Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Bipolar disorder in postpartum women: Epidemiology, clinical features, assessment, and diagnosis

Victoria Hendrick, MD
Section Editor
Paul Keck, MD
Deputy Editor
David Solomon, MD


A nationally representative survey of the United States general population estimated that among postpartum women, the 12 month prevalence of bipolar disorder was 2.9 percent [1]. Many postpartum bipolar patients suffer acute mood episodes [2-4], and the risk of episodes in female bipolar patients may be greater during the puerperium than at other times [2,5].

This topic reviews the epidemiology, pathogenesis, clinical features, assessment, and diagnosis of postpartum bipolar mood episodes. Treatment of postpartum bipolar disorder, postpartum psychosis, and postpartum unipolar major depression are discussed separately. (See "Bipolar disorder in postpartum women: Treatment" and "Treatment of postpartum psychosis" and "Postpartum blues and unipolar depression: Epidemiology, clinical features, assessment, and diagnosis".)


Onset of postpartum bipolar mood episodes occurs within a limited time period following birth of a live child. However, there is no established cut-off that separates postpartum-onset episodes from subsequent nonpostpartum episodes [6]; definitions of the puerperium include the following:

The American Psychiatric Association's Diagnostic and Statistical Manual, Fifth Edition (DSM-5) defines the postpartum period as the first four weeks following childbirth [7]

For “episodes that are associated with the puerperium,” the World Health Organization's International Classification of Diseases-10th Revision (ICD-10) requires onset of the episode within six weeks of delivery [8]


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jul 11, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Vesga-López O, Blanco C, Keyes K, et al. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 2008; 65:805.
  2. Viguera AC, Tondo L, Koukopoulos AE, et al. Episodes of mood disorders in 2,252 pregnancies and postpartum periods. Am J Psychiatry 2011; 168:1179.
  3. Bergink V, Bouvy PF, Vervoort JS, et al. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry 2012; 169:609.
  4. Payne JL, Roy PS, Murphy-Eberenz K, et al. Reproductive cycle-associated mood symptoms in women with major depression and bipolar disorder. J Affect Disord 2007; 99:221.
  5. Viguera AC, Nonacs R, Cohen LS, et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry 2000; 157:179.
  6. Wisner KL, Moses-Kolko EL, Sit DK. Postpartum depression: a disorder in search of a definition. Arch Womens Ment Health 2010; 13:37.
  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  8. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. http://www.who.int/classifications/icd/en/bluebook.pdf (Accessed on September 27, 2012).
  9. Munk-Olsen T, Laursen TM, Pedersen CB, et al. New parents and mental disorders: a population-based register study. JAMA 2006; 296:2582.
  10. Harlow BL, Vitonis AF, Sparen P, et al. Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry 2007; 64:42.
  11. Jones I, Heron J, Blackmore ER, Craddock N. Incidence of hospitalization for postpartum psychotic and bipolar episodes. Arch Gen Psychiatry 2008; 65:356.
  12. Wesseloo R, Kamperman AM, Munk-Olsen T, et al. Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. Am J Psychiatry 2016; 173:117.
  13. Freeman MP, Smith KW, Freeman SA, et al. The impact of reproductive events on the course of bipolar disorder in women. J Clin Psychiatry 2002; 63:284.
  14. Akdeniz F, Vahip S, Pirildar S, et al. Risk factors associated with childbearing-related episodes in women with bipolar disorder. Psychopathology 2003; 36:234.
  15. Doyle K, Heron J, Berrisford G, et al. The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse. Eur Psychiatry 2012; 27:563.
  16. Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol 2011; 117:961.
  17. Munk-Olsen T, Jones I, Laursen TM. Birth order and postpartum psychiatric disorders. Bipolar Disord 2013.
  18. Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry 2001; 158:913.
  19. Robertson E, Jones I, Haque S, et al. Risk of puerperal and non-puerperal recurrence of illness following bipolar affective puerperal (post-partum) psychosis. Br J Psychiatry 2005; 186:258.
  20. Munk-Olsen T, Laursen TM, Pedersen CB, et al. Family and partner psychopathology and the risk of postpartum mental disorders. J Clin Psychiatry 2007; 68:1947.
  21. Sharma V, Xie B, Campbell MK, et al. A prospective study of diagnostic conversion of major depressive disorder to bipolar disorder in pregnancy and postpartum. Bipolar Disord 2014; 16:16.
  22. Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am 2010; 33:273.
  23. Chaudron LH, Pies RW. The relationship between postpartum psychosis and bipolar disorder: a review. J Clin Psychiatry 2003; 64:1284.
  24. Burt VK, Rasgon N. Special considerations in treating bipolar disorder in women. Bipolar Disord 2004; 6:2.
  25. Bergink V, Lambregtse-van den Berg MP, Koorengevel KM, et al. First-onset psychosis occurring in the postpartum period: a prospective cohort study. J Clin Psychiatry 2011; 72:1531.
  26. Stewart DE, Klompenhouwer JL, Kendell RE, van Hulst AM. Prophylactic lithium in puerperal psychosis. The experience of three centres. Br J Psychiatry 1991; 158:393.
  27. Heron J, McGuinness M, Blackmore ER, et al. Early postpartum symptoms in puerperal psychosis. BJOG 2008; 115:348.
  28. Frey BN, Macritchie KA, Soares CN, Steiner M. Bipolar disorder in women. In: Bipolar Disorder: Clinical and Neurobiological Foundations, Yatham LN, Maj M. (Eds), Wiley-Blackwell, West Sussex 2010. p.463.
  29. Doucet S, Jones I, Letourneau N, et al. Interventions for the prevention and treatment of postpartum psychosis: a systematic review. Arch Womens Ment Health 2011; 14:89.
  30. Friedman SH. Postpartum mood disorders: genetic progress and treatment paradigms. Am J Psychiatry 2009; 166:1201.
  31. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. Br J Psychiatry 1987; 150:662.
  32. Videbech P, Gouliaev G. First admission with puerperal psychosis: 7-14 years of follow-up. Acta Psychiatr Scand 1995; 91:167.
  33. Schöpf J, Rust B. Follow-up and family study of postpartum psychoses. Part I: Overview. Eur Arch Psychiatry Clin Neurosci 1994; 244:101.
  34. Blackmore ER, Jones I, Doshi M, et al. Obstetric variables associated with bipolar affective puerperal psychosis. Br J Psychiatry 2006; 188:32.
  35. Heron J, Robertson Blackmore E, McGuinness M, et al. No 'latent period' in the onset of bipolar affective puerperal psychosis. Arch Womens Ment Health 2007; 10:79.
  36. Sharma V. Treatment of postpartum psychosis: challenges and opportunities. Curr Drug Saf 2008; 3:76.
  37. Berga SL, Parry BL, Moses-Kolko EL. Psychiatry and reproductive medicine. In: Kaplan and Sadock's Comperhensive Textbook of Psychiatry, Ninth Edition, Sadock BJ, Sadock VA, Ruiz P. (Eds), Lippincott Williams & Wilkins, Philadelphia 2009. Vol II, p.2539.
  38. Spinelli MG. Postpartum psychosis: detection of risk and management. Am J Psychiatry 2009; 166:405.
  39. Packer S. Family planning for women with bipolar disorder. Hosp Community Psychiatry 1992; 43:479.
  40. Mahon PB, Payne JL, MacKinnon DF, et al. Genome-wide linkage and follow-up association study of postpartum mood symptoms. Am J Psychiatry 2009; 166:1229.
  41. Kumar HB, Purushottam M, Kubendran S, et al. Serotonergic candidate genes and puerperal psychosis: an association study. Psychiatr Genet 2007; 17:253.
  42. Payne JL, MacKinnon DF, Mondimore FM, et al. Familial aggregation of postpartum mood symptoms in bipolar disorder pedigrees. Bipolar Disord 2008; 10:38.
  43. Jones I, Hamshere M, Nangle JM, et al. Bipolar affective puerperal psychosis: genome-wide significant evidence for linkage to chromosome 16. Am J Psychiatry 2007; 164:1099.
  44. Colom F, Cruz N, Pacchiarotti I, et al. Postpartum bipolar episodes are not distinct from spontaneous episodes: implications for DSM-V. J Affect Disord 2010; 126:61.
  45. Mota N, Cox BJ, Enns MW, et al. The relationship between mental disorders, quality of life, and pregnancy: findings from a nationally representative sample. J Affect Disord 2008; 109:300.
  46. Azorin JM, Angst J, Gamma A, et al. Identifying features of bipolarity in patients with first-episode postpartum depression: findings from the international BRIDGE study. J Affect Disord 2012; 136:710.
  47. Viguera AC, Whitfield T, Baldessarini RJ, et al. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry 2007; 164:1817.
  48. Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002; 59:530.
  49. Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003; 60:261.
  50. Sharma V, Khan M, Corpse C, Sharma P. Missed bipolarity and psychiatric comorbidity in women with postpartum depression. Bipolar Disord 2008; 10:742.
  51. Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry 2013; 70:490.
  52. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990; 264:2511.
  53. McElroy SL, Altshuler LL, Suppes T, et al. Axis I psychiatric comorbidity and its relationship to historical illness variables in 288 patients with bipolar disorder. Am J Psychiatry 2001; 158:420.
  54. Jones I, Craddock N. Bipolar disorder and childbirth: the importance of recognising risk. Br J Psychiatry 2005; 186:453.
  55. Fisher SD, Wisner KL, Clark CT, et al. Factors associated with onset timing, symptoms, and severity of depression identified in the postpartum period. J Affect Disord 2016; 203:111.
  56. Munk-Olsen T, Laursen TM, Mendelson T, et al. Risks and predictors of readmission for a mental disorder during the postpartum period. Arch Gen Psychiatry 2009; 66:189.
  57. Di Florio A, Forty L, Gordon-Smith K, et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013; 70:168.
  58. Grof P, Robbins W, Alda M, et al. Protective effect of pregnancy in women with lithium-responsive bipolar disorder. J Affect Disord 2000; 61:31.
  59. Marangell LB. Current issues: women and bipolar disorder. Dialogues Clin Neurosci 2008; 10:229.
  60. Burt VK, Stein K. Treatment of women. In: The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition, Hales RE, Yodofsky SC, Gabbard GO. (Eds), American Psychiatric Publishing, Inc., Washington, DC 2008. p.1489.
  61. Sharma V, Sommerdyk C, Xie B, Campbell K. Pharmacotherapy of bipolar II disorder during and after pregnancy. Curr Drug Saf 2013; 8:246.
  62. Serretti A, Olgiati P, Colombo C. Influence of postpartum onset on the course of mood disorders. BMC Psychiatry 2006; 6:4.
  63. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014; 384:1789.
  64. Robling SA, Paykel ES, Dunn VJ, et al. Long-term outcome of severe puerperal psychiatric illness: a 23 year follow-up study. Psychol Med 2000; 30:1263.
  65. Oates M. Suicide: the leading cause of maternal death. Br J Psychiatry 2003; 183:279.
  66. Appleby L, Mortensen PB, Faragher EB. Suicide and other causes of mortality after post-partum psychiatric admission. Br J Psychiatry 1998; 173:209.
  67. Silverman JJ, Galanter M, Jackson-Triche M, et al. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. Am J Psychiatry 2015; 172:798.
  68. APA Work Group on Psychiatric Evaluation. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition. http://psychiatryonline.org/guidelines (Accessed on September 22, 2015).
  69. Bergink V, Armangue T, Titulaer MJ, et al. Autoimmune Encephalitis in Postpartum Psychosis. Am J Psychiatry 2015; 172:901.
  70. Gelfand JM. One Brain, Two Specialties, Converging Mechanisms: Neuronal Autoantibodies as a Rare Cause of Postpartum Psychosis. Am J Psychiatry 2015; 172:824.
  71. Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry 2003; 64:161.
  72. Sharma V, Xie B. Screening for postpartum bipolar disorder: validation of the Mood Disorder Questionnaire. J Affect Disord 2011; 131:408.
  73. Chessick CA, Dimidjian S. Screening for bipolar disorder during pregnancy and the postpartum period. Arch Womens Ment Health 2010; 13:233.
  74. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry 2000; 157:1873.
  75. Frey BN, Simpson W, Wright L, Steiner M. Sensitivity and specificity of the Mood Disorder Questionnaire as a screening tool for bipolar disorder during pregnancy and the postpartum period. J Clin Psychiatry 2012; 73:1456.
  76. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16:606.
  77. Yawn BP, Pace W, Wollan PC, et al. Concordance of Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9) to assess increased risk of depression among postpartum women. J Am Board Fam Med 2009; 22:483.
  78. Sharma V, Burt VK, Ritchie HL. Bipolar II postpartum depression: Detection, diagnosis, and treatment. Am J Psychiatry 2009; 166:1217.
  79. Solomon DA, Leon AC, Maser JD, et al. Distinguishing bipolar major depression from unipolar major depression with the screening assessment of depression-polarity (SAD-P). J Clin Psychiatry 2006; 67:434.
  80. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782.
  81. Gibson J, McKenzie-McHarg K, Shakespeare J, et al. A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatr Scand 2009; 119:350.
  82. Leung SS, Leung C, Lam TH, et al. Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. J Public Health (Oxf) 2011; 33:292.