Bipolar, pregnancy and after the birth

Support during bipolar pregnancy

As soon as you know you are pregnant, get your GP or psychiatrist to refer you to a specialist perinatal mental health service. There should be one in your area.

If there isn’t a specialist perinatal mental health service in your area, ask your GP or psychiatrist to refer you to Cardiff University Psychiatry Services (CUPS), which offers a second opinion on the risk, diagnosis and management of bipolar during pregnancy and birth.

Planning how you can stay as well as you can will reduce the risk of a severe episode during pregnancy or just after giving birth.

You will usually get two appointments with perinatal mental health services. One appointment will be before you get pregnant, or as soon as you know you are if it’s unplanned. You’ll have another appointment once your pregnancy is established.

You can talk about things like:

• How to make sure you’re as well as possible when you start your pregnancy, and during pregnancy.
• Your risk of developing postpartum psychosis or postnatal depression.
• Risks and benefits of medication in pregnancy and after birth. This will mean you have the information you need to make decisions about your treatment.
• The type of care you can expect in your local area. For example, how professionals will work together with you and your family, and whether there is a specialist midwife or a mother and baby unit near you.

You can take your partner, family member or friend along to help make notes and ask questions they want to ask, too. 

Get to know your healthcare team

The NHS also recommends a pre-birth planning meeting at around 32 weeks with your partner, family or friends, mental health professionals, your midwife, obstetrician, health visitor and GP to create a care plan.

Once you go home with your baby, you’re also entitled to regular home visits from a midwife, health visitor and mental health nurse.

Get support from your family and friends

Your loved ones can play a crucial role in supporting you to stay well during pregnancy and after the birth.

If you do become unwell, you may not realise you are ill, so having a good support network around you is key.

• Tell people you trust your ‘early warning signs’ – the symptoms you’ve experienced in the past just before you’ve become unwell. This means those closest to you can watch out for them and get you specialist support quickly if it’s needed. For example, do you start to get up very early in the morning, stop eating properly or become much more argumentative than usual?
• Involve your partner so they can help support you at the hospital, and help to judge if you’re getting over-tired or your symptoms are coming on, to get help quickly.
• Ask your healthcare team if they can organise a private room in the hospital to help you get better sleep to reduce your risk of becoming unwell.
• If you can, organise help for when you’re home – for example, asking a relative, friend or partner to take on night feeds to support your sleep patterns.
• Try to avoid loads of visitors in the first few weeks – you can talk to people in advance about why you’ll need to stay quiet and pace yourself.
• Try to avoid major life changes like starting a new job and moving house – ideally you would wait for a year or so.

How can I stay well during pregnancy and after giving birth when I have bipolar?

About half of women with bipolar disorder (50 in 100) stay well after having a baby and about half may have an episode of illness at this time of big hormonal change.

Some research suggests women who find hormone changes during their menstrual cycle affect their bipolar symptoms might be more likely to have episodes during pregnancy and after the birth.

• Postnatal depression happens for around 25% (25 in 100) of women with bipolar who have a baby.
• Postpartum psychosis happens for around 20 to 25% (20 to 25 in 100) of women with bipolar who have a baby.

Write an Advance Choice Document

An Advance Choice Document (ACD) allows people living with a mental health condition to express their wishes and preferences for mental healthcare while they are well. It’s a plan you put in place so that if you do become unwell, your partner or family knows what to do and your healthcare professionals can take action quickly.

The ACD should include emergency contacts for you and your partner to use if you see signs of becoming unwell. Postpartum episodes can get worse quickly, so don’t wait if you need to get help.

Create an ACD when you’re pregnant

Weigh up the pros and cons of bipolar medications in pregnancy

‘Most women with bipolar will need to take some medication during pregnancy to stay stable, as depressive symptoms and episodes can happen while they’re pregnant,’ says Dr Clare Dolman. ‘Certain medications are safer for the foetus than others.’

Your healthcare professional will work with you to balance the benefits and risks of taking a medicine with the risks involved in your bipolar being untreated.

• The latest thinking on medicines has shifted – for example, many psychiatrists and maternal mental health specialists see lithium as a viable option throughout pregnancy. It’s important to talk through all your options.
• For many women, staying on medication might be the best choice.
  One piece of research showed that around seven out of ten women have at least one mood episode during pregnancy, more likely depressive or mixed. The risk of recurrence was much higher in women who stopped taking their mood stabilisers than those who kept going with treatment. The women who stopped the mood stabilisers also spent over 40% of their pregnancy in an illness episode, versus only 9% for women who kept taking theirs.
• Talk through whether a relapse might lead to looking after yourself and your health less well than you would if you were on treatment – and could that affect the baby? Are you more likely to smoke or drink alcohol or not to eat as well or sleep less, for example?
• For women who are not taking medication or who have stopped taking medication because of the pregnancy, there is the option of starting medication in late pregnancy or soon after the baby is born, to reduce the risk of becoming ill. Many women who have responded very well to a mood-stabilising medication previously may decide to take it again, to reduce their chances of becoming unwell after the birth. This is because it is the immediate postnatal period that carries the highest risk of illness.

Consider non-medication options in bipolar pregnancy

‘You could ask your psychiatrist about treatments such as ECT, psychotherapy, omega-3 fish oils and bright light treatment, says Dr Clare Dolman. ‘Your doctor might agree these could be added to an updated treatment plan.’

• A 2023 review of research shows that electroconvulsive therapy (ECT) is an effective therapy during pregnancy. It needs to be agreed with your multidisciplinary team. That means talking to your obstetrician as well as your psychiatrist. You can find out more about ECT here[SO2] .
• Talking therapies such as psychotherapy can lower the chances of bipolar coming back during and after pregnancy.
• Bright light therapy has been shown to help treat bipolar mood episodes in women, and to improve depression during pregnancy (though not all evidence has been specifically in pregnant women with a bipolar diagnosis). Key elements for you and your healthcare professionals to consider are how bright the light is, how long you use it for each day, when in the day you use it, and how many weeks you carry on with it. One trial on women and men with bipolar showed using midday bright light therapy alongside other therapies could increase the chance of a remission from a depressive episode. One small piece of research showed women with bipolar may need fewer minutes of bright light, and with use at midday rather than first thing in the morning to help reduce a risk of mixed episodes.
• Omega-3s from fish oils have shown some promising results for mood disorders such as postpartum depression, and bipolar depressive episodes. Evidence is mixed so talk to your psychiatrist about your situation and what doses to take.

Postnatal depression (PND) in bipolar disorder

Around 25% (25 in 100) of women with bipolar experience postnatal depression (PND) after giving birth.

Postnatal depression has symptoms similar to those of depression at other times – low mood, poor sleep, lack of energy, lack of appetite and negative thoughts – and they go on for more than two weeks.

PND can start within days or, more rarely, up to 12 months after the birth of the baby, and symptoms include feeling less able to bond with your baby.

It can range from mild to severe – and it can be hard to tell the difference between severe postnatal depression and postpartum psychosis.

Being aware of your symptoms, especially the early warning signs, and talking to a partner, friends and family and your healthcare team about how you’re feeling is an important part of spotting and treating PND.

It’s not uncommon to experience feelings of worthlessness and inadequacy as a mother. Don’t be ashamed to talk about this and, if you have suicidal thoughts, get help as soon as you can.

You can get extra support from the postnatal depression charity PANDAS via WhatsApp, a bookable phone call service, online and in face-to-face support groups. Find out more at pandasfoundation.org.uk

Postpartum psychosis (PP) in bipolar

Postpartum psychosis (PP) happens for around 20 to 25% (20 to 25 in 100) of women with bipolar who have a baby. This is several hundred times higher than for women who have not had previous psychiatric illness.

The symptoms of PP usually begin in the first few days or the first two weeks after giving birth. Sometimes symptoms can start several weeks after the baby is born, but this is less common.

PP is a psychiatric emergency. A mother experiencing PP needs urgent medical attention, medication in the early stages, and psychiatric help in the longer term to come to terms with what has happened.

Symptoms of postpartum psychosis?

Women living with bipolar can be affected by mood episodes after giving birth, including, highs, lows and more mixed states than usual. But a more severe episode with psychotic symptoms can come on very quickly.

As well as feeling high or depressed, symptoms of postpartum psychosis can include:

• hallucinations
• believing things that aren’t true
• seeing things
• hearing things that aren’t there
• feeling confused or as if you’re in a dream world
• finding it hard to sleep
• not wanting to sleep
• feeling paranoid, suspicious or fearful

There can also be a changing pattern of symptoms, elated one minute, despairing the next.

Who’s most at risk of postpartum psychosis?

Some research shows around 15 to 20% of women are admitted to hospital in the postpartum period. This can be a general psychiatric ward or a mother and baby unit (MBU) where you can be admitted with your baby.

It is clear from the data that women with bipolar type 1 are most at risk, but women living with bipolar type 2 should also be aware of the symptoms and get help as soon as any warning signs are spotted.

Your risk is higher if you, your mother or sister have had a previous severe postpartum illness. In this case, your risk of having postpartum psychosis may be over 50% (greater than 50 in 100).

What causes postpartum psychosis?

More research is needed, but it’s thought that hormonal changes, sleep deprivation, immune changes and genetic factors all contribute to a rapid-onset, severe episode of postpartum psychosis after giving birth.

Where can I find out more about postpartum psychosis?

Action on Postpartum Psychosis (APP) is the charity for mothers and families affected by postpartum psychosis. Find out more about everything from symptoms and how other women coped, to what to expect in a mother and baby unit.

Find more information here 

Bipolar and breastfeeding

‘It’s important to consider the pros and cons of breastfeeding in your particular situation,’ says Dr Clare Dolman. ‘It’s not the end of the world if you don’t breastfeed or if you need some extra help. Having a baby is enormously challenging for all new parents. It’s more important for you to be as well as possible so you can look after your baby than to stick with breastfeeding at all costs.’

Key things to talk through with your healthcare professionals and your partner:

• Your health and treatment is key. Most women with a postpartum episode of bipolar disorder need treatment with medication to recover and to stay as well as possible. You may also have chosen to keep taking, or to restart, mood stabilisers later into your pregnancy to reduce the high risk of postpartum depression or psychosis.
• You can breastfeed while taking some medications. Your psychiatrist can discuss the risks and benefits of medications in breastfeeding with you. Breastfeeding might be a reasonable option for you and your baby if, for example, you have a stable mood and feel able to monitor your baby for any potential health issues, a healthy full-term baby, and a collaborative midwife or health visitor who understands how important it is to monitor the baby and how to do it.
• You may not want to breastfeed – or might want to mix it with bottle feeds.
  • If lack of sleep is a trigger for you, night feeds could be a problem, so bottle feeding or mixed feeding might be a good option for you.
  • You may feel more confident and less anxious if you stay on a medication that works well for you but means you can’t breastfeed. This could ease the worry of being constantly on the look-out for symptoms of you getting worse.
  • You might just prefer bottle feeding if it means you can share the load with a partner or trusted friend or family member, especially at night.