DSM-V: Modifying the postpartum-onset specifier to include hypomania

By failing to include it under the rubric of the postpartum-onset specifier, Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR has ignored the clinical reality that childbirth is a potent trigger of hypomania. Given the serious and occasionally tragic consequences of misdiagnosis of bipolar II depression as unipolar depression in the postpartum period, it is argued that DSM-V should consider modifying the postpartum-onset specifier to include episodes of hypomania. © 2010 The Author(s)

DSM-V: modifying the postpartum-onset specifier to include hypomania

By failing to include it under the rubric of the postpartum-onset specifier, Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR has ignored the clinical reality that childbirth is a potent trigger of hypomania. Given the serious and occasionally tragic consequences of misdiagnosis of bipolar II depression as unipolar depression in the postpartum period, it is argued that DSM-V should consider modifying the postpartum-onset specifier to include episodes of hypomania

When women hurt in mind and body: Managing depression and physical symptoms

It is estimated that depression will become the second most disabling condition worldwide by the year 2020. Overcoming some of the challenges of global epidemiology, studies worldwide have shown that women are affected by depression at twice the rate of men, with earlier age of onset and higher rates of hospitalization. Depression in young women can cause failure during critical life transitions, such as occupational advancement and child rearing, which has a cascading effect on the severity and chronic course of depression. This is compounded by the fact that speed of initial treatment contact is inversely related to age. Depression in both men and women is a treatable condition that may be ameliorated if detected and addressed at early onset. Physicians must be aware that while emotional symptoms are usually the focus of the diagnosis and treatment of depression, many depressed patients present only with physical symptoms. New evidence suggests a common neurochemical pathway for the physical symptoms in depression, which implicates both serotonin and norepinephrine dysregulation. Dual reuptake inhibitors may have advantages over selective serotonin reuptake inhibitors and tricyclic antidepressants in achieving a more robust response and complete remission of depression

Clinical Case Conference 892 Bipolar Disorder and Pregnancy: Maintaining Psychiatric Stability in the Real World of Obstetric and Psychiatric Complications

sulting in relapse and ultimately the reinstatement of medications that had previously maintained the patient's clinical stability over an extended period. This report describes the complex, real-life issues faced by a woman with bipolar disorder who was determined to do all that she could to conceive and bear a healthy child while remaining psychiatrically well. What will become clear is that using an organized algorithm derived from evidencebased data is complicated by realities confronted on a daily basis in the context of unpredictable but not unexpected variables, such as miscarriage, abnormal or questionable prenatal screening tests, gestational diabetes, and the emergence of fetal decelerations, preterm labor, and psychiatric decompensation. The importance of family dynamics and beliefs, the viability of an available support system, and education regarding preconception planning as well as the risks and benefits of using psychotropic medications during pregnancy will be discussed in the context of real-life events. It should be noted that even when evidence-based decisions are made, clinicians and patients are often faced with newly published data that is inconsistent with prior data. The references cited below reflect both the literature available at the time of this patient's presentation and the literature published since then. Case Presentation Patient Description "Ms. M" was a 29-year-old Caucasian married woman, gravida 0, with a history of bipolar disorder diagnosed at Bi polar disorder poses uniquely gender-specific challenges for women considering the health and well-being of their unborn children. They struggle with decisions about taking mood stabilizers and other psychiatric medications during pregnancy and whether to breastfeed their babies. Recognizing these concerns, treatment guidelines have been published to provide clinicians and patients with recommendations for moving forward to conceive and bear children in the safest way possible (1-7). While these thoughtful guidelines are based on available perinatal psychopharmacologic data, psychiatrists in tertiary centers for women with reproductive psychiatric concerns have found that in the real world of perinatal psychiatry, strict adherence to these clear and logical guidelines is not always possible. In order to maximize the likelihood that maternal mood and behavioral stability will be maintained, treating bipolar disorder during pregnancy frequently requires polypharmacy with potentially teratogenic medications that may result in adverse side effects for both mother and fetus. Women with bipolar disorder often have complicating comorbid medical conditions such as hypothyroidism and polycystic ovary syndrome that affect their fertility and their psychiatric and medical stability. Routine assessments of prolactin levels are important in bipolar women who require certain neuroleptics for stability. Not infrequently, obstetric complications such as gestational diabetes further complicate psychiatric and obstetric management. Furthermore, despite the severity of bipolar illness, decisions on whether or not to use medications are often based on the patient's wishes and available data (which are sometimes limited and sparse), re- This article describes complex, real-life issues faced by a woman with bipolar I disorder who wished to bear a healthy child while remaining psychiatrically well. The therapeutic issues include balancing treatment decisions that affect fetal and maternal risks. The authors address the importance of carefully considering the patient's history of response to medications when evaluating risks to maternal and fetal health. They discuss the role of the psychiatrist as a part of the treatment team faced with unpredictable but not unexpected complexities, such as miscarriage, abnormal or questionable prenatal screening tests, gestational diabetes, and the emergence of fetal decelerations, preterm labor, and psychiatric decompensation. The article presents and evaluates treatment decisions made in the setting of multiple obstetric and psychiatric complications that do not clearly fit published algorithms. The importance of incorporating family and social supports as an integral part of the treatment plan is emphasized

Prospective Longitudinal Study of Predictors of Postpartum-Onset Depression in Women With a History of Major Depressive Disorder

Risk factors for postpartum depression in euthymic pregnant women with histories of major depressive disorder (MDD) were evaluated. From April 2003 to March 2009, 343 pregnant women with a history of Structured Clinical Interview for DSM-IV (SCID)-diagnosed major depressive disorder were prospectively assessed from the third trimester into the postpartum period using the SCID mood module and 17-item Hamilton Depression Rating Scale (HDRS). Data from 300 subjects who completed at least 2 mood module assessments (1 within 60 days before and the other within 60 days after delivery) were analyzed for predictive associations between variables assessed in the third trimester and the development of a postpartum depression. The majority of women were euthymic in pregnancy by SCID criteria. Women with third trimester SCID-diagnosed depression (n = 45) versus euthymia (n = 255) had a significantly higher risk for having depression after delivery (24% vs 11%, P = .013). For pregnant euthymic women, third trimester total HDRS scores significantly predicted postpartum depression (P < .0001); specifically, scores on 3 HDRS items alone-work activities, early insomnia, and suicidality-significantly predicted postpartum depression. Antidepressant use in the third trimester in euthymic women did not confer protection against the onset of postpartum depression. Among women with a history of MDD who are euthymic in the third trimester, 3 HDRS items-work activities, early insomnia, and suicidality-may be useful as screening items for clinicians working with pregnant women with histories of MDD to identify a group at risk for developing postpartum depression. Additionally, in euthymic women with a history of MDD, antidepressant use in the third trimester may not reduce the risk of developing postpartum depression