors including obstetric complications, sleep loss, psychosocial factors relating to pregnancy (social support for example), comorbid physical and psychiatric conditions, menstrual history, and major adverse life events occurring lifetime ever and in the perinatal period specifically. These data are highly complex and multifaceted; there is considerable variation not only between participants but also individually throughout the perinatal period. For research, but also in clinical practice, there is a need to summarize this complex information and we have therefore developed a visual timeline tool as a means of graphically representing these detailed psychiatric and medication data longitudinally and simply across the perinatal period. Figure 1 provides an example timeline generated from data collected during the second pregnancy of a participant with DSM-5 (American Psychiatric Association 2013) bipolar I disorder. This woman, who had a previous episode of postpartum psychosis, took quetiapine prophylactically throughout her pregnancy. She experienced an episode of major depression at 24 weeks gestation. Following an increase in the dose of quetiapine, she recovered and remained euthymic throughout the rest of the pregnancy. The quetiapine dose was increased again at 32 weeks of pregnancy and she delivered at 37 weeks. At 24 days postpartum, she developed an episode of postpartum psychosis requiring compulsory admission to a psychiatric mother and baby unit and the addition of further psychotropic medication. * Amy Perry a.perry@worc.ac.uk