Bipolar disorder and childbirth: the importance of recognising risk.

of an inquiry into the death of a psychiatric colleague that raised a number of important questions – not least regarding our management of women with bipolar disorder in pregnancy and the postpartum period (North East London Strategic Health Authority, 2003). Dr Daksha Emson took the life of herself and her 3-month-old daughter, Freya. This tragedy took place during a psychotic episode triggered by childbirth and was a consequence of her history of bipolar affective disorder. Sadly, the case of Dr Emson is far from unique. The Confidential Enquiries into Maternal Deaths (2001) found that suicide had become the leading cause of maternal mortality in the UK, accounting for 28% of maternal deaths (Oates, 2003a). The majority of the women who died by suicide suffered an abrupt onset of a severe psychotic illness within days of childbirth – a ‘puerperal psychosis’, to use the traditional nosological label. For some women an episode of puerperal psychosis will be the first experience of severe mental illness, but a significant proportion of women will have had previous episodes. In the Confidential Enquiries into Maternal Deaths (2001), for example, 46% of the women who killed themselves (the majority by violent means) had previously been in contact with psychiatric services – and half of these had had a previous admission with a severe episode of illness following childbirth (Oates, 2003b). In many maternal suicides, therefore, the occurrence of an episode of severe post-partum psychiatric illness is an eminently predictable event. Although some women in the report were in contact with psychiatric services, none had received a detailed risk assessment, none had a formal management plan, and none was under close surveillance in the puerperium. It is also worth noting that none of the women in the cases of maternal suicide reported in the Confidential Enquiries was under the care of a mother and baby unit or perinatal psychiatric service (Oates, 2003a). The report on maternal deaths in 2000–2002 has now been published (Confidential Enquiries into Maternal Deaths, 2004) and, sadly, the findings are similar. Compelling evidence points to women with bipolar disorder being at particularly high risk of puerperal psychosis, with episodes following 25–50% of deliveries (Brockington, 1996; Jones & Craddock, 2001). This high rate of illness represents a many hundred-fold increase from the base rate of approximately 1 in 1000 deliveries. In addition to a history of bipolar disorder, other important risk factors include having experienced a previous episode of puerperal psychosis, having a first-degree relative who has experienced an episode of puerperal psychosis and having a firstdegree relative with bipolar disorder (Jones & Craddock, 2001). Women can be identified, therefore, who are at a vastly increased risk of developing puerperal psychosis – a risk of approximately 60% in women with bipolar disorder and a personal or family history of puerperal psychosis (Jones & Craddock, 2001; Robertson et al, 2005). However, because of the relapsing and remitting nature of bipolar disorder, these women may be currently well and not in contact with mental health services. Under such circumstances, it is particularly likely that such individuals themselves – and, indeed, others – will fail to recognise the serious risks of the situation. In addition, because of concerns about potential adverse effects on the foetus, medications that may have been successfully used for maintenance treatment are often stopped, by the woman’s medical team or by the woman herself, prior to conception or when the pregnancy is discovered. It is clear, therefore, that women with a history of bipolar disorder need careful management before conception, through pregnancy and during the post-partum period. We suggest a number of key principles on which their care should be based.