Bipolar Disorder During the Perinatal Period: Importance of a Correct Diagnosis

Studies have shown an average delay of 7 to 10 years for a correct diagnosis of bipolar disorder, with the majority of patients being misdiagnosed with (unipolar) major depressive disorder.¹ Importantly, the main reasons for such a delay are that hypomanic symptoms are underreported by those who suffer from bipolar disorder and that health care providers quite often do not effectively ask their patients about these symptoms. It is not difficult to understand why hypomanic symptoms are underreported, given that hypomania by definition does not cause significant impairment and, in fact, hypomanic states may be perceived as beneficial in terms of work productivity, self-confidence, and sense of well-being. If one does not actively investigate signs and symptoms of hypomania, these symptoms will go undetected. Screening tools such as the Mood Disorders Questionnaire (MDQ) can be used to begin the diagnostic process.¹

A timely diagnosis of bipolar disorder is particularly crucial for pregnant and postpartum women. The scientific literature has provided evidence that women who suffer from bipolar disorder can face significant emotional distress during the perinatal period and that sometimes the health and safety of their babies are at risk. It appears that both the medications for bipolar disorder and the illness itself can carry different types of risks for mothers and babies.^2–4 Soon-to-be and new mothers with bipolar disorder deserve to be well educated about the potential risks and benefits associated with different treatment options.

While the usefulness of the MDQ in nonpsychiatric perinatal/obstetric settings is unknown, a recent study⁵ by my colleagues and me showed that the MDQ is an excellent self-report tool that can be used to screen for bipolar symptoms in pregnant and postpartum women who are referred for psychiatric assessment. From a clinical perspective, the MDQ is particularly useful in ruling out bipolar disorder, which is the main asset of a screening tool. However, one cannot forget that the use of screening tools never precludes a careful diagnostic assessment in order to not overdiagnose bipolar disorder.

I hope our study can resonate as a wake-up call to mental health providers who see women during pregnancy and the postpartum period. With so many uncertainties that still remain in terms of balancing the risks and benefits associated with taking medications during pregnancy and breastfeeding, accurate diagnosis and education are the least we should do to help mothers (and fathers) decide what they believe is best for themselves and their children.

Financial disclosure:Dr Frey had no financial relationships to report relevant to the subject of this article.

References

1. Hirschfeld RM. Screening for bipolar disorder [published correction appears in Am J Manag Care. 2008;14(2):76]. Am J Manag Care. 2007;13(7 suppl):S164–S169. PubMed

2. Kim J-H, Choi SS, Ha K. A closer look at depression in mothers who kill their children: is it unipolar or bipolar depression? J Clin Psychiatry. 2008;69(10):1625–1631. Full Text

3. Jones I, Craddock N. Bipolar disorder and childbirth: the importance of recognising risk. Br J Psychiatry. 2005;186(6):453–454. PubMed

4. Bodén R, Lundgren M, Brandt L, et al. Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study.BMJ. 2012;345:e7085. PubMed

5. Frey BN, Simpson W, Wright L, et al. Sensitivity and specificity of the Mood Disorders Questionnaire as a screening tool for bipolar disorder during pregnancy and the postpartum period. J Clin Psychiatry. 2012;73(11):1456–1461. Full Text​