The Diagnostic and Statistical Manual of Mental Disorders or DSM does not consider postpartum psychiatric disorders as separate entities; instead, these disorders are identified using a peripartum onset specifiers. There has long been debate as to whether postpartum psychiatric disorders are distinct from disorders occurring outside of pregnancy and the postpartum period. In a recent article, Sharma and colleagues revisit this question and discuss whether bipolar disorder emerging during the postpartum period represents a distinct entity.

Revisiting the debate about whether bipolar disorder in the postpartum period is different from its non-postpartum counterpart is crucially important to improve the detection, diagnosis, and treatment of postpartum bipolar disorder.

Postpartum Manic Episodes

Compared to non-postpartum manic episodes, postpartum manic episodes appear more likely to be characterized by depressive symptoms, anxiety, mood lability, perplexity, disorientation, and excessive self-reproach. In within-subject comparisons, postpartum manic episodes have been associated with fewer classic manic symptoms (specifically pressured speech and increased sociability) but more depressive symptoms and anxiety.  Psychotic symptoms are common in bipolar mania.  For example, an Italian study found that 67.8% of patients with mania, and 87.5% with mixed episodes had psychotic features.

The duration of hospitalization and short-term outcomes are similar for postpartum and non-postpartum manic episodes.

Postpartum Bipolar Depression

In women with histories of bipolar disorder, depressive episodes occur more commonly than mixed or manic episodes in the postpartum period. First-onset depression in the postpartum period is more likely to reflect bipolar disorder than first-onset of depression occurring at other times. First-onset depressive episodes during the postpartum period are more likely to be characterized by higher rates of manic symptoms in first-degree relatives, psychotic symptoms, atypical features, mixed symptoms, younger age at onset, and antidepressant-induced hypo/mania compared to non-postpartum onset depression. 

To date, there are no within-subject or between-subject studies directly comparing bipolar postpartum depression with bipolar depression occurring outside the postpartum period.

Course and Outcomes

Some, but not all, studies have reported a better prognosis for bipolar disorder with postpartum onset compared with bipolar disorder with non-postpartum onset. Some studies indicate that patients may experience mood episodes that are limited to the postpartum period; however, non-postpartum recurrences appear to be the rule rather than the exception.

Treatment Considerations

Due to the lack of controlled data on the acute treatment of bipolar mood episodes during the postpartum period, it remains unclear whether the medications generally considered effective for the acute treatment of bipolar disorder are also equally effective in the postpartum period. 

The treatment of depressive episodes with postpartum onset immediately after delivery poses unique challenges, particularly when there is no known family history of bipolar disorder and antidepressant-induced switching is a concern. Atypical antipsychotics, alone or in combination with mood stabilizers, such as lamotrigine or lithium, may be preferable options for mothers who experience the first onset of depression immediately after delivery, especially when bipolarity is suspected.

There are significant gaps in our current understanding of bipolar disorder in the postpartum period. Based on the available evidence, the authors of the recent commentary conclude that “it is reasonable to conclude that bipolar disorder in the postpartum period is neither the same as its non-postpartum counterpart nor distinct, but similar.”