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Correspondence |
Section of Perinatal Psychiatry, Mother and Baby Unit, Bethlem Royal Hospital, and Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. E-mail: v.o'keane{at}iop.kcl.ac.uk
The report by Robertson et al (2005) on the rates of recurrence of post-partum and non-post-partum psychosis in women who have experienced a previous episode of post-partum psychosis teaches us something new about the prognosis for these women. The risk of developing a subsequent non-puerperal episode is increased in women who have a family history of mental illness and is non-significantly increased for women with a personal history of illness prior to the puerperal episode. Robertson et al (2005) report rates of relapse following subsequent deliveries of 57%. They did not report the effects, if any, of treatment in preventing further puerperal episodes. Prophylactic treatment was only alluded to in the discussion, where, following a listing of the side-effects associated with lithium and other mood stabilisers, it was stated that treatment should only be instituted following a ‘very careful weighing up of risks and benefits’. This apparently negative emphasis may be unintentional but is unfortunate for two reasons. First, although there are few studies in this area, the rates of recurrence of post-partum psychosis vary widely and have been as high as 90% (Kendell et al, 1987). It is very probable that these recurrence rates vary according to whether women are actively managed with prophylactic medication. Second, clinical observations of the benefits of lithium prophylaxis in post-partum psychosis are supported by some published reports which suggest that lithium prevents recurrence in up to 90% of cases (Stewart et al, 1991; Cohen et al, 1995).
The relatively low rates of recurrence of puerperal psychosis reported by Robertson et al (2005) may partly result from the now common practice of treating women prophylactically with mood-stabilising medication. For perinatal psychiatrists, the risk – benefit weighting of treatment with mood stabiliser v. no treatment in the puerperium for women who have had a prior episode of post-partum psychosis falls down very convincingly on the side of active treatment.
REFERENCES
Cohen, L. S., Sichel, D. A., Robertson, L. M., et al
(1995) Postpartum prophylaxis for women with bipolar
disorder. American Journal of Psychiatry,
152, 1641
-1645.
Kendell, R. E., Chalmers, J. C. & Platz, C.
(1987) Epidemiology of puerperal psychoses.
British Journal of Psychiatry,
150, 662
-673.
Robertson, E., Jones, I., Haque, S., et al
(2005) Risk of puerperal and non-puerperal recurrence of
illness following bipolar affective puerperal (post-partum) psychosis.
British Journal of Psychiatry,
186, 258
-259.
Stewart, D. E., Klompenhouwer, J. L., Kendell, R. E., et
al (1991) Prophylactic lithium in puerperal psychosis.
The experience of three centres. British Journal of
Psychiatry, 158, 393
-397.
Section of Perinatal Psychiatry, Department of Psychological Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK. E-mail: jonesirl{at}Cardiff.ac.uk
We agree with Dr O’Keane regarding the severity and potentially devastating consequences of post-partum psychosis in women with a history of bipolar disorder and assure her that any negative emphasis she detected in our brief comments regarding prophylactic treatment were indeed unintended. The brief report format did not allow us to discuss this aspect of management at length but we have taken up this issue more fully in our recent editorial (Jones & Craddock, 2005).
We would, however, defend our contention that the decision to commence mood-stabilising (or indeed any) medication in women of child-bearing years should follow a ‘very careful weighing up of risks and benefits’. Any medication should be started assuming that the women may become pregnant and future pregnancy and contraception should be actively discussed at the earliest possible opportunity.
We would also argue that the evidence base for the use of prophylaxis in women with bipolar illness in the post-partum period is not as robust as would be ideal. As Dr O’Keane has outlined, the literature does support the use of lithium in this context, although the retrospective (and partially overlapping) studies differed in when lithium was commenced – important as there may be practical problems in achieving therapeutic levels quickly following delivery and the onset of puerperal psychosis is typically in the few days following delivery. In our series of 101 women with post-partum psychosis more than half had an onset on days 1–3 with over a fifth on the first post-partum day (further details available from the authors on request). With regard to other mood stabilisers, there are few data in the literature. A recently published study demonstrated no efficacy for sodium valproate (Wisner et al, 2004) and, despite anecdotal reports of the benefit of typical or atypical antipsychotic medication as prophylaxis, there are no data regarding their use in this context.
Finally, it is our experience that women have strong views on the acceptability of taking medication during pregnancy and while breast-feeding. This may account for the fact that out of the 54 women in our study who went on to have a further pregnancy, only six took prophylactic medication in the puerperium (lithium or haloperidol). Although only two went on to have a recurrence of puerperal psychosis, the numbers are clearly too small to draw conclusions regarding the efficacy of prophylaxis.
This is an area, therefore, in which management decisions are not straightforward but the frequency and severity of post-partum episodes in women with bipolar disorder must weigh heavily in the risk – benefit analysis. What is needed, we can all agree, is further research to provide empirical data on which clinicians, women, and their families can base these difficult decisions.
REFERENCES
Jones, I. & Craddock, N. (2005) Bipolar
disorder and childbirth: the importance of recognising risk.
British Journal of Psychiatry,
186, 453
-454.
Wisner, K. L., Hanusa, B. H., Peindl, K. S., et al (2004) Prevention of postpartum episodes in women with bipolar disorder. Biological Psychiatry, 56, 592 -596.[Medline]
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