Understand the symptoms that set postpartum bipolar apart from regular postnatal mood swings.
Mood changes after giving birth are common. So common, in fact, that postpartum depression is one of the most frequent complications of pregnancy, with 1 in 8 birthing women worldwide experiencing symptoms, according to the Centers for Disease Control and Prevention (CDC).
But for a portion of pregnant and postpartum women who screen positive for depression, the true diagnosis is something else.
Around 1 in 5 women initially diagnosed with postpartum depression will eventually go on to have a bipolar disorder diagnosis, notes Lauren M. Osborne, MD, a reproductive psychiatrist at NewYork-Presbyterian and Weill Cornell Medicine in New York City. “They’re presenting with a depressive episode, but it’s in the context of a bipolar illness,” she explains.
Catching postpartum bipolar disorder early is critical. “It’s something that you can’t dismiss and will think gets better on its own,” says Dr. Osborne. The good news is that, while serious, bipolar disorder is also a treatable illness that’s compatible with being a good parent and partner.
Here’s more on what postpartum bipolar disorder is, its causes, treatments, and long-term impact.
What Is Postpartum Bipolar Disorder?
Bipolar disorder is a brain-based illness that causes dramatic mood swings and changes in energy and behavior. Someone with bipolar experiences periods of emotional highs (mania or hypomania) and lows (depression), per the National Institute of Mental Health.
The type of bipolar disorder you’re diagnosed with reflects how severe and long-lasting the symptoms are, according to the American Psychiatric Association (APA). Types of bipolar disorder include:
- Bipolar 1 disorder
- Bipolar 2 disorder
- Cyclothymic disorder
In postpartum bipolar disorder, the word “postpartum” just means you’re experiencing bipolar disorder in the context of the perinatal period, says Ashlie Butler, DNP, a psychiatric mental health nurse practitioner in the Women’s Mental Health @Ob/Gyn at NewYork-Presbyterian and Columbia University Irving Medical Center in New York City.
If you experience bipolar symptoms for the first time during pregnancy or in the six weeks after birth, you’ll likely be diagnosed with a bipolar disorder with perinatal onset, a specifier used in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the main guidelines used for diagnosing mental illness in the United States.
Signs and Symptoms of Postpartum Bipolar Disorder
Just like bipolar disorders that occur in other contexts, postpartum bipolar disorder includes both depressive and manic symptoms, and sometimes psychosis, which can occur at separate times or at the same time. Either symptom type can show up first in postpartum bipolar disorder.
Depressive Symptoms
Postpartum bipolar 1 and 2 disorders have a major depressive episode embedded, says Misty Richards, MD, a reproductive psychiatrist at UCLA Health in Los Angeles. According to Cleveland Clinic, symptoms of major depressive episodes that are part of bipolar disorder include:
- Feeling sad, empty, hopeless, tearful, or down
- Loss of interest or pleasure in most activities
- Unintended changes in weight or appetite
- Changes in sleep patterns, including insomnia and oversleeping
- Acting restless or super slow
- Not having energy or feeling tired
- Feeling worthless or guilty
- Difficulty thinking, focusing, or making decisions
- Having thoughts of hurting yourself (including suicidal ideation)
Telling the difference between typical postpartum experiences and signs of a depressive episode of postpartum bipolar disorder can be difficult, says Dr. Richards. For example, she notes that some degree of fatigue is normal when someone is building or supporting a baby.
But there may be features that set the depression of postpartum bipolar disorder apart from stand-alone postpartum depression, research suggests. Agitation may be one aspect, which Richards describes as a “carbonated depression.”
Manic and Hypomanic Symptoms
“Bipolar 1 has manic episodes that are really hard to miss,” says Richards. But the hypomanic symptoms of bipolar 2 are more subtle and easier to overlook, she notes.
Per Mayo Clinic, signs of both manic and hypomanic episodes include:
- Feeling unusually upbeat, jumpy, or wired
- Increased activity, energy, or agitation
- Feeling euphoric, like everything is great and you’re great
- Not sleeping, and not feeling like you need to
- Abnormal talkativeness
- Racing thoughts
- Distractable
- Acting recklessly or impulsively
As with depressive symptoms, it can sometimes be difficult to tell the signs of mania and hypomania apart from healthy excitement at welcoming a new life into your home. But the increased energy and activity characteristic of bipolar disorder isn’t just about having a productive Target trip where you knock five items off your list, clarifies Richards. “It’s like, ‘I’m going to go to six different Targets and get 70 different things,’” she says.
Psychosis
Postpartum bipolar disorder is also linked with postpartum psychosis, a serious condition impacting around 5 in 1000 women, according to a review of the research. Postpartum psychosis can be freestanding, but in the majority of cases, it is part of a postpartum bipolar disorder episode, says Osborne.
When someone experiences postpartum psychosis, they may have intense symptoms like hearing voices, hallucinations, and extreme paranoia or suspicion, per the APA.
While normal postpartum sleep deprivation can lead to odd experiences, such as occasionally thinking you hear your baby crying when they’re fast asleep, psychosis is a step beyond the ordinary. It may include false beliefs and unusual behavior, says Osborne. For example, if you’re repeatedly hearing your baby’s cries, and you go check on the baby and the baby’s not crying, but you can’t quite believe that’s true, that’s a problem, she says.
Likewise, Osborne says that if you hear something else that isn’t related to what you would expect, such as a voice telling you to do something, that would be a sign of psychosis.
How Is Postpartum Bipolar Disorder Diagnosed?
If you’re concerned you may be having symptoms of postpartum bipolar disorder, the best thing to do is see a reproductive psychiatrist, says Osborne. These providers specialize in mood disorders related to transitions in the reproductive cycle, including postpartum. “But there are not very many of us, so your first point of contact should be your obstetrician’s office.” Your obstetrician-gynecologist (ob-gyn) will be able to screen you and, if needed, help you connect with a psychiatrist, she says.
Screening
During the perinatal period, the American College of Obstetricians and Gynecologists (ACOG) recommends screening all women for bipolar disorder using the short 14-item Mood Disorder Questionnaire, commonly called the MDQ.
It’s especially important to check for potential bipolar disorder before beginning a prescription for an antidepressant since the depressive episodes of bipolar disorder can be easily mistaken for postpartum depression. That’s because, for people with an underlying bipolar disorder diagnosis, common antidepressants can trigger manic symptoms, explains Osborne.
Assessment
The next step, if you screen positive or otherwise are concerned about postpartum bipolar disorder, is to meet with a mood disorder specialist in psychiatry, says Richards. These professionals are qualified to do an assessment for bipolar disorder, which includes a full personal and family history. “It’s granular, it’s detailed,” she says.
However, if you’re showing signs of severe mania or psychosis, your ob-gyn may recommend going to a psychiatric emergency department to be evaluated right away. “It’s an emergency until you’re told otherwise,” says Osborne.
If you’re concerned, you don’t have to wait for your ob-gyn to tell you to go to the emergency department. After the birth of her second child, California-based mom Dyane Harwood noticed symptoms that reminded her of her father’s manic episodes, which, for her, included loads of energy and hypergraphia, a compulsive need to write. That’s when she knew she needed to admit herself to a psychiatric hospital. There, Harwood, author of Birth of a New Brain: Healing from Postpartum Bipolar Disorder, was initially diagnosed. “It was obvious even to me that something was wrong,” she says.
Causes of Postpartum Bipolar Disorder
“The No 1. risk factor is a personal or family history of bipolar disorder or postpartum psychosis,” says Osborne. Studies suggest that the majority of people who have bipolar disorder also have a relative with bipolar disorder or depression, according to the APA.
The time after birth comes with changes that can create a perfect storm of risk factors for those with a vulnerability. Hormone shifts, sleep deprivation, inflammation, and stress may all contribute to developing postpartum bipolar disorder, per a review of the research. “There is an increased risk for those who may have had underlying bipolar disorder but never had a manic or hypomanic episode before,” says Dr. Butler.
“Beyond that, we don’t really know,” says Osborne. Postpartum bipolar disorder is relatively rare, making it difficult to collect the kind of data needed to define its causes with certainty, she says. “We don’t know what the smoking gun is at this point.”
Treatment for Postpartum Bipolar Disorder
Prescription medications, including mood stabilizers and antipsychotics, are the best way to treat postpartum bipolar disorder, according to a review of the research.
But not every medication is appropriate during pregnancy and postpartum because of potential risks to the growing baby, says Butler. She adds that pregnancy-related changes in hormones and blood volume mean the same medications can also impact you differently depending on when they are taken during the perinatal period. Close monitoring is key. It’ll help you find the lowest effective dose to control your bipolar symptoms while also ensuring your baby’s safety and development, she says.
For example, lithium (Lithobid), a gold-standard mood stabilizer for bipolar disorder, can often be taken safely during pregnancy and postpartum, says Butler. Research holds that lithium exposure during the perinatal period carries little risk, particularly when taken outside of the first trimester and at doses under 600 milligrams per day, according to an analysis of over a dozen studies on the safety of lithium during this time. Other research focusing on breastfeeding found that little lithium makes its way to the nursing infant, and results found that the medication had no impact on growth or development for the babies studied.
What about other options? “If what you’re presenting with is a fairly mild depressive episode or even a mild hypomania, you could try some nonpharmacologic options,” says Osborne. Light therapy, yoga, exercise, and talk therapy can all help, she says.
“But if you have mania or psychosis, you have to be on medication. It’s not an option,” says Osborne. The higher rates of suicide and infanticide make pharmacological treatment a non-negotiable, she says.
Managing Triggers for Postpartum Bipolar Disorder
Managing the stress of new parenthood alongside a new bipolar diagnosis can be extremely difficult. Here are ways to help:
- Prioritize sleep. Not getting enough sleep can push someone into a bipolar episode, notes Osborne. But the advice to sleep when your baby sleeps will only get you so far. For mental health, one good chunk of sleep is superior to a whole lot of cat naps. She says she’d much rather her patients sleep four consecutive hours than eight hours broken up into 90-minute segments.
- Create a care plan. Work with your partner, family, friends, and others in your community to ensure you have the help you need, says Butler. Loved ones and professionals, including doulas and lactation consultants, can all support you so you can focus on your and baby’s well-being. Help can look like it would for anyone postpartum, such as dropping off food, caring for the baby, or just providing company, she says.
- Invite in flexibility. Sometimes, caring for yourself means changing your plans. For instance, if it’s your goal to exclusively breastfeed, but nursing overnight makes it impossible to get the sleep you need, you may have to open yourself to alternatives, says Butler.
- Seek out specialized support. Having postpartum bipolar disorder can be an isolating experience, says Butler, so finding others who are navigating similar challenges can be a lifeline. You can find mental health support groups dialed into your needs, including ones just for birthing people with bipolar disorder, queer families, and people of color, she says. Harwood suggests the nonprofit Postpartum Support International, whose offerings include online groups and a helpline in English and Spanish, and the free, confidential National Maternal Meantal Health Hotline.
- Be in close touch with your medical team. Your body changes in big ways postpartum, and it’s likely your medication dosages will need to change, too. Because of this, Richards says she sees her patients with bipolar disorder weekly during pregnancy and until six weeks postpartum to ensure prescriptions are dialed in.
How to Support Someone With Postpartum Bipolar Disorder
If you are the partner or family member of someone with postpartum bipolar disorder, you have a role to play in helping her manage her illness. “Patients during this time really need the support of their family,” says Butler.
Harwood’s remote mountain location meant that friends and relatives were scarce during her own crisis with postpartum bipolar disorder, she says. That meant her family was thrown into survival mode, says Harwood. “I wish we could’ve reached out via social media for support,” she shared with bpHope’s network site Everyday Health.
Here are ideas on how to show up for someone dealing with postpartum bipolar disorder:
- Help her sleep. Protecting sleep should be priority number one, says Richards. Do what you can to make sure a new mom with bipolar disorder gets at least four hours of uninterrupted sleep, even if it means making some hard choices about how her baby is fed, she says.
- Know the signs. If you see a new mother not getting sleep but feeling energized or otherwise behaving out of character, connect with her care team, says Osborne. “The woman herself may not understand that it’s time to seek help,” she adds.
- Step up with household and care tasks. While more research is needed, scientists think that reducing stress improves outcomes for women with postpartum bipolar disorder. Jumping in with childcare tasks and managing day-to-day challenges can buffer the stress new mothers face, says Osborne.
- Consider talk therapy. When one partner has a new mental health diagnosis, Osborne always recommends couples therapy to help process how you’ll manage it together.
- Reassure your loved one. Having postpartum bipolar disorder is not something in a woman’s control, says Butler. Rather, it’s like any other medical condition you have to treat, such as diabetes. “This is not about personal failings,” she affirms.
- Learn about postpartum bipolar disorder. Butler recommends that family members seek education about bipolar disorder. Start with trusted information sources like Postpartum Support International or the International Bipolar Foundation.
Impact of Postpartum Bipolar Disorder on Parenting and Family Life
“There are many functioning parents who have bipolar spectrum disorders and are doing wonderful things with their lives,” says Richards. In fact, in her experience, treating bipolar disorder helps improve quality of life overall since, for many women, low-grade symptoms may have been smoldering in the background for years.
But when bipolar disorder is not well treated, it can be devastating. Harwood says during the years she was ill, she was hospitalized at psychiatric units for up to several weeks at a time. “Bipolar disorder robbed my girls of a present mother, and it placed an enormous burden upon my husband,” she says. “I wish with all my heart I could get those lost years back.”
Bipolar disorder can negatively affect:
- Bonding and Attachment Bonding is your sense of the parent-child relationship, while attachment is your child’s. Both can be impacted by postpartum bipolar disorder, explains Richards, who is also a child psychiatrist. If women feel like having their baby brought out the worst in them and their mood, it can make it harder to feel connected, she says. Likewise, if poorly managed bipolar disorder causes a parent to act unpredictable and chaotic, over time, it could compromise a child’s secure attachment to that parent. The good news is that the quality of both bonding and attachment can improve with effective bipolar treatment, she says.
- Family Relationships Bipolar symptoms can impact your ability to feel connected to your partner, notes Butler. When one member of a couple has bipolar disorder, it’s more common to experience conflict and arguments than when no one has the disorder, according to the results of a study involving over 100 couples.
- Safety The impulsivity and increase in energy of mania can lead to dangerous behaviors that, in the extreme, can potentially put mother and child at risk of harm, says Richards. But there are usually warning signs along the way, she notes. That’s why it’s so important to treat postpartum bipolar disorder early and never let things get to that point.
Prevention of Postpartum Bipolar Disorder Episodes
If you know you have bipolar disorder or suspect you may be vulnerable to it, you can take steps to help prevent a disruptive mood episode postpartum.
- Practice self-care to support your mood. Osborne likes to ask her patients, “When do you feel your mental health is best, and what gets you in that place?” Their answers provide clues to what self-care looks like for them. For some of her patients, self-care looks like yoga, swimming, or a daily walk by the river. Harwood says, for her, sleep and exercise are key.
- Stay ahead of things and stick to your treatment plan. When you notice early signs and triggers, you can adapt your medication regimen to prevent a manic episode, says Butler. If you’re not yet diagnosed, and you have any concerns or question marks about your mood or behavior, seek out a mood disorder specialist in psychiatry, says Richards.
- Secure adequate sleep. Sleep deprivation is common postpartum. Unfortunately, lack of sleep can make bipolar symptoms more severe, says Butler. Research published in the Journal of Affective Disorders in February 2024 has found a link between women with bipolar disorder who experience sleep loss during and right after birth and an increased risk of postpartum psychosis.
Outlook for Postpartum Bipolar Disorder
“If you’re presenting for the first time in the postpartum, you don’t know if it’s going to be a lifelong disorder yet,” says Osborne. It may be that bipolar disorder will be a chronic health condition, or it could be confined to the times you are postpartum, she says.
Women with postpartum bipolar disorder do have an increased risk of having another episode during and after future pregnancies, according to a study that analyzed outcomes for over 400 women. Someone with a known bipolar disorder should work with their loved ones and medical team to form a plan to manage triggers and medications during subsequent pregnancies, says Butler.
In most cases, bipolar disorder will be an ongoing concern, Richards says. However, with adequate treatment, it’s possible to avoid its most disruptive, unpredictable symptoms. Ongoing treatment usually means a simplified medication regime to maintain mood, which differs from what’s required to deal with an acute episode, she says.
Richards encourages women with postpartum bipolar disorder to be open to the possibility that treatment like this can drastically impact and improve their quality of life.
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