Many researchers believe that postpartum psychosis is either a variant or a manifestation of a manic/mixed episode and in many women demarcates the onset of bipolar disorder (110,120,121). Postpartum psychosis is a rare condition affecting 0.1-0.2% of all women experiencing childbirth (110,122). Women with bipolar disorder have a significantly higher risk than women without a psychiatric disorder of developing postpartum psychosis (5,12,17,18,104-108,123). Recent studies have found that for women with bipolar disorder, the risk of developing postpartum psychosis is increased to 20-50%, particularly when mood-stabilizing medications (i.e., lithium) are discontinued during pregnancy and not reinstated within 48 h of delivery (5,110,116,122). Furthermore, additional research has demonstrated that many women with postpartum psychosis will later develop bipolar disorder (7,12,17,104-108,111,124-128).
One study found that one-third of 486 women admitted psychiatri-cally with postpartum psychosis in the first 3 mo following delivery had a prior diagnosis ofbipolar illness (5). Several studies suggest that recurrent bipolar disorder usually follows an episode of postpartum psychosis (5,110,120). In addition, primiparity, family history of bipolar disorder, and psychosocial stressors increase the risk of the disorder (110).
Studies have consistently found that more than two-thirds of women who develop postpartum psychosis do so within the first 2 wk following childbirth (107,117,129,130). Symptoms of postpartum psychosis typically occur rapidly, within 48-72 h of delivery, and share features with manic or mixed episodes—elated mood alternating rapidly with depressed mood, irritability, restlessness or motor excitement, sleep and appetite disturbance, disorganized behavior, and psychotic symptoms (i.e., auditory hallucinations) (5,110). The delusions often revolve around the infant or children and must be carefully assessed because women with postpartum psychosis may have thoughts of harming their infants and sometimes act on these thoughts (117,131-133). Risks of infanticide have been estimated as high as 4% (110,134). Many authors have reported a "delirious" or "perplexed" state with waxing and waning confusional presentation (17,117,129,131,132).
Studies that support a link between bipolar illness and postpartum psychosis found that the risk of having an affective episode among first-degree relatives of women with postpartum psychosis is similar to the risk among first-degree relatives of patients with bipolar disorder (117,130,135,136). A single large study that used direct interview of relatives suggested that familial factors play a role in the vulnerability to postpartum triggering itself. Episodes ofpostpartum psychosis occurred in 74% (n = 20) of the 27 parous women with bipolar disorder who had a family history of postpartum psychosis in a first-degree relative but in only 30% (n = 38) of the 125 women with bipolar disorder with no such family history (137). This study also reported that there is significant evidence (p < 0.003) that variation at the serotonin transporter gene exerts a substantial and important influence on susceptibility to bipolar affective postpartum psychosis (137,138).
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