About 15% of girls experience a depressive episode after the birth of a baby.  While most  women presenting with depressive symptoms have  unipolar depression, some women even have bipolar depression.  At this juncture, making the proper diagnosis is important, because the treatment of bipolar depression differs from the treatments typically used for unipolar depression on this setting.  The usage of antidepressants in a lady with bipolar disorder is probably not effective and should actually make the symptoms worse.

While women with pregravid bipolar disorder may experience mana or postpartum psychosis after childbirth, it’s important to keep in mind that it is definitely more common for ladies to experience depressive symptoms on this setting.  

First, A Thorough Review of Psychiatric History  

Step one in making this distinction is a careful review of past psychiatric symptoms.  The next questions will help clinicians to discover individuals with a history of bipolar disorder, or symptoms suggestive of bipolar disorder:

• Has the patient previously received a diagnosis of bipolar disorder?  
• Has the patient previously been treated with mood stabilizers, comparable to lithium, lamotrigine, or atypical antipsychotic agents?
• Does the patient have a history of mania or hypomania?  The Mood Disorders Questionnaire or MDQ is a standardized questionnaire that might be helpful in screening for manic or mixed symptoms. Here’s a printable version of the MDQ.
• Is there a family history of bipolar disorder? If one parent has bipolar disorder, there’s a ten% to 25% probability of getting bipolar disorder.  The danger is higher if multiple relations are affected.  

In individuals presenting with postpartum depressive symptoms, making the proper diagnosis might be tricky.  It just isn’t difficult to acknowledge a full-blown manic episode; nevertheless, most girls with bipolar disorder don’t present with classic manic symptoms.  In reality, for many ladies with bipolar disorder, depressive episodes are more common than manic episodes.  It’s fairly common for the primary episode of bipolar disorder to be depressive in nature, and this episode may occur prior to the onset of a hypomanic or manic episode.

Making the Diagnosis in Women with No History of Bipolar Disorder

When there isn’t a history of bipolar disorder, is it possible to tell apart unipolar from bipolar depression?  In a study of a big cohort of patients with bipolar disorder, researchers attempted to discover clinical and demographic features that might help clinicians distinguish bipolar from unipolar depression in postpartum individuals.  

Using data from the FACE-BD (FondaMental Academic Centers of Expertise for Bipolar Disorders), a French multicenter cohort of patients with bipolar disorder, researchers identified all women who reported a serious depressive episode as the primary episode of bipolar illness and who had at the least one child.  They compared two groups of girls, depending whether the onset of bipolar illness occurred during or outside of the postpartum period.

Among the many 759 women on this cohort, 93 (12.2%) experienced postpartum onset of bipolar illness, and 666 (87.8%) experienced onset outside of the postpartum period.   Women who had postpartum onset of bipolar disorder had a more stable family life, more children, and were older at age at illness onset.  They were more more likely to have Bipolar Disorder Type 2, less more likely to hav e history of suicide attempts, and had fewer depressive episodes.  

While that is certainly one of the few studies the features which can help clinicians to tell apart unipolar from bipolar postpartum depression, the knowledge is of limited clinical utility.  Nonetheless, it might provide some reassurance; the onset of bipolar disorder (with depression) in the course of the postpartum period is less common than non-postpartum onset.  Moreover, it appears that ladies who present with bipolar depression in the course of the postpartum period are inclined to have less severe illness (fewer depressive episodes, fewer suicide attempts, lower risk for mania) and have higher levels of family support.

Using the Mood Disorder Questionnaire to Discover Bipolar Depression

Vigilance is required in screening women who present with depressive symptoms in the course of the postpartum period.  Women with bipolar depression, in addition to unipolar depression, typically present with elevated scores on the Edinburgh Postnatal Depression Scale. In a single study where the EPDS was used to screen postpartum women, a few third of the ladies with a positive screen on the EPDS didn’t have unipolar depression but actually had bipolar disorder.  In other words, if we were using the EPDS as our only tool to guide diagnosis and treatment, we can be unsuitable about 30% of the time.

A recent study evaluated the capability of the Mood Disorder Questionnaire (MDQ) to discover bipolar disorder in perinatal individuals who screened positive for depression on the Patient Health Questionnaire-9, a screening tool commonly used to discover depression in perinatal populations (Millan et al, 2023).

Between January 2017 and April 2021, 1510 pregnant or postpartum individuals were included on this study. On this group of perinatal individuals who scored positive on the PHQ-9 (cutoff 10 or greater), 62 (4.1%) were diagnosed with bipolar disorder that was confirmed with a clinical evaluation using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria. 

The primary query of the MDQ includes 13 “yes” or “no” items about current and past bipolar symptoms.  While a rating of seven or greater on Query 1 of the MDQ is usually used to discover individuals with bipolar disorder in the final population, this cutoff when utilized in the perinatal population had a 60% sensitivity and 88% specificity.  Which means if we used a cutoff rating of seven, about 40% of the individuals screening positive on the PHQ-9 can be misdiagnosed with unipolar depression, when the truth is that they had bipolar depression.

Lowering the cutoff rating of the MDQ to 4 or greater resulted in increased sensitivity (81%), on the expense of specificity (69%). This modification may result in a greater variety of false positives (patients who even have unipolar depression); nevertheless, it reduces the likelihood of misidentifying individuals with bipolar disorder.  

This study suggests that as an adjunct to routine screening with the EPDS or the PHQ-9, the administration of the Mood Disorder Questionnaire in the course of the perinatal period may help to discover which individuals usually tend to have bipolar or unipolar disorder. On this context, the researchers observed that lowering the cutoff rating for the MDQ to 4 or greater reduces the danger of a missed diagnosis of bipolar disorder.

Some Final Thoughts

The diagnosis of bipolar depression within the postpartum period might be extremely difficult, and even probably the most seasoned clinicians may struggle to accurately distinguish unipolar from bipolar depression on this setting.  While using standardized screening tools may help to discover a greater number of girls with psychiatric illness in the course of the perinatal period, it’s important to acknowledge that screening tools aren’t an alternative choice to clinical diagnosis.  They merely discover those that need a more thorough evaluation.

Using screening tools just like the EPDS or PHQ-9 discover women with a wide selection of psychiatric disorders, including major depressive disorder, bipolar disorder, PTSD, generalized anxiety disorder.  Further evaluation is required to verify the diagnosis.  In situations where there is restricted access to mental health resources, using additional screening tools, comparable to the Mood Disorder Questionnaire may help clinicians to discover women with bipolar disorder and to make sure that these individuals receive the suitable care. 

Ruta Nonacs, MD PhD

REFERENCES

Millan DM, Clark CT, Sakowicz A, Grobman WA, Miller ES. Optimization of the Mood Disorder Questionnaire in identification of perinatal bipolar disorder. Am J Obstet Gynecol MFM. 2023 Jan;5(1):100777. 

Tebeka S, Godin O, Mazer N, Bellivier F, et al.  Clinical characteristics of bipolar disorders with postpartum depressive onset.  Prog Neuropsychopharmacol Biol Psychiatry. 2020 Dec 18.

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