This Isn't What I Expected
Notes on healing postpartum depression
Postpartum Depression and Bipolar Illness: What's the Connection?
We still aren't asking the right questions.
To date, research on bipolar disorder and postpartum illness typically focuses on bipolar I and psychosis. According to a recent study by Sharma, Burt and Ritchie (Am J Psychiatry 2009), bipolar depression is often misdiagnosed as major depressive disorder during the postpartum period.
What does this mean? Well for one thing, it certainly can delay appropriate treatment. It also raises the following clinical questions for therapists:
1) Are we overlooking hypomanic symptoms during the postpartum period because they overlap with the “normal” elation of new motherhood?
2) Are we being vigilant enough during the early postpartum weeks when the peak prevalence of hypomania occurs?
3) Are we dismissing hypomanic symptoms during the postpartum period as irritability or agitation that may be consistent with extreme anxiety?
4) Are we forgetting to include a bipolar screen when we are assessing postpartum women?
As well as these questions for postpartum moms:
1) Does your provider know if you have a history or family history of bipolar illness?
2) Are you familiar with the symptoms of bipolar illness so you and your family can be informed consumers?
3) Are you satisfied with the course of your treatment or do you need another opinion or discussion with your provider?
4) Are you reporting symptoms of hypomania or are you primarily concerned with symptoms of depression?
Let’s start with some definitions.
Bipolar spectrum disorder includes Bipolar I, Bipolar II and Bipolar NOS (Not otherwise specified). Bipolar I is defined by recurrent episodes of mania and depression, while bipolar II is characterized by recurrent episode of depression and hypomania. Bipolar NOS is the presence of mania and depressive symptoms but does not meet diagnostic criteria for bipolar I.
To be diagnosed with Bipolar I, you must have at least one manic episode lasting for at least a week. Usually, there is also the presence of depressive episodes, typically lasting at least two weeks.
For a diagnosis of Bipolar II, you must have had at least one hypomanic episode and at least one depressive. There can be a pattern of depressive episodes shifting with hypomanic episodes, but no history of a manic episodes.
Bipolar Disorder Not Otherwise Specified (BP-NOS), is diagnosed when symptoms do not meet diagnostic criteria for either bipolar I or II. Although the symptoms are beyond the normal range for a particular person, they may not last long enough, or may be too few to be diagnosed with bipolar I or II.
Mania is a mood state most commonly characterized by excessive energy (it can feel as though you have an endless supply of energy) and a decreased need to sleep. (This is NOT an inability to sleep because of a wakeful baby or anxious thoughts, rather, it refers to the decrease in sleep requirement.) Other symptoms include: rapid speech (and changing topics frequently), grandiose (extremely boastful) thinking, abnormally elevated mood with impaired judgment, rash or reckless spending, hypersexuality. Psychotic symptoms, such as hallucinations, may also be present. Symptoms are typically sustained and interfere substantially with one’s ability to function.
Hypomania literally means “below mania”, in other words, less severe mania symptoms. Most mania symptoms are present in hypomania, but are less intense. It is characterized by a distinct period of persistently elevated or irritable mood for at least 4 days. Symptoms may interfere with functioning to some degree but the impairment may not be noticeable. No symptoms of psychosis (e.g. hallucinations, delusions, paranoia) are present in hypomania.
Regarding diagnoses, an important marker is the time frame. For instance, even though there is some degree of euphoria considered to be normal during baby blues, symptoms of postpartum hypomania are usually present at day 1, as opposed to day 3 or 4. Hypomania is clinically significant because it can be a precursor to bipolar manifestations later.
Screening for bipolar symptoms is essential. At the PPSC, we use the MDQ (Mood Disorder Questionnaire). It may feel heavy-handed to both the clinician and the postpartum mom, but it’s important to rule out hypomania, especially during the very early postpartum days and weeks.
How do you know if you’ve been misdiagnosed?
Misdiagnosis of bipolar illnesses can be twofold, the diagnosis can be inunder-diagnosed if symptoms are missed, or it can be over-diagnosed, particularly in some hospital in-patient settings, where doctors see a high proportion of severely distressed or suicidal women. At the risk of oversimplifiying this, sometimes, providers may confuse early euphoria as consistent with the joy of new motherhood, and perhaps may not ask the right questions to make a differential diagnosis, thereby missing the diagnosis. Other times, the opposite is the case; women with PPD symptoms may be extremely agitated and risk being misdiagnosed as bipolar to an untrained eye.
There is another subset of women that wonder about their own diagnoses, perhaps because the course of their treatment has not been what they expected or perhaps they are not responding to treatment the way they had hoped. Can someone who has been treated for PPD for some time, be misdiagnosed? Certainly, that’s possible. But let me clear about this. Bipolar symptoms don’t usually hide for too long. If hypomanic symptoms are missed in the early postpartum period, they are likely to emerge in full force later in the postpartum year. In our practice, we don’t see that very often.
Other potential scenarios for women with enduring PPD symptoms are 1) characterologic variables (those pertaining to personality traits) or 2) extenuating environmental circumstances (such as unstable marriage, multiple losses, trauma, to name only a few things that could underlie a sustaining depression. It should be noted, in instances where a mood stabilizing medication (often used in the treatment of bipolar illness) is added after months (or years?) of PPD treatment, it may NOT be because there is a new diagnosis of bipolar illness. Rather, there are cases when a mood stabilizer is useful to treat sub-clinical mood changes that are problematic but do not meet the diagnostic criteria for bipolar disorder. If someone came to The Postpartum Stress Center with a long-standing depression that was not responding to medication or psychotherapy, we would not conclude that there is an untreated bipolar illness unless we saw evidence of symptoms that met the DSM-IV criteria.
The relationship between postpartum depression and bipolar illness is the subject of ongoing research, although thus far research on bipolar II has been lacking. As always, clinicians must be vigilant about screening questions and thorough assessments, and postpartum mothers need to advocate for their own best healthcare. If we can maximize our attention to this matter from both angles, we will reduce the likelihood of either under or overdiagnoses.