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Bipolar Disorders 2015: 17: 102–105

BIPOLAR DISORDERS

Brief Report

Bipolar disorder, miscarriage, and termination Di Florio A, Jones L, Forty L, Gordon-Smith K, Craddock N, Jones I. Bipolar disorder, miscarriage, and termination. Bipolar Disord 2015: 17: 102–105. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. Objectives: To compare rates of bipolar episodes following miscarriage and termination with those occurring in the postpartum period. Methods: Information in relation to pregnancy and childbirth was gathered retrospectively for 1,283 women with broadly defined bipolar disorder by interview and case-notes review. Results: Rates of mania or affective psychosis were significantly higher after full-term delivery than after termination (p < 0.001) or miscarriage (p < 0.001). Rates of non-psychotic major depression were similar following full-term deliveries, miscarriages (p = 0.362), and terminations (p = 0.301). Conclusions: While women with bipolar disorder and their clinicians should be aware of the possible onset of depression in the weeks following miscarriage or termination, episodes of mania or affective psychosis are less common in comparison with the high rates observed in the postpartum period.

Women with bipolar disorder face very difficult decisions in relation to pregnancy, with consistent evidence of a high risk of severe postpartum episodes (1). However, there is a paucity of studies that can inform women and their clinicians about the risk of a recurrence after a miscarriage or termination. Data from a Danish population-based cohort showed that, although admission rates were high in women who had a termination, there was no evidence for an increased risk of readmission with bipolar disorder in the months following the induced abortion (2)—rates were high before and following the procedure. There is less information regarding the impact of miscarriage on bipolar episodes, with data limited to small studies and case reports (3). In a large sample of women with bipolar disorder, we here compare the rates of episodes follow-

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Arianna Di Florioa, Lisa Jonesb, Liz Fortya, Katherine Gordon-Smitha,b, Nick Craddocka and Ian Jonesa a National Centre for Mental Health, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, bDepartment of Psychiatry, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK

doi: 10.1111/bdi.12217 Key words: bipolar disorder – childbirth – miscarriage – termination Received 12 July 2013, revised and accepted for publication 27 December 2013 Corresponding author: Professor Ian Jones National Centre for Mental Health MRC Centre for Neuropsychiatric Genetics and Genomics Cardiff University Hadyn Ellis Building, Maindy Road Cathays Cardiff CF24 4HQ UK E-mail: [email protected]

ing miscarriage and termination with those occurring in the postpartum period.

Methods Recruitment

The recruitment, assessment methods, and detailed demographic and clinical characteristics of our mood disorder sample have been described in detail elsewhere (1). In summary, women were recruited into our clinical and genetic study of bipolar disorder using systematic and non-systematic methods. All participants were ≥18 years and provided written informed consent. Potential participants were excluded if they had (i) a lifetime diagnosis of intravenous drug dependence, (ii) experienced affective illness only as a result of alco-

Bipolar disorder, miscarriage, and termination hol or substance dependence, or (iii) experienced affective illness only secondary to medical illness or medication. Women were included in the current analyses if: (i) they had a lifetime DSM-IV diagnosis of bipolar disorder or schizoaffective disorder–bipolar type (4), (ii) we had detailed information for at least one pregnancy, (iii) they reported an age at onset before 50 years of age, and (iv) they were recruited not specifically because of a history of illness in relation to childbirth. Data on postpartum episodes were collected throughout the course of the study and are therefore available for all women in the sample; however, we collected data about psychiatric episodes following miscarriage and termination for a more limited period and hence these data are not available for all women. Assessment

Participants were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (5), and psychiatric case notes were reviewed. Information was obtained for each participant about obstetric history and about episodes of bipolar disorder in relation to pregnancy. Best-estimate lifetime diagnoses were made according to DSM-IV, and key clinical variables, such as age at onset and number of episodes, were rated. We defined: (i) postpartum, post-miscarriage, or post-termination mania or affective psychosis as a new episode of DSM-IV mania or psychotic depression with onset within six weeks of the end of the pregnancy. (ii) postpartum, post-miscarriage, or post-termination non-psychotic major depression as a new episode of DSM-IV non-psychotic major depression with onset within six weeks of the end of the pregnancy. Statistical analyses

Statistical analyses were performed using R, version 2.13.0 (6). Estimates were calculated with 95% confidence intervals (CIs). Different pregnancies from the same woman cannot be considered independent events; thus we fitted mixed-effects models using the lmer function (package lme4) and setting the individual woman as a random effect and obstetric outcome and parity order as explanatory variables.

der (n = 873), bipolar II disorder (n = 341), schizoaffective disorder–bipolar type (n = 42), or bipolar disorder not otherwise specified (n = 27). Sample characteristics are summarized in Table 1. As described above, we collected information on postpartum episodes for the whole of the sample and therefore we had data on many more live births than other pregnancy outcomes. The episode after pregnancy was the first lifetime episode for 107 (42.5%) women with a history of post-pregnancy psychosis and 93 women (31.6%) with a history of post-pregnancy non-psychotic depression. Data were collected for 2,566 live births, 108 miscarriages, 88 terminations, and 12 stillbirths. Mean age at pregnancy was 26.6 years (standard deviation = 5.52 years). Distribution of lifetime diagnoses (p = 0.834), age at first impairment (p = 0.815), rates of lifetime psychosis (p = 0.757), and alcohol misuse (p = 0.107) did not differ across pregnancy outcome groups, while miscarriage and termination groups had significantly higher rates of substance misuse (p = 0.011). Proportions of pregnancies followed by mania/affective psychosis and non-psychotic depression are shown in Figure 1. Overall, 332 pregnancies were followed by the onset of mania/affective psychosis within six weeks. Rates of mania/psychosis after a live birth were consistent with those previously reported by our group (1) for women with bipolar I disorder (n = 282, 19.2%; 95% CI: 17.2–21.3) and for those with bipolar II disorder (n = 14, 2.3%; 95% CI: 1.3–4.0). In women with broadly defined bipolar disorder, rates of mania/affective psychosis were significantly higher after a live birth (n = 320, 12.5%; 95% CI: 11.2–13.8) than after a termination (n = 4, 4.3%; 95% CI:

Bipolar disorder, miscarriage, and termination.

To compare rates of bipolar episodes following miscarriage and termination with those occurring in the postpartum period...
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