Carley J. Pope

Pregnancy and bipolar disorder: a systematic review.

OBJECTIVE The postpartum period is generally considered a time of heightened vulnerability to bipolar disorder; however, there is controversy about the effect of pregnancy on the course of bipolar disorder. This article reviews the literature on the relationship between pregnancy and bipolar disorder and suggests areas for future research. DATA SOURCES AND STUDY SELECTION Three electronic databases, MEDLINE (1966-2010), PsycINFO (1840-2010), and EMBASE, were searched on April 30, 2010, using the following keywords: pregnancy, bipolar disorder, manic depressive disorder, suicide, hospitalization, pharmacotherapy, and psychotherapy. The reference lists of articles identified were also searched. All relevant papers published in English were included. RESULTS A total of 70 articles were identified and included in the review. Evidence from studies using nonclinical samples, some retrospective studies, and studies on psychiatric hospitalization rates is suggestive of a positive effect of pregnancy on bipolar disorder; however, recent studies conducted at tertiary care facilities have reported high rates of recurrence following discontinuation of mood stabilizers. CONCLUSIONS Understanding the relationship between pregnancy and bipolar disorder has implications for perinatal treatment and etiologic understanding of the disorder. Research is urgently needed to estimate the prevalence of bipolar disorder during pregnancy, using both clinical and nonclinical samples.

A Systematic Review of the Association Between Psychiatric Disturbances and Endometriosis

We read with great interest the article by Pope et al., an interesting review that examined the existing empirical findings about the association between endometriosis and psychiatric conditions. We agree that our knowledge of this association is limited because of methodological differences and the limited number of controlled studies in the published literature. Although we appreciated the reported methodology, we take the opportunity to point out several elements which would let us further realize the results of this study. First of all, we observed that only four of the identified studies used clinical diagnostic criteria to assess for psychiatric diagnosis. Nevertheless, the diagnosis of any psychiatric condition requires the use of a specific validated test, as we recently did. Second, the characteristics of the cohort varied between studies: some included women with a diagnosis of endometriosis whereas others used a sample of women with chronic pelvic pain secondary to endometriosis. We believe that future research studies should include only patients with a diagnosis of endometriosis obtained through the visualization of lesions at the time of laparoscopy and histological analysis, according to the most updated international guidelines. Additionally, it might be helpful to divide the patients by disease stage, according to the American Fertility Society classification, in order to obtain more information regarding a possible correlation between endometriosis severity and psychiatric comorbidity. Third, of the reported three studies using a comparator group, one used a healthy control group, and the others consisted of women with chronic pelvic pain due to another medical condition. Moreover, several studies showed a close correlation between psychiatric disorders, such as anxiety and depression, and medical conditions. Considering this last point, it would not be possible to accurately state whether the psychiatric disorder could be clearly related to endometriosis or to other comorbidities, impairing the validity of results. Based on this element, we strongly suggest that future studies should exclude patients with other underlying conditions both in endometriosis and control groups. Fourth, none of the studies reported about other pharmacological, surgical, or psychosocial treatment, although it is widely accepted that some of the medications for endometriosis are associated with adverse side effects, including psychiatric symptoms. For example, oral contraceptives have been associated with decreased psychosexual arousal or negative changes in mood. Furthermore, gonadotropin-releasing hormone agonists have been found to be associated with emotional lability and depression. As the use of different hormonal therapies in some patients with endometriosis may influence the onset and progress of psychiatric disorders, prophylactic treatment with an antidepressant may reduce the risk for the experience of treatment-induced depressive symptoms. Finally, we believe that future studies should consider separately the patients with “endometriosis and chronic pelvic pain” and “endometriosis and infertility.” These two complaints adversely affect quality of life and mental health of patients, causing emotional distress, social isolation, relationship difficulties, and worse job performance; these last points could also modulate the relationship between endometriosis and psychiatric disorders. Moreover, chronic pelvic pain and infertility require specific and individualized pharmacological and psychosocial treatments. In conclusion, considering the impact of endometriosis on psychological health and the paucity of papers on this topic, we take the opportunity to solicit further studies in order to find clearer evidence and to provide the best evidence-based treatment for the patients.

A prospective study of diagnostic conversion of major depressive disorder to bipolar disorder in pregnancy and postpartum

The aim of the present study was to determine the rate of, and risk factors for, a change in diagnosis from major depressive disorder to bipolar disorder, and from bipolar II disorder to bipolar I disorder in pregnancy and postpartum.

Breastfeeding and Postpartum Depression: An Overview and Methodological Recommendations for Future Research.

Emerging research suggests that a relationship exists between breastfeeding and postpartum depression; however, the direction and precise nature of this relationship are not yet clear. The purpose of this paper is to provide an overview of the relationship between breastfeeding and postpartum depression as it has been examined in the empirical literature. Also, the potential mechanisms of action that have been implicated in this relationship are also explored. PubMed and PsycINFO were searched using the keywords: breastfeeding with postpartum depression, perinatal depression, postnatal depression. Results of this search showed that researchers have examined this relationship in diverse ways using diverse methodology. In particular, researchers have examined the relationships between postpartum depression and breastfeeding intention, initiation, duration, and dose. Due to a number of methodological differences among past studies we make some recommendations for future research that will better facilitate an integration of findings. Future research should (1) use standardized assessment protocols; (2) confirm diagnosis through established clinical interview when possible; (3) provide a clear operationalized definition for breastfeeding variables; (4) clearly define the postpartum period interval assessed and time frame for onset of symptoms; (5) be prospective or longitudinal in nature; and (6) take into consideration other potential risk factors identified in the empirical literature.

Recognition, diagnosis and treatment of postpartum bipolar depression.

Bipolar disorder is a serious and often chronic disorder characterized by episodes of depression, hypomania, mania or mixed states that affects many individuals worldwide, and is a leading cause of years of ‘healthy’ life lost as a result of disability and premature mortality. For women, bipolar disorder tends to cluster during the childbearing years. Detection of bipolar disorder can be complicated and therefore it is essential that women presenting with mood episodes after childbirth receive a comprehensive examination to allow for accurate diagnosis, with particular attention to manic symptoms. Once a diagnosis of bipolar disorder is confirmed, pharmacotherapy with consideration made to breastfeeding status may be considered alone or in combination with psychotherapy.

Breastfeeding and postpartum depression: Assessing the influence of breastfeeding intention and other risk factors.

BACKGROUND Risk and protective factors for postpartum depression have been extensively studied, and in recent studies an association between breastfeeding and maternal mood has been reported. The present retrospective, cross-sectional study was conducted to evaluate the association between breastfeeding-related variables and postpartum depression (based on Edinburgh Postnatal Depression Scale threshold criteria) within the context of other known risk factors. METHOD Breastfeeding information, demographic information, and scores on the Edinburgh Postnatal Depression Scale were examined from the Canadian Maternity Experience Survey. This survey contains data collected from 6421 Canadian mothers between October 2006 and January 2007, and 2848 women between five and seven months postpartum were included in the current analyses. RESULTS In contrast to previous research, logistic regression analyses revealed that when considered within the context of other risk factors, breastfeeding attempt and duration were not associated with postpartum depression at five to seven months postpartum. Although a relationship between the prenatal intention to combination feed and postpartum depression was observed, these variables were no longer related once other potential risk factors were controlled for. Factors that were associated with postpartum depression included lower income, higher perceived stress, lower perceived social support, no history of depression, or no recent history of abuse. LIMITATIONS A clinical diagnostic instrument was not used and variable selection was restricted to data collected as part of this survey. CONCLUSION These findings suggest that the association between breastfeeding and postpartum depression reported by previous researchers may in fact be due to alternative risk factors.

The hormonal sensitivity hypothesis: A review and new findings

Previous womens health practitioners and researchers have postulated that some women are particularly sensitive to hormonal changes occurring during reproductive events. We hypothesize that some women are particularly sensitive to hormonal changes occurring across their reproductive lifespan. To evaluate this hypothesis, we reviewed findings from the existing literature and findings from our own lab. Taken together, the evidence we present shows a recurring pattern of hormonal sensitivity at predictable but different times across the lifespan of some women (i.e., menarche, the premenstrual phase, hormonal contraceptive use, pregnancy, the postpartum period, and menopause). These findings provide support for the hypothesis that there is a subgroup of women who are more susceptible to physical, psychological, and sexual symptoms related to hormonal shifts or abrupt hormonal fluctuations that occur throughout the reproductive lifespan. We propose that this pattern reflects a Hormonal Sensitivity Syndrome.

Antidepressants and recurrence of depression in the postpartum period

To examine postpartum recurrence rates of depression comparing women receiving antidepressant treatment to women not being treated with psychotropic medication. This was a prospective study of 130 women with major depressive disorder (MDD) who attended a tertiary care perinatal clinic during and after pregnancy. Depression recurrence was defined as a score of 13 or more on the Edinburgh Postnatal Depression Scale (EPDS) or a score of greater than 13 on the Hamilton Depression Rating Scale (HDRS). Over half of women (56.9%) were not receiving medication during pregnancy to treat their mood disorder, with the rate of medication use increasing over the 1-year postpartum period. When comparing women being treated with antidepressant medication (monotherapy or combination therapy) to women receiving no psychotropic medication, no significant differences in recurrence rates were observed during the postpartum period. However, we did observe that the occurrence of depression in our sample fluctuated between rates comparable to general population estimates to rates that were at times more than twofold higher, regardless of treatment with antidepressant medication. The findings of this study align with research which suggests that the postpartum period is a particularly vulnerable time for recurrence of depression. Moreover, our results suggest that this remains the case regardless of antidepressant treatment.