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)

Burt, Vivien K.

Sharma, Verinder

English

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Western University Scholarship@Western Paediatrics Publications Paediatrics Department 2-1-2011 DSM-V: Modifying the postpartum-onset specifier to include hypomania Verinder Sharma Western University, vsharma@uwo.ca Vivien K. Burt David Geffen School of Medicine at UCLA Follow this and additional works at: https://ir.lib.uwo.ca/paedpub Citation of this paper: Sharma, Verinder and Burt, Vivien K., "DSM-V: Modifying the postpartum-onset specifier to include hypomania" (2011). Paediatrics Publications. 1829. https://ir.lib.uwo.ca/paedpub/1829 SHORT COMMUNICATIONDSM-V: modifying the postpartum-onset specifierto include hypomaniaVerinder Sharma & Vivien K. BurtReceived: 22 January 2010 /Accepted: 9 September 2010 /Published online: 25 September 2010# The Author(s) 2010. This article is published with open access at Springerlink.comAbstract By failing to include it under the rubric of thepostpartum-onset specifier, Diagnostic and StatisticalManual of Mental Disorders (DSM)-IV-TR has ignoredthe clinical reality that childbirth is a potent trigger ofhypomania. Given the serious and occasionally tragicconsequences of misdiagnosis of bipolar II depression asunipolar depression in the postpartum period, it is arguedthat DSM-V should consider modifying the postpartum-onset specifier to include episodes of hypomania.Keywords Hypomania . Childbirth . Classification .Bipolar disorderIntroductionWith Diagnostic and Statistical Manual of Mental Disorders(DSM)-V scheduled to be published in 2012, efforts areunderway to revise DSM-IV-TR (APA 2000). There isgeneral agreement that DSM-IV-TR requires major revi-sions in format and content to make diagnoses including thespecifiers more scientifically valid and clinically relevant(Colom and Vieta 2009). The DSM-IV-TR episode andcourse specifiers (also known as modifiers) provide ameans of establishing sub-categories or variants within thepsychiatric disorders and thus provide useful clinicalinformation about anticipated illness course, prognosis,and selection of appropriate treatments.The postpartum disorders have traditionally been classi-fied as the maternity blues, postpartum depression andpostpartum psychosis. DSM-IV-TR does not recognizepostpartum disorders as distinct diagnostic entities, but inthe text it does acknowledge that among women withpostpartum mood or psychotic episodes there are certainsymptoms that are more likely to occur (APA 2000). Theseinclude mood fluctuations, mood lability, and preoccupa-tion with infant well-being ranging from over-concern tofrank delusions. There is also some evidence that postpar-tum episodes are more likely to be characterized bypsychotic features among women with a family history ofbipolar disorder. Women with postpartum major depressiveepisode often have severe anxiety that manifests in the form ofa fear of being alone with the infant, or over-intrusiveness thataffects the development of a mother/infant relationship.The postpartum-onset specifier can be applied to thecurrent or most recent depressive, manic, or mixed episodein major depressive disorder, bipolar I disorder, bipolar IIdisorder, or brief psychotic disorder if the onset of theV. Sharma (*)Department of Psychiatry, University of Western Ontario,London, ON, Canadae-mail: vsharma@uwo.caV. SharmaDepartment of Obstetrics and Gynecology,University of Western Ontario,London, ON, CanadaV. SharmaPerinatal Clinic, St. Joseph’s Health Care,London, ON, CanadaV. K. BurtDepartment of Psychiatry,Geffen School of Medicine at UCLA,Los Angeles, CA, USAV. K. BurtWomen’s Life Center,Resnick Neuropsychiatric Hospital at UCLA,Los Angeles, CA, USAArch Womens Ment Health (2011) 14:67–69DOI 10.1007/s00737-010-0182-2episode is within 4 weeks postpartum (APA 2000).Postpartum-onset is an important course marker for bipolarversus unipolar depression (Ghaemi et al. 2008). However,the postpartum-onset specifier cannot be used to denote ahypomanic episode. This omission is surprising for severalreasons. Firstly, there is accumulating evidence that most ofbipolarity including that in the postpartum period existsbeyond the realm of bipolar I disorder. Secondly, hypo-manic symptoms are particularly common in the earlypuerperium but are often overlooked due to lack ofawareness. Thirdly, the consequences of misdiagnosingbipolar II disorder as major depressive disorder can beparticularly catastrophic in the postpartum period due to thehigh risk of suicide and infanticide.Prevalence of bipolar spectrum disorderThe term bipolar spectrum disorder generally includesbipolar I disorder, bipolar II disorder, and bipolar disordernot otherwise specified. Bipolar I disorder is characterizedby recurrent episodes of mania and depression, whilebipolar II disorder is marked by recurrent episodes ofhypomania and depression. Patients with bipolar disordernot otherwise specified also have symptoms of depressionand mania but these don’t reach the DSM-IV thresholdcriteria for bipolar I or II disorder. DSM-IV-TR reports alifetime community prevalence of 0.5% for bipolar II disorderbut more recent studies have shown a higher prevalence ofbipolarity beyond bipolar I disorder. The recently publishedNational Comorbidity Survey Replication study for examplereported prevalence rates of 1.0% for bipolar I, 1.1% forbipolar II, and 2.4% for bipolar disorder NOS (Merikangaset al. 2007). Angst and colleagues reported that the totalprevalence of the bipolar spectrum was about 11%, which issimilar to that of major depressive disorder. Among outpatientswith major depression, 25% to 50% have been found to havebipolar disorder (Angst et al. 2003). Using the StructuredClinical Interview for DSM-IV, Sharma et al. (2008) reportedthat 54% of patients with postpartum depression had a lifetimediagnosis of bipolar spectrum disorder; however, only a smallnumber (10%) of these patients reported receiving a previousdiagnosis of bipolar disorderUbiquity of postpartum hypomaniaSimilar to a dramatic rise in the incidence of manic,depressive and psychotic episodes, hypomanic symptomsare a common occurrence in the postpartum period.Estimates of the prevalence of postpartum hypomania innon-clinical populations have ranged from 9.6% to 20.4%on day 3 postpartum (Webster et al. 2003; Farías et al.2007; Heron et al. 2005; Glover et al. 1994; Lane et al.1997; Sharma et al. 2009). Symptoms of postpartumhypomania are similar to the symptoms of non-puerperalhypomanic episodes and include elation, increased goal-directed activity, over-talkativeness, racing thoughts,decreased sleep requirement, distractibility, and irritability.Childbirth appears to be a specific trigger for hypomanicsymptoms, as the prevalence of hypomania is eightfoldhigher in the first week after delivery than during pregnancy.By contrast, the prevalence of depression does not signifi-cantly increase from pregnancy to the postpartum period(Heron et al. 2009).Diagnostic and treatment issuesBipolar I disorder is a reliable and relatively stable diagnosticcategory but there is controversy surrounding the diagnosis ofbipolar II disorder and bipolar disorder NOS. Bipolar IIdisorder and bipolar disorder NOS are often under-diagnosedor misdiagnosed as major depressive disorder but there arealso concerns about the over-diagnosis of bipolar disorder(Zimmerman et al. 2010). Unfortunately the question ofwhether bipolar disorder is under-diagnosed or over-diagnosed in the postpartum period has not been studied.Hypomanic episodes tend to cluster during the earlypostpartum period as there is a higher incidence during thefirst 5 days post-delivery (Glover et al. 1994; Lane et al.1997; Heron et al. 2009), with about 50% of women withhypomania reporting onset of symptoms on day 1 (Gloveret al. 1994), and a significant decrease in hypomanicsymptoms at 6–8 weeks postpartum (Glover et al. 1994;Lane et al. 1997; Heron et al. 2009). Diagnosing hypomaniacan be particularly challenging in the postpartum period dueto the difficulty of differentiating it from normal happinessaccompanying childbirth. Decreased sleep requirement, acommon symptom of hypomania, may be difficult todistinguish from post-delivery sleep changes in women. Byitself, postpartum hypomania causes no significant impair-ment in social or occupational functioning. The clinicalsignificance lies in its association with later postnataldepression. Glover et al. (1994) reported that 50% of womenwith the “highs” (postpartum hypomania) developed aprobable depression compared to 18% of women withabsence of psychopathology at day 3 postpartum.Perhaps the main reason for the neglect of bipolar IIpostpartum depression is the absence of hypomania fromthe DSM-IV-TR postpartum-onset specifier. Failure todetect hypomanic symptoms frequently results in bipolarpostpartum depression being misdiagnosed as major depres-sive disorder (Ghaemi et al. 2001). The consequences of68 V. Sharma, V.K. Burtmisdiagnosis can be particularly serious in the postpartumperiod. The use of antidepressants may precipitate mania or amixed state and thereby increase the risk of further disabilityand possibly psychiatric hospitalization at a crucial time ina mother’s life. There is also a concern that antidepressantsare not as effective in the treatment of bipolar depression asin major depressive disorder. Failure to recognize thebipolar diathesis of postpartum depression can thus leadto treatment refractoriness and chronicity. More importantly,the unopposed use of antidepressants in women withbipolar disorder may increase the risk of suicide (Akiskalet al. 2005) and infanticide (Kim et al. 2008). Unfortunately,despite data supporting high attendant morbidity andmortality, there is a common impression that bipolar IIdisorder and bipolar disorder NOS are milder forms ofbipolar illness.SummaryThe existing literature although limited in nature, supports themodification of the postpartum-onset specifier to includehypomania in DSM-V. Clinically, the modified postpartum-onset specifier would likely facilitate early detection anddiagnosis, as well as appropriate and safe treatment of bipolarII postpartum depression. The identification of women withpostpartum-onset hypomania will provide an opportunity toidentify mothers at risk for developing early postpartumdepression. The prevalent nature of hypomanic symptoms andtheir close temporal association with delivery should providean opportunity to increase our understanding of the etiologyand pathophysiology of bipolar disorder. Research is neededto further validate postpartum hypomania using a researchdiagnostic interview as the standard for a diagnosis of bipolarII disorder. As studies on postpartum hypomania havegenerally focused on a brief period, it is not clear how longwomen remain at risk of developing hypomania after delivery.Studies of family history, phenomenology, naturalistic out-come, and screening instruments are also needed to enhanceour understanding andmanagement of bipolar II depression inthe postpartum period.Acknowledgements The authors would also like to thank the lateMs. Vineeta Kalia for her help in the preparation of this manuscript.Dr. Sharma has received grant support from, participated on scientificadvisory boards for, or served on the speakers bureaus of AstraZeneca,Bristol-Myers Squibb, Eli Lilly, Janssen, Lundbeck, the Ontario MentalHealth Foundation, Pfizer, Servier, and the Stanley Foundation.Dr. Burt has served as an advisor or consultant to, or on thespeakers’ bureaus of AstraZeneca, Eli Lilly, Noven Pharmaceuticals,Takeda Pharmaceuticals, and Wyeth Ayerst.Open Access This article is distributed under the terms of theCreative Commons Attribution Noncommercial License which per-mits any noncommercial use, distribution, and reproduction in anymedium, provided the original author(s) and source are credited.ReferencesAkiskal H, Benazzi F, Perugi G, Rhimer Z (2005) Agitated unipolardepression re-conceptualized as a depressive mixed state:implications for the antidepressant-suicide controversy. 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DSM-V: Modifying the postpartum-onset specifier to include hypomania

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

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