Elated. Exhausted. Confident. Anxious. It’s normal to experience moods that swing from negative to positive and back again in the days after giving birth.

“The whole experience of birth is traumatic,” says Katherine Wisner, M.D., Director of the Asher Center for the Study and Treatment of Depressive Disorders at the Northwestern University Feinberg School of Medicine. “The hospitalization, pain, medications, potential surgical delivery, physical recovery, sleep deprivation, and incredibly high hormone levels going down to next to nothing in the days following delivery—your poor body has huge internal and external stress to deal with.”

But if those highs and lows are extreme to the point of jeopardizing your well-being or that of your newborn’s, a condition called postpartum bipolar disorder might be at play. It’s rare compared to major depression or postpartum depression, but it’s also commonly misdiagnosed. In fact, one study of new mothers conducted by Dr. Wisner found that of the 14 percent who had been positively identified as having postpartum depression, a striking 22.6 percent actually had bipolar disorder.

Those missed cases are no small thing. There are real consequences, including higher rates of insecure attachment and poor cognitive performance in the child, and higher rates of infanticide and suicide among women. And because pregnancy and the act of giving birth can trigger postpartum bipolar disorder in some women, it’s crucial that all new at-risk mothers get screened within six weeks of giving birth, says Dr. Wisner.

 Signs And Symptoms Of Postpartum Bipolar Disorder

Just like classic bipolar disorder, postpartum bipolar disorder is characterized by a fluctuation of extremely high and extremely low moods, the primary difference being that onset occurs in the days or weeks following giving birth. “The onset of symptoms is very rapid, within zero to two months,” says Dr. Wisner. Compare that to postpartum depression, which typically has a longer onset period of zero to five months after delivery.

The high moods of postpartum bipolar disorder can manifest as either mania or hypomania. “Mania is very severe symptoms that cause functional impairment,” explains Dr. Wisner. “You may require hospitalization, or become psychotic—say, you believe you’re God and start telling people how you’re going to save them.” For the elevated mood to be considered mania, it must last for at least seven consecutive days and be present most of the days.

Hypomania, on the other hand, is less disruptive, and must last at least four consecutive days for a diagnosis. “You’re energized, wired, talkative, creative, and need less sleep than usual, but it’s not necessarily functionally impairing,” says Dr. Wisner. “A lot of my patients who are artists or physicians or lawyers say they are incredibly productive during these hypomanic phases, but it’s a change in behavior that’s observable by other people.”

Symptoms Of Mania And Hypomania

  • Periods when mood is much better than normal
  • Rapid speech, talkative
  • Requiring less sleep than usual
  • Racing thoughts
  • Trouble concentrating, easily distracted
  • Highly energized, wired
  • Overly confident
  • Impulsiveness and poor judgment
  • Exaggerated sense of self-importance
  • In severe cases, delusions and hallucinations

A diagnosis for bipolar requires at least one depressive and one manic or hypomanic episode, but the two are not always easy to distinguish. “We now know that bipolar disorder can be subtle cycling of mood, and depression and manic symptoms can occur together in what’s called a mixed state,” says Dr. Wisner.

Symptoms Of Postpartum Depression

Symptoms of postpartum depression are very similar to those for depression, and may also include some that are specific to motherhood:

  •   Feeling sad, depressed, or “empty”
  •   Feeling distant and withdrawn from family and friends
  •   Feeling numb or disconnected from your baby
  •   A loss of interest in hobbies and activities (including sex)
  •   Overeating or loss of appetite
  •   Trouble sleeping or excessive sleeping
  •   Feeling tired and low energy
  •   Feeling angry or irritable
  •   Feeling anxious or worried, or having panic attacks or racing thoughts
  •   Crying more often than usual
  •   Worrying that you will hurt your baby
  •   Feelings of guilt for being a bad mom, or lack of confidence in your ability to care for your baby

How Is Postpartum Bipolar Different From Postpartum Depression And Postpartum Psychosis?

Postpartum depression is a unipolar depression, meaning it’s the lows without the highs. It’s also significantly more common than postpartum bipolar depression, affecting as many as one in five women, according to the Centers for Disease Control.

Postpartum psychosis is rare and almost invariably a sign of bipolar illness that requires hospitalization and immediate medical attention, says Dr. Wisner. Symptoms occur one to four weeks after delivery and include:

  • Auditory hallucinations
  • Delusional beliefs
  • Disorientation and confusion
  • Attempts to hurt yourself or your baby
  • Paranoia (fear of others harming you or your baby)
  • Rapid mood swings
  • Agitation
  • Reckless behavior

Risk Factors For Postpartum Bipolar Disorder

There are four key risk factors for experiencing an onset of bipolar disorder during the postpartum period:

  1. Personal history of postpartum depression
  2. Personal history of bipolar disorder
  3. Personal history of postpartum psychosis
  4. Family history of a first-degree relative with bipolar disorder

Indeed, these are strong predictors. For instance, between 50 percent and 70 percent of women with bipolar disorder will experience a recurrence during the postpartum period, according to findings in the American Journal of Psychiatry. And postpartum psychosis is 100 times more likely in women who’ve had a previous episode compared to the general population.

“Other than a personal and family history of bipolarity, we don’t have good predictors,” says Dr. Wisner. But it’s good to be aware of stressors like sleep deprivation or a traumatic birth experience that are top triggers for an onset of bipolar or a manic episode, as well as the predictors for mood disorders in general, which include psychosocial disadvantages such as having a baby at a young age, low social support, unemployment, poverty, and low educational status.

How To Diagnose Postpartum Bipolar Disorder

Tools for diagnosing postpartum bipolar disorder have been lacking historically, but Dr. Wisner’s research has found good success in using a combination of two different screenings in the four to six weeks after delivery.

The first, called the Edinburgh Postnatal Depression Scale (EPDS), is a set of 10 questions that screens for postpartum depression. It’s the most commonly used by healthcare professionals and is highly accurate, with some research showing it correctly identifies 86 percent of postpartum depression cases. The trouble is, the EPDS doesn’t distinguish between bipolar and unipolar depression, and the wrong diagnosis can be disastrous: Antidepressant treatment for unipolar depression can trigger rapid mood cycling, mania, or mixed states in women with bipolar.

The second screening, called the Mood Disorders Questionnaire (MDQ), was developed by a team of psychiatrists, researchers, and consumer advocates to assesses lifetime history of mania and hypomania. Like the EPDS, it’s short and simple: a checklist of 13 symptoms plus two supplementary questions about timing and severity. In Wisner’s study of nearly 1300 women, combining the EPDS with the MDQ improved their ability to distinguish between unipolar and bipolar postpartum depression by nearly 70 percent.

The EPDS has become fairly standard, but not all new moms need both screenings, says Dr. Wisner. Anyone with a personal history of bipolar disorder will screen positive for the illness, so they can skip that step and go straight to treatment considerations. Those with other bipolar risk factors should complete both the EPDS and MDQ.

Dr. Wisner also recommends that women who screen positive for postpartum depression on the EPDS should then be given the MDQ before any treatments are prescribed. And those who are still prescribed an antidepressant for unipolar depression should contact their doctor immediately if they experience worsening symptoms, anxiety, agitation, or distress—all signs that they have bipolar and need a different treatment protocol.

Know Your Treatment Options

Step one for obtaining the proper treatment is making sure you have an accurate diagnosis. Remember, bipolar disorder is often misdiagnosed as unipolar depression—in part because people tend to seek help during their lows, not their feel-good highs.

“For postpartum bipolar disorder and postpartum psychosis, the treatment of choice is pharmacotherapy,” says Dr. Wisner. “Psychosis, in particular, doesn’t remit without treatment. In fact, I would argue it becomes chronic.”

There are a number of medications available, including lithium, an antimanic agent which Dr. Wisner and others have found to be the most successful for postpartum bipolar disorder. Some women also do well on a combination of medications that might include anticonvulsants like Depakote (divalproex sodium) or Lamictal (lamotrigine), or antipsychotics like Abilify (aripiprazole), Risperdal (risperidone), or Zyprexa (olanzapine).

For women who want to breastfeed, Dr. Wisner says lithium is still the best treatment option. “We’re one of the few groups who have published data on lithium and breastfeeding, and we feel comfortable with it with careful monitoring, though the babies do have a low level of lithium in their blood,” she says. “This is a controversial topic, but the decision has to be balanced against the other side of the equation and the health benefits of breastfeeding to the mother and infant. It’s a very personal choice.”

If you’re pregnant or thinking of becoming pregnant and you know you have a history of bipolar disorder, tell your doctor immediately so you can determine your best course of treatment for both before and after delivery.

Depakote should not be taken during pregnancy, for instance, because it causes birth defects in about 25 percent of infants, warns Dr. Wisner. She’s also seen great success in starting lithium immediately postpartum in women who’ve had episodes of only postpartum psychosis. “You can get that medicine in quickly—baby comes out, medicine goes in—and that’s been quite successful in keeping women well.”

Finally, minimizing the stress factors that can trigger the onset of bipolar is also key, the biggest one being sleep deprivation. “A lot of what we do for women with mood disorders is to make sure they sleep, because disruptions in circadian rhythm can stimulate hypomania, depression, and mixed-state hypomania,” says Dr. Wisner. “So that might mean not only medication support for sleeping, but also partner support and assistance with feeding at night.” Proving once again that asking for help and getting a good night’s rest is sound advice for any new mom.

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Last Updated: May 19, 2021