Bipolar Disorder, Affective Psychosis, and Schizophrenia in Pregnancy

Series Perinatal mental health 2 Bipolar disorder, aff ective psychosis, and schizophrenia in pregnancy and the post-partum period Ian Jones, Prabha S Chandra, Paola Dazzan, Louise M Howard The perinatal period is associated with an increased risk of severe mental disorders. We summarise the evidence Lancet 2014; 384: 1789–99 regarding the epidemiology, risk factors, and treatment of severe mental illness in relation to childbirth, focusing on This is the second in a Series of bipolar disorder, aff ective psychosis, and schizophrenia. We discuss women with ongoing chronic conditions and three papers about perinatal those with the onset of new episodes of post-partum psychosis. Despite the importance of perinatal episodes, with mental health suicide a leading cause of maternal death, few studies are available to guide the management of women with severe National Centre for Mental Health, MRC Centre for mental disorders in pregnancy and the post-partum period. However, general principles of management are Neuropsychiatric Genetics and discussed, including the need for an individual risk–benefi t analysis for each woman. Genomics, Cardiff University, UK (Prof I Jones MRCPsych); Introduction increasing use of non-prolactin-raising antipsychotics.7 National Institute of Mental Health and Neurosciences Pregnancy is a major event in any woman’s life. The However, because schizophrenia in particular can aff ect (NIMHNS), Bangalore, India 8 transition to motherhood involves major challenges in a women’s ability to make and sustain relationships, (P S Chandra FRCPsych); the psychological, social, and biological domains. For a some reduction in fertility is likely to continue. Department of Psychosis woman with, or who is susceptible to, severe mental Nevertheless, most women with schizophrenia and Studies (P Dazzan MRCPsych) and Health Service and 9 illness this transition might prove particularly complex bipolar disorder do have children, although their Population Research and diffi cult. Although many forms of psychiatric pregnancies are more likely to be unplanned and Department illness can be severe, in this Series paper severe mental unwanted than are those of women in the general (Prof L M Howard MRCPsych), illness refers to schizophrenia, aff ective psychosis, and population.10 Of those women with psychotic disorders Institute of Psychiatry, King’s College London, UK bipolar disorder, including psychotic and non-psychotic who do have children, some describe motherhood as 11 Correspondence to: forms of bipolar disorder. This defi nition includes both central to their existence. Prof Ian Jones, National Centre women with pre-existing illness who become pregnant, for Mental Health, MRC Centre and those who develop severe post-partum episodes Epidemiology for Neuropsychiatric Genetics as the fi rst manifestation of psychiatric illness. The The prevalence of severe mental disorders in pregnancy and Genomics, Hadyn Ellis Building, Maindy Road, Cardiff acute onset of severe psychiatric episodes following has rarely been studied, although a US epidemiological University, Cardiff CF24 4HQ, UK childbirth—post-partum (or puerperal) psychoses—are study showed no diff erence in the prevalence of psychotic [email protected] among the most severe forms of illness seen in (0·4%) and broadly defi ned bipolar disorder (2·8%) in psychiatry. Psychiatric disorders in the perinatal period past-year pregnant women compared with non-pregnant result in signifi cant distress, can disrupt the developing women.12 Few studies have examined the incidence bond between mother and child, and have long-term of severe mental illness in pregnancy, but a Danish implications for the wellbeing of the woman, the baby, registry-based study reported a reduced risk in pregnancy her family, and wider society. In rare but tragic cases, for fi rst psychiatric admissions with both schizophrenia the illness can lead to suicide, a leading cause of 1,2 3 maternal death, and infrequently, infanticide. Key messages • Severe mental illness in the perinatal period occurs as a continuation of chronic Severe mental illness and pregnancy psychotic illness or a new onset, often shortly after childbirth (post-partum psychosis), Fertility and these episodes can result in substantial distress and have long-term implications Women with severe mental illness have consistently for the wellbeing of the woman, her family, and wider society been reported to have lower fertility rates than do • Childbirth is a powerful trigger of mania and psychosis, and episodes at this time cause women in the general population, with women with substantial morbidity and mortality, with suicide a leading cause of maternal death schizophrenia usually having much lower fertility than • Pregnancy should be an important consideration in the treatment of all women with 4–7 do women with bipolar disorder. Although women severe mental illness in their reproductive years, and careful counselling of the woman with psychiatric disorders have high rates of abortion and her partner to acknowledge the many areas of uncertainty is crucial to optimal care compared with the general population, this does • Individualised risk–benefi t analyses are needed when psychotropic drugs are regarded 5 not appear to explain the decrease in fertility. for use in the perinatal period, and the risk of untreated illness for the mother and Prolactin-raising antipsychotics, which reduce fertility, fetus or infant should be taken into account seem to partly explain the reduction in general • Further research is essential to help understand more about the triggering of psychotic 6 fertility rate, with evidence that the general fertility rate episodes by pregnancy and childbirth, enable better prediction of women at risk, and among women with schizophrenia has increased develop improved treatments for women who become unwell at this time modestly over the past 13 years coinciding with the www.thelancet.com Vol 384 November 15, 2014 1789 Series new onset13 and relapse during pregnancy,19 and a Search strategy and selection criteria retrospective study in 201320 noted that only 8% of We searched PubMed, Embase, PsycINFO, and the Cochrane Library without language perinatal episodes in 980 women with bipolar I disorder restrictions. Original searches were done for systematic reviews (past 20 years) and had their onset in pregnancy. Other clinic-based studies 21 epidemiological or experimental studies (past 3 years) with the following search terms: provide confl icting results, with one study reporting “pregnancy” or “prenatal” or “antenatal” or “postnatal” or “postpartum” or “perinatal” high recurrence rates in pregnancy, particularly in or “puerperal” or “breastfeeding” or “birth” or “weaning” or “childbirth” or “trimester” women who discontinue prophylactic medication 22 or “peripartum” or “lactation” or “ante-natal” or “post-natal” or “post-partum” and (53 [85%] of 62 women). A subsequent study from the “psychosis” (exploded MeSH term) or “mood disorder” (exploded MeSH term) or same group in an expanded sample of parous women “schizophrenia” (exploded MeSH term) or “psychosis” or “mania”. with bipolar disorder (n=283 BPI and n=338 BPII) noted that 23% had illness episodes during pregnancy compared These search terms were combined with specifi c terms for the following sections, with with 52% with an episode in the post-partum period. date limits based on the amount of recent research output in each area: “prevalence” or Few data exist for the nature of psychotic relapse during “incidence” or “relapse” or “course” (limited to past 5 years); or “fertility” (exploded pregnancy although case reports suggest severe psycho- MeSH term) or “fertility” (limited to past 10 years); “ECT” or “electroconvulsive pathology can occur.23,24 Women who are usually therapy” or “electro convulsive therapy” (limited to past 10 years); “mother baby unit” maintained on medication to stabilise their condition or “mother baby units” or “mother and baby unit” or “mother and baby units” or might stop treatment when they discover that they are “MBU” or “services” or “safe guarding” or “safeguarding” (limited to past 10 years); pregnant because of fears about potential teratogenicity, “lithium” or “Carbamazepine” or “Sodium Valproate” or “Valproic acid” or and this can lead to a rebound psychosis. Women who are “Amisulpride” or “Flupentixol Decanoate” or “Aripiprazole” or “Fluphenazine chronically unwell might develop psychotic denial of Decanoate” or “Benperidol” or “Fluspirilene” or “Chlorpromazine” or “Haloperidol” or pregnancy, particularly if they have previously lost custody “Clozapine” or “Pipotiazine Palmitate” or “Cyamemazine” or “Zuclopenthixol of a child. This denial can lead to refusal of antenatal care Decanoate” or “Droperidol” or “Flupentixol” or “Fluphenazine” or “Haloperidol” or or failure to recognise labour, with consequent unassisted “Levomepromazine” or “Loxapine” or “Olanzapine” or “Oxypertine” or “Paliperidone” delivery, although this occurrence seems to be rare.25 or “Pericyazine” or “Perphenazine” or “Pimozide” or “Promazine” or “Quetiapine” or “Remoxipride” or “Risperidone” or “Sertindole” or “Sulpiride” or “Thiopropazate Severe mental illness in the post-partum period Hydrochloride” or “Trifl uoperazine” or “Zotepine” or “Zuclopenthixol Dihydrochloride” Severe mental illness can occur in the post-partum or “Ziprasidone” (limited to past 5 years). period as the continuation of a chronic psychotic condition that began in or before pregnancy, or as an and bipolar

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