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Bipolar disorder and childbirth: the importance of recognising risk

  • Ian Jones (a1) and Nick Craddock (a1)
Extract

In October 2003 the report was published of an inquiry into the death of a psychiatric colleague that raised a number of important questions – not least regarding our management of women with bipolar disorder in pregnancy and the postpartum period (North East London Strategic Health Authority, 2003). Dr Daksha Emson took the life of herself and her 3-month-old daughter, Freya. This tragedy took place during a psychotic episode triggered by childbirth and was a consequence of her history of bipolar affective disorder. Sadly, the case of Dr Emson is far from unique. The Confidential Enquiries into Maternal Deaths (2001) found that suicide had become the leading cause of maternal mortality in the UK, accounting for 28% of maternal deaths (Oates, 2003a). The majority of the women who died by suicide suffered an abrupt onset of a severe psychotic illness within days of childbirth – a ‘puerperal psychosis', to use the traditional nosological label. For some women an episode of puerperal psychosis will be the first experience of severe mental illness, but a significant proportion of women will have had previous episodes. In the Confidential Enquiries into Maternal Deaths (2001), for example, 46% of the women who killed themselves (the majority by violent means) had previously been in contact with psychiatric services – and half of these had had a previous admission with a severe episode of illness following childbirth (Oates, 2003b). In many maternal suicides, therefore, the occurrence of an episode of severe post-partum psychiatric illness is an eminently predictable event. Although some women in the report were in contact with psychiatric services, none had received a detailed risk assessment, none had a formal management plan, and none was under close surveillance in the puerperium. It is also worth noting that none of the women in the cases of maternal suicide reported in the Confidential Enquiries was under the care of a mother and baby unit or perinatal psychiatric service (Oates, 2003a). The report on maternal deaths in 2000–2002 has now been published (Confidential Enquiries into Maternal Deaths, 2004) and, sadly, the findings are similar.

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Copyright
Corresponding author
Dr Ian Jones, Department of Psychological Medicine, Henry Wellcome Building for Biomedical Research, Academic Avenue, Heath Park, Cardiff CF14 4XN, UK. Tel: +44 (0) 29 2074 4663; fax: +44 (0) 29 2074 6554; e-mail: jonesir1@cf.ac.uk
References
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Brockington, I. F. (1996) Puerperal psychosis. In Motherhood and Mental Health, pp. 200284. Oxford: Oxford University Press.
Confidential Enquiries into Maternal Deaths (2001) Why Mothers Die 1997–1999. London: Royal College of Obstetricians & Gynaecologists. http://www.cemach.org.uk/publications.htm
Confidential Enquiries into Maternal Deaths (2004) Why Mothers Die2000–2002. London: Royal College of Obstetricians & Gynaecologists. http://www.cemach.org.uk/publications.htm
Emson, D. (2004) Obituary of Daksha Emson. BMJ, 328, 291.
Jones, I. & Craddock, N. (2001) Familiality of the puerperal trigger in bipolar disorder: results of a family study. American Journal of Psychiatry, 158, 913917.
National Institute for Clinical Excellence (2003) Antenatal Care – NICE Guideline. London: NICE.
North East London Strategic Health Authority (2003) Report of an Independent Inquiry into the Care and Treatment of Daksha Emson and Her Daughter Freya. http://www.nelondon.nhs.uk/documents/de=inquiry=report.pdf
Oates, M. (2003a) Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British Medical Bulletin, 67, 219229.
Oates, M. (2003b) Suicide: the leading cause of maternal death. British Journal of Psychiatry, 183, 279281.
Robertson, E., Jones, I., Hague, S., et al (2005) Risk of puerperal and non-puerperal recurrence of illness following bipolar affective puerperal (post-partum) psychosis. British Journal of Psychiatry, 186, 258259.
Royal College of Psychiatrists (2000) Perinatal Maternal Mental Health Services. Council Report CR88. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/publications/cr/cr88.htm
Scottish Intercollegiate Guidelines Network (2002) Postnatal Depression and Puerperal Psychosis. http://www.sign.ac.uk/guidelines/fulltext/60index.html
Stewart, D. E., Kompenhouwer, J., Kendell, R. F., et al (1991) Prophylactic lithium in puerperal psychosis. The experience of three centres. British Journal of Psychiatry, 158, 393397.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Bipolar disorder and childbirth: the importance of recognising risk

  • Ian Jones (a1) and Nick Craddock (a1)
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