Bipolar

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Bipolar II Postpartum Depression: Detection, Diagnosis, and Treatment Sharma, Verinder; Burt, Vivien K, MD, PhD; Ritchie, Hendrica L, MD. The American Journal of Psychiatry166. 11 (Nov 2009): 1217-21.

Bipolarity and the Postpartum Period
Bipolar spectrum disorder generally includes bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified (1). Bipolar I disorder is characterized by recurrent episodes of mania and depression, while bipolar II disorder is defined as recurrent episodes of depression and hypomania. The illness course inbipolar disorder not otherwise specified is also punctuated with manic and depressive symptoms, but the disorder does not reach the DSM -IV threshold criteria for bipolar I or II disorder. There is accumulating evidence that the majority of bipolarity exists beyond the realm of bipolar I disorder. The U.S. National Comorbidity Survey Replication Study reported lifetime prevalence estimates of 1.0% for bipolar 1 disorder, 1.1% for bipolar II disorder, and 2.4% for bipolar disorder not otherwise specified (2). Despite the combined high prevalence of bipolar II disorder and bipolar disorder not otherwise specified, research on postpartum mood disorders has focused primarily on major depressive disorder, mania, and puerperal psychosis. While the nosological status of postpartum psychosis remains a topic of debate, it is usually a manifestation of bipolar disorder triggered by childbirth. The study of postpartum bipolarity beyondbipolar I disorder has been largely ignored; consequently, uhere are scant data on the prevalence of depressive presentations in bipolar II disorder and bipolar disorder not otherwise specified. Freeman et al. [3) reported that 67% of 30 women with bipolar 1 and II disorder had a postpartum mood episode within 1 month of delivery; in the eight women who had experienced episodes following their first delivery, the recurrence rate following a subsequent delivery was 100%. Identified postpartum episodes were almost exclusively of the depressive type. Another study (4) found that approximately 20% of women with bipolar disorder retrospectively reported having postpartum mood episodes, mainly of the depressive type. Compared to women with major depressive disorder, those with bipolar disorder are more likely to have episodes of postpartum depression; however, no prospective studies have been conducted to ascertain the comparative prevalence of postpartum depression in women with major depression and those with bipolar disorder. Misdiagnosis of bipolar depression as major depressive disorder during the postpartum period appears to be common. For example, Sharma et al. (5) reported triât 54% of 56 outpatients seen consecutively with the referral diagnosis of postpartum depression were rediagnosed as having a lifetime diagnosis of bipolardisorder. In terms of frequency of occurrence, the primary diagnoses in this sample were major depressive disorder (46%), bipolar disorder not otherwise specified (29%), bipolar II disorder (23%), and bipolar I disorder (2%). Thirty percent of patients had a positive screen for bipolar spectrum disorder on the Mood Disorders Questionnaire, and 86% of those who screened positive met DSM-IV criteria for a diagnosis ofbipolar disorder; however, only a small number (10%) of these patients reported receiving a past diagnosis ofbipolar disorder. Postpartum Hypomania

Hypomanic symptoms are common after delivery, with various studies reporting rates in the range of 9%-20% (68). While no comparative studies have been conducted on the prevalence of hypomania during the piierperium compared with the nonpuerperal periods, the rates of hypomania reported in various studies are higher than the lifetime prevalence of bipolar disorder. It has been suggested that postpartum hypomania does not simply reflect happiness at having a baby but is a manifestation of bipolar disorder (9). Associated symptoms include increased goal-directed...
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