Research report
Identifying features of bipolarity in patients with first-episode postpartum depression: Findings from the international BRIDGE study

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Abstract

Objectives

The aims of this study were to assess rates of bipolar spectrum disorders in women experiencing their first episode of postpartum depression, and to find out features indicative of bipolarity in these patients.

Methods

As part of the international BRIDGE study designed to detect hypo/mania in patients with a major depressive episode, 52 (5.85%) were found to experience a first episode of postpartum (FEPP) depression, whereas 833 (94.13%) had a first episode of nonpostpartum (FENPP) depression. Hypo/mania was assessed using varying definitions of bipolarity, and the two groups compared on sociodemographic, family history and clinical characteristics.

Results

Compared to FENPP depressive patients, women with FEPP depression had higher rates of bipolar disorders, with more hypo/mania in first degree relatives. Psychotic symptoms, atypical features, mixed depression, younger age at onset, high number of prior episodes, episodes of short duration, switches on antidepressants, seasonality of mood episodes as well as mood episodes with free intervals were found to be more frequent in FEPP depressives.

Limitations

The following are the limitations of this study: centres not randomly selected, recall bias, cross-sectional design, and limited training of participating psychiatrists.

Conclusions

This study confirms, in women experiencing a first depressive episode, high rates (15 to 50%) of bipolar disorders during the postpartum period and is the first to systematically assess and demonstrate the higher prevalence of identifying features of bipolarity in FEPP versus FENPP depression. Early recognition of bipolarity in these patients may help prevent the harmful consequences of this illness.

Introduction

Studies of postpartum mood disorders have traditionally included the maternity blues, puerperal psychosis, and postpartum depression (Sharma et al., 2010).

In the DSM-IVTR (American Psychiatric Association, 2000) the “postpartum onset” specifier can be applied to the current or most recent depressive, manic or mixed episode in major depressive disorder, bipolar I disorder, bipolar II disorder, or brief psychotic disorder if the onset of the episode is within 4 weeks postpartum. Nevertheless, the literature on postpartum depression has focused almost exclusively on major depressive disorder, despite clear indication of an elevated risk for mood episodes after delivery in bipolar women (Sharma et al., 2010). Retrospective as well as prospective studies indicate that approximately 60–70% of women with bipolar disorder experienced a mood episode during pregnancy and the postpartum period (Freeman et al., 2002, Viguera et al., 2007). Moreover, women with bipolar disorder are more than 23 times more likely to be admitted to the hospital for a mood disorder during the first 30 days after delivery than during the pregnancy (Munk-Olsen et al., 2006). Rates as high as 67% were found for postpartum depression (Freeman et al., 2002), and between 25% and 50% for postpartum mania and psychosis (Brockington, 1996, Jones and Craddock, 2001). Postpartum depression increases risk of harmful consequences. These include chronicity of the depression (Cox et al., 1993), suicide and infanticide (Brockington, 2004), disruption in marital relationship (Da Costa et al., 2006) and adverse effects on child development (O'Hara, 2009). Furthermore, the risk of recurrence with each subsequent delivery could be high especially if episodes are associated with psychotic features (American Psychiatric Association, 2000). It is highly likely that missing the diagnosis of bipolar disorder in the postpartum period may increase the risk of such consequences: in a study on 45 filicidal women, 75% were diagnosed with major depression and 26.4% with bipolar disorder at admission to a forensic psychiatric unit, whereas at discharge, 73.3% had been rediagnosed with bipolar disorder (Spinelli, 2009). While postpartum episodes in the context of bipolar disorder may be undistinguishable from spontaneous episodes (Colom et al., 2010), early recognition of bipolarity, during the first-episode postpartum (FEPP) depression, may be essential to prevent these risks and provide effective and specific care to women affected by this disorder (Sharma et al., 2010). This is particularly challenging, given that depression may be the most common presentation of women with bipolar disorder during the perinatal period (Chessick and Dimidjian, 2010, Yonkers et al., 2011).

The BRIDGE (Bipolar Disorders: Improving Diagnosis, Guidance and Education) study is a large, multinational study which applied a descriptive, bottom–up approach to detect hypomania in patients with a major depressive episode (Angst et al., 2011). The study offers a unique opportunity to examine specific aspects of this pathology.

The aims of the current investigation were, (1) to estimate the prevalence and incidence of FEPP depression, (2) to assess the rates of bipolarity in FEPP depressive patients versus first-episode nonpostpartum (FENPP) depressives and (3) to compare the clinical profile of these two groups with respect to features deemed to be indicative of bipolar disorders.

Section snippets

Sample and assessment

The general methodology of the BRIDGE study has been described in detail previously (Angst et al., 2011). In summary, it is a cross-sectional diagnostic investigation of 5635 depressed patients conducted in 18 countries in Europe, Asia and North Africa between April 2008 and May 2009. Community- and hospital-based psychiatrists recruited consecutively all eligible adult patients consulting with a diagnosis of major depressive episode (MDE). At this consultation, participating psychiatrists

Prevalence

Eight hundred and eighty five female patients experiencing a first episode of major depression were included in the analyses. Of those, 52 (5.87%) were suffering from FEPP depression whereas 833 (94.13%) had FENPP depression.

Sociodemographic, family history and comorbidity characteristics

FEPP depressive patients did not significantly (p = 0.7) differ from FENPP depressives in regard to age and use of screening registry (p = .95). Significant differences were found for marital status (p = .00), patient status (p = .02), and respective rates by country (p = .00) (

Frequency of FEPP depression

Reported prevalence estimates of depression in the postpartum period range from nearly 0% to 60%, depending on the study population and methodology (Halbreich and Karkun, 2006). Some evidence suggests that depression during the postpartum period may be more common than at any other discrete period of time in a woman's life (Vesga-Lopez et al., 2008). Although two epidemiological surveys (Kendell et al., 1987, Terp and Mortensen, 1999) reported the incidence of postpartum psychosis as somewhat

Conclusions

The results of this study confirm, in a subsample of patients with a first episode of depression, the higher prevalence of bipolar disorders in the postpartum period compared to any other period in a woman's life, with an incidence of first-episode postpartum depression estimated at 44.61 per 100,000 person per year. They provide the first evidence that the identifying features suggestive of a bipolar disorder in patients diagnosed with major depression may already be present during the first

Role of funding source

This study was supported by an unrestricted grant from Sanofi-Aventis, CNS Department, Paris, France. Sanofi-Aventis had no further role in study design, in the collection and analysis of data, in the writing of the report, and in the decision to submit the paper for publication.

Conflict of interest

JMA has undertaken consultancy work for Lilly, Janssen, Sanofi-Aventis, Lundbeck, Astra-Zeneca and Bristol-Myers-Squibb; and has received honoraria from Lilly, Janssen, Lundbeck, Sanofi-Aventis, Pfizer, and Novartis in relation to conference presentations.

JA has served on the advisory board for Lilly, Janssen, Lundbeck, on the speaker's bureau for Lilly and Astra Zeneca, and as a consultant for Sanofi-Aventis.

AG has no conflicts of interest to declare.

CB has acted as consultant for Pfizer,

Acknowledgements

The authors of this report would like to thank the principal investigators of all participating study centres.

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