When It’s Not Postpartum Depression: The Bipolar Diagnosis Many Moms Miss

Is it postpartum depression—or could it be bipolar disorder?

In this episode, Sarah sits down with reproductive psychiatrist Dr. Claire Smith to talk about why bipolar disorder during pregnancy and postpartum is often missed, especially bipolar II. They break down the key differences between bipolar disorder, postpartum depression, and postpartum psychosis, why sleep is a critical factor in mood stability, and how the right diagnosis can completely change a mom’s treatment and recovery.

An important conversation for mothers, partners, and providers who want to better understand bipolar illness in the perinatal period—and why getting the diagnosis right matters.

Transcript

Why Bipolar Awareness Matters

SPEAKER_02 0:09

Hi, guys. Welcome to the Previewance Podcast. I am with you. And guys, we're in the month of March, and I'm going to tell you what month of March is. And you're going to be like, I never knew that. Maybe you shouldn't have known that. Now I know it. It's bipolar awareness. And I brought back our favorite reproductive characters, Dr. Claire Smith, to tell us more about it. Welcome, Claire. What an anxiety topic. People are probably like, oh, yes, turning in. But it's really educational and something we all need to know.

SPEAKER_00 0:35

Yes, agreed.

SPEAKER_02 0:36

You know, some of your other episodes I feel like are just more intriguing, but this one's more of awareness and education because, you know, we'll jump to it: postpartum depression and anxiety. Most people can say, okay, I know that. I've experienced that. But what we see is now out in the news, or you may come across a provider that speaks, you know, before they really get all the facts and they throw out bipolar and people are going, okay, how is that different? Why does it matter? Like, and we're talking like pre-pregnancy, then pregnancy and postpartum. So just kind of give us this insight of more awareness of it. Okay.

SPEAKER_00 1:19

Generally speaking, kind of like you're saying, there's a lot of misconceptions about bipolar disorder, and not just amongst patients, you know, regular people. A lot of non-psychiatrists don't understand bipolar disorder. And it's used almost like a slang term, sort of like how people call themselves OCD. And it's there are two types, bipolar one and bipolar two. The biggest thing to know is that bipolar disorder is not mood swings, it's not your mood changing over the course of a few minutes or a few hours. It's a sustained, marked change from your baseline. And there are lots of criteria that need to be met. I mean, you could even include like a link to the DSM criteria for bipolar if you wanted to in this episode. But the prevalence in the population is only around 2%. It's not a common illness. Bipolar one, especially, is very serious. And it is highly heritable. I think we'll talk about that a little bit more. So if you have a family history of true bipolar disorder, you do need to be aware of your own increased risk generally, but also why the perinatal period is vulnerable for that first time. Mood episode. And mood episode, for anyone who doesn't know, means depression or mania or hypomania. It's just an umbrella term for any of that to do with bipolar disorder or depression.

SPEAKER_02 2:47

Now, when people are saying, okay, so if I was depressed, but then I felt better, is that kind of the same thing? Or are we talking about, give us a couple examples of maybe some of your patients or that you've seen studies of or presentations that would be really kind of a mob? Let's say she's because I mean it's right, we're all sleep deprived and we're all just like, well, Claire, I I'm I'm I don't even know what I am most days.

unknown 3:13

Right.

Why Pregnancy Can Unmask Bipolar

SPEAKER_02 3:14

Right.

SPEAKER_00 3:15

Okay. I will elaborate more on kind of perinatal context for mood disorders and particularly bipolar disorder. So there is no like higher rate in pregnancy that that same 2% remains consistent, like amongst men and women. But pregnancy and especially postpartum, it's kind of this perfect storm. So the average age of onset or initial presentation of bipolar disorder overlaps with your typical childbearing years. So mid-20s to mid-30s. And pregnancy and then postpartum, it just comes with lots of different assaults, as we say, to someone's genetics or other factors. So sleep deprivation, hormonal changes, physical and psychological stress, other factors, all these things can precipitate bipolar disorder in anybody, like going to college for the first time. That stress of going to college. That's a very common presentation for people. One example. So pregnancy comes with like 10 different ways that they can psychologically or physically stress you out. And generally you are predisposed, meaning it's in your genetics somewhere, and it's kind of this hypothesis where you've got the predisposition, and then these other things happen, and that's how it first presents. And untreated bipolar disorder in the perinatal period, so pregnancy or postpartum, you are almost guaranteed to have a mood episode, so either depression or mania. It's only most quoted as around 80%. And you are behaving very differently or making very bizarre decisions. We can talk about that more in more detail. But bipolar two can, and I think that's probably like what you're asking about, is under more of that bipolar two category. It's often misdiagnosed andor treated for a long time as just depression, meaning major depressive disorder. It can happen for many years. And one telltale sign is somebody who has had depression, maybe they don't know what hypomania is, and then their providers have asked about it, and it's just this weird thing that happens every now and then. But they've been treated for depression with SSRIs or SNRIs, well, butri and whatever, and they've none of them have really helped, or they've made them feel worse. That is an excellent red flag of should I talk to somebody about bipolar too? These years of depression diagnosis, a laundry list of med trials, ineffective, or they made them feel more irritable or angry or worse. That that's a good clue.

Medication Risk Versus Untreated Risk

SPEAKER_02 5:59

So I think listeners are saying, okay, so I could have my first episode, if I was in that percent, small percent, during pregnancy. Yeah. Or I could have had it before, right? Now, during pregnancy, what they're going to be concerned about is medications and safety. So speak to that for a second. Of their going, okay, we'll do it twofold. First one is it's her first episode, she's found someone to treat her and she's pregnant, right? Risk versus benefit or risk versus risk here of her being treated for this.

SPEAKER_00 6:35

Okay, so you know I don't like speaking in black and white, but for bipolar one, medication is always needed. It really isn't an option pregnancy or not to be unmedicated and have bipolar one. For the risk of untreated bipolar disorder in the perinatal period is a mood episode, as we already said, and kind of secondary to a mood episode would be things like suicide risk. If you're manic and you are in dangerous situations or behaving in a way you don't normally do, substance use, communicable infections, that's a nice way to say, STIs, hepatitis C. I know this seems very drastic, and this isn't your average person, but that's the risk of something like mania if it were to be untreated in pregnancy. And plenty of people who have bipolar one, true bipolar one, are taking off their medications in pregnancy. So if you have a few listeners that this applies to, I want them to hear that as well. But higher rates of C-section, placental abnormalities, hemorrhage, preeclampsia, preterm birth, low birth weight, poor developmental outcomes, meaning developmental delays. So the risk is significant. To your point, though, medication that's commonly used to treat bipolar illness or mood stabilizers. These are medications like lithium, depicot, lamectal, trileptal, tegritol, and so on. This is one of the classes, one of the few classes that have truly elevated risk in pregnancy to attend the birth defects. Depicotte in particular. Even despite that, you will essentially never hear me tell someone to come off of their medications without a follow-up plan of like, okay, what are we going to switch to? Or like, what's what's the game plan here? Depicode is probably the exception for that, but still, given the risk we know exists, we need to then start them on something else or have a different plan. We do have mood stabilizers, lamyctal most commonly, and lithium that we use routinely in pregnancy, where the risks of untreated illness are just significantly greater than the risk of medication. So that's the short version. Yeah.

Preconception Planning With Family History

SPEAKER_02 8:47

So say someone who goes, okay, my mom has the history of this, or I have a history of trying to get pregnant. What would be a step they could do in this moment if they don't have a you? Because a lot of people don't, right? Like reproductive psychiatry is we wish it was in every state, we wish it was in every city, but it's simply not. What would you say to that listener? Or you know, maybe it's a loved one that they're like, okay, I know she's trying to get pregnant. What should we be doing in this situation?

SPEAKER_00 9:17

And she knows she has a known family history, or she herself already has a diagnosis. We'll do both. We'll do both. Known family history, I don't, there's nothing specifically to do other than I think be aware and know that you are at increased risk and know how heritable the illness is. And we can talk about more specific, like true signs and symptoms of bipolar illness, one and two. If you have a known illness and are taking medication for bipolar whatever, mood stabilizer, antipsychotic, whatever it might be, and you're wanting to get pregnant. I would at the at the very least, now this all depends on your provider, but I would be proactive and have a preconception visit with your OB or midwife and have that conversation. And my hope would be that if they don't know exactly how to counsel you or what to tell you to do, they at least have a resource, a PSI or an access line or something. But generally speaking, stay on your meds. I mean, that's like as simple as I can make it. I would not recommend you come off your meds and get pregnant and destabilize. That would be worst case scenario.

Postpartum Depression And Psychosis Clarity

SPEAKER_02 10:34

Do you see most people at their first said episode, right? So it's triggered. Is it more during pregnancy or is it during postpartum more? More postpartum. Postpartum. And so I think that gets even trickier, right? Yeah. Is then we the difference between, okay, I am having my first bipolar experience versus postpartum psychosis, because I know our listeners know what that is. And they're probably going, okay, Claire, so what's that difference?

SPEAKER_00 11:01

So actually, well, two things. One, the most common mood episode, perinatal mood episode for a woman with bipolar disorder is postpartum depression. So as scary as mania is, postpartum psychosis is, you're far more likely to have postpartum depression. So women with bipolar are at more risk of PPD than someone who has major depressive disorder. So that's the greatest risk. Postpartum psychosis is actually bipolar disorder until proven otherwise. So most of the time it's one and the same. And the risk is elevated. If you have known bipolar illness, the risk of postpartum psychosis is elevated. It's one of our very few known risk factors for postpartum psychosis. And postpartum psychosis is not always bipolar disorder, not 100% of the time, not by a long shot. However, most of the time it is a to that point undiagnosed bipolar disorder. And they're usually leaving that experience with the diagnosis of bipolar disorder, if that makes sense.

SPEAKER_02 12:05

It is. And is it for the depression episodes? You know, people are going, okay, is this the first six weeks? Is this six months? Like, how far into postpartum could I be having these episodes?

SPEAKER_00 12:21

The strictest definition of postpartum depression would be the third trimester or those first four weeks. I think in reality, it's a little bit more gray than that. I mean, anyone who's had a baby can tell you that, like, what's even going on that first month? You know, you're as hard, it's in hindsight, usually, people feel like, yes, it started then, but maybe they're not truly realizing it, or people just assume they're going to be tearful, feel, you know, like the lack of motivation, energy, interest, all those symptoms of depression. But in terms of truly postpartum related, in terms of hormonal changes, sleep deprivation, I think that first six months is fair game. Although plenty of providers you see will call postpartum depression anytime in that first 12 months postpartum. So there's different definitions of it. And I think clinically it can be, you know, when it gets beyond that six-ish month, it can be like life stuff. Like life is hard. Life is harder. Whether you go from zero to one, one to two, two to three. And so sometimes that can be more of a factor than like the true quote-unquote postpartum depression. But the treatment of it isn't all that different, you know, unless you're talking about using xorantolone or one of these newer newer medications. So it doesn't really matter that much clinically.

SPEAKER_02 13:41

And so for the listener, just to hound in more, they're like, okay, I think I know what depression or these depressive episodes would feel like or look like. Versus the other mud swing. Yeah. Just give us just kind of the quick hit with the most common things you may hear them say or feel, or maybe their their spouse says, so that they can kind of just have this almost like a little bit of a, you know, you go to the doctor's office, it's like, are you experiencing XYZ? You know, in their heads because they're going, okay, well, I was depressed in pregnancy, or I was depressed in postpartum. And then I, you know, I want to make it just kind of clear because it is very messy. Like all this is like not for you to self-diagnose, so as a listener, right? To go, this is why we have glares in our life, is to go and say, This is what I'm experiencing.

SPEAKER_00 14:29

Okay, so let me, I will take a minute to elaborate on mania and hypomania, if that sounds good.

SPEAKER_02 14:34

Yeah.

SPEAKER_00 14:34

Because I think that is the most misunderstood piece. So, mania, you can't really miss it. Someone is manic, you're talking to them as a stranger, and you know this person, there's there's something wrong here. Not even like you know them on an intimate level. That person is behaving differently, oddly, can be bizarrely. Their mood is elevated, what we call expansive, could be euphoric, could be extremely irritable. They could be talking fast, thinking fast, making unsafe decisions, spending large amounts of money, like I said, substance use or like sexual promiscuity that's very out of character for them. Sleep is a big piece of mania. So they're not sleeping or barely sleeping, but not feeling fatigued. This is not like I'm laying in bed awake and I'm staring at my ceiling and I just cannot go to sleep. This is like up, active, doing strange things in the middle of the night, not tired. They can even be paranoid, they can be psychotic, they can be delusional, their neighbors are spying on them, someone's tapping my phone, that kind of thing. It has to last for at least seven days. Which they wind up getting hospitalized before that point. So mania is like, it's big time. So hypomania is different. That's the one that can fly under the radar. The impairment is not going to be to the level of bipolar one. It may not ever result in significant enough presentation that someone is hospitalized, that someone is making these really drastic decisions that people are like, whoa, what's going on? But part of the criteria is that it needs to be observable by others. So it does need to be a change. And there still is the impact for sleep or irritability, mood elevation, you know, the decision making, the money spending, whatever it might be, this goal-directed behavior, they call it, it's just to a less intense degree. It doesn't have to last as long. They don't have to be hospitalized. And oftentimes for that bipolar two, depression is the more prominent part of your illness. So if you've had one of these periods of time of hypomania, and the rest has been depression your whole life, you meet criteria for bipolar two.

SPEAKER_02 16:47

Interesting. Yeah. And I can see why that would be just because I mean it could be just that small blip in time, right? And it's you could have been, I mean, studying abroad. You could have been in college, right? And like kind of around a new group of people who didn't have that baseline of you, and they could just be like, oh, okay. And you just never, you always store it in your brain, right? And so I think that is something we really just want to draw attention to, is just until you hear about it, you it may not restore with you about yourself or someone else.

SPEAKER_00 17:17

And particularly in certain families, communities, culturally, like it just can be seen as like, oh, it's have Sarah's having one of her weeks, you know, it happens every few years, or you know, whatever, like that kind of a thing. Or they just they experience it themselves. People think, you know, their their spouse or their friends might be like, she's disappeared for a while. And that's kind of the extent of it. You don't realize it until the physician is asking you all these pointed specific questions.

SPEAKER_02 17:47

I mean, if you hear you hear back, and I I know, especially Lizard's me and Claire are from a similar part of where we grew up of the country, as you hear of like, well, my aunt or my cousin, or this, you hear stories of kind of like around childbirth or pregnancy postpartum of them saying, okay, she went away for a little bit, or this is what she would do a c you know ever so often. And it just now starts to really click in your head. And that again is getting really curious about your family history and and giving people grace in the sense they they never may have received a diagnosis. They never maybe had these conversations.

SPEAKER_00 18:24

Right. And I will say conversely, a lot of people, women specifically, especially when they were teenagers, like acting out or they were have an unstable home situation, ongoing trauma, abuse, substance use, whatever it might be, like behavioral, they're running away or getting in fights at school or whatever. I see that all the time where someone has was told when they were a teenager they have bipolar disorder, and it stays with them, and they've they are trying to be responsible. So they're telling their providers, yes, I have bipolar disorder. And of the people that tell me I have a history of bipolar disorder, I would say probably 75% do not. Wow. It's very, like we talked at the beginning, misunderstood, misdiagnosed. It's not impossible, but it's just not likely that a whole bunch of 16-year-olds are presenting that early. That would be unusual. So I want to say that, but yes, there is, it's like this weird phenomenon of people are labeled bipolar who aren't, and then people who have particularly a bipolar two never know it.

SPEAKER_02 19:27

Yeah, yeah, no. And that's why, you know, I love that we're having this conversation. And too, it is something that you hear people say, you know, this link to our operator. It's like she's bipolar. And it's just like, it's become, again, in this world, TikTok, Instagram of just where everybody like almost wants to become their diagnosis a little bit. Sure. And it it's it's something that, you know, we're looking at through the lens of know your history, know yourself. We want you to have successful pregnancies, postpartums, and life. And mental health is health. And we have to be educated. We have to know treatment options, we have to be advocates for our own safety, our children's safety. But something that I've heard you mentioned a couple of times, but we want to focus in is sleep. Why does sleep matter so much? Well, we know it does in general for moms, right? Because we're a lack of it. We see what happens. But in the terms of bipolar, why is that so critical?

Sleep Protection And Feeding Plans

SPEAKER_00 20:20

Okay, to put it super simply, sleep disturbances can precipitate hypomania or manin, meaning cause. They can contribute to like someone becoming hypomanic or manic. And that is typically a warning sign that the wheels are coming off. So it can precipitate and is also a symptom of mania. And I honest, I mean, I we could talk about circadian rhythms and brain circuitry, and I probably wouldn't get it all right anyways, and that would be boring, but that's that's the quick of it. And I think though, if it's okay with you all transition to like particularly if you have known bipolar disorder and sending the postpartum period. Okay. So I think it's really important to say that this conversation, the sleep, the breastfeeding, the pumping, the formula conversation should be had well in advance when you are pregnant and have bipolar disorder. So if your provider hasn't mentioned it, be proactive and bring it up yourself. It is not unusual for someone with bipolar illness to choose or even to be recommended to formula feed instead of breastfeed. If someone wants to breastfeed, I'm in full support of that. But regardless of their choice, we we will have a very pointed conversation of especially if they're if they want a breastfeed, if that's a priority for them. What's the plan for overnight? Who are your support people? Because you have to have them. What's the pumping plan? We you cannot go stretches and stretches of not sleeping. You will have a limited episode. And that can get scary quickly. The biggest piece of advice, both broadly and still applicable to this population, is to structure overnights. So that you're getting stretches of consolidated sleep. And I think probably this has been covered in by someone, if not me, prior on the previous. But obviously, not everyone has a spouse or partner. But if they do or they have another support person on some nights or all nights, they should take shifts rather than turns. So getting four to five hours of consolidated sleep is better than six hours, say, of sleep in one and a half hour chunks.

SPEAKER_02 22:30

Yeah, totally agree. I mean, it's you will go, wow, I can live whole day now on my four-hour stretch versus to that. And it you're right. So not a lot of people have that. But if you do, I mean, I always say, you know, a lot of things in the nursery decor can weigh a lot of, I mean, the baby really just needs a few simple things, you know. And if you can say, hey, donate for me to get someone to walk get me one night a week of sleep or you know, a babysitter for even for you two to, you know, she would come over and you sleep from seven to ten. Yeah. That's a good start. Yeah, no, I agree. But it's things that you just do not realize the impact of sleep deprivation until you experience it, like many of our listeners have. But on that point, it is it's must be really scary to be like, well, I know if I do not sleep, what could happen?

Stigma Myths And Staying Stable

SPEAKER_00 23:27

Yes. And most people who have bipolar illness, even if it's their first kid, are very receptive to this conversation and intimately understand the sleep concern and you know, are like I said, open to having this, like what's what's the feeding plan? And we can work through the the guilt, the formula guilt, you know, preemptively, and or come up with a compromise if if you know that will make them feel better or help them feel better or whatnot. But yeah, that's a it's a specific conversation we're having.

SPEAKER_02 24:01

Well, this has been incredibly helpful. What is something you kind of wish to almost debunk, demyth, like just about bipolar, like just from like I think people put, I mean, with anything in extremes, right? Is you put people in this box, maybe if the listener's like, well, that doesn't impact me, it doesn't impact anybody else. But I mean, these are again, I'm like, this person did not choose this, right? This is either this is hereditory in genetics. We really don't know sometimes why this is happening. So what what's just kind of something to put out there? Because I mean, I think mental health just has such a bad stigma in general and bipolar, like we said earlier, it's kind of been that labeled word of people maybe we don't want to deal with or don't feel uncomfortable with.

SPEAKER_00 24:44

Yes. I yeah, I think I think piggybacking off that is a good, I mean, first and foremost, that people who have bipolar illness, when you come across them or work with them or they're part of your family, you might not have any idea like if they're stable and doing well. People can function very highly, live a perfectly normal life, including parenthood who have bipolar illness. And I think from a clinical perspective, one thing I want to reiterate is do not let your doctor stop your medication without a new plan or a referral to the right place if that's a possibility. That bipolar disorder is a serious illness, but a very treatable illness. And again, that it's not mood swings. You know, I think that women, like you said, women get labeled as bipolar. I've got a lot of women who are like, My boyfriend said I'm bipolar and I need to come talk to you. And that just grinds my gears, you know, on the inside when having to provide that education and why that's not what's happening here. And I think those are probably my biggest takeaways.

SPEAKER_02 25:53

Well, before you leave, we're gonna flip the switch and ask you about now. We know that we've you've been with us through pregnancy, a postpartum, and now you're two years out, my friend. So you're you're hitting veteran status here that we can say, all right, Claire, what again do you wish you knew about motherhood that she didn't before? Because now you've got you've got we're hitting toddler years for you. So we're we're getting some good stuff.

SPEAKER_00 26:21

Toddler years are not for the week. Yes, we were uh we had our first within the last few weeks, like true blood curdling scream because we had to keep walking past, you know, past the playground, you know, like that kind of thing.

SPEAKER_02 26:35

How dare you!

SPEAKER_00 26:35

How do you like literally kicking, screaming up the stairs of our front porch? The neighbors, you know, can hear from a mile away. And my husband is like, what is wrong with her? And I said, Terrible twos. You ever heard of it? This is this is what that means. And he was like, Are you sure? Do we need to talk to the doctor? And I'm like, yes, I mean just buckle up. But I think one lesson from years zero to two is that it will be temporary, you know, like I'm really trying to lean into it, will pass. And I think the lesson I'm trying to focus on is consistency, like in the face of the tantrums and the behaviors and how stressful it is to like remain consistent, whether with its voice discipline, not giving X treat, whether it's looking at she likes to look at pictures, you know, she's always actually asking to look at pictures. That is a very fast way to get her to calm down. But I'm trying my damnedest not to do it, you know, like trying to stick to those, I think, is my biggest challenge and goal right now.

SPEAKER_02 27:41

And my own question to you is do you feel like your professional career has prepared you to deal with this toddler years? Or you're going, wait, this is a foreign tarot. I mean, I can give me a patient any day, but my child, who is half me, half my husband, who's triggering us all.

unknown 27:59

Right.

SPEAKER_00 28:00

Both. I think both. It is foreign territory, like you said, it is a new experience. I do not have any kind of experience to draw on, and I'm learning as I go, just like every other parent. And I think I also have for years had to deal with patients who are psychotic or upset or agitated or whatever and have to maintain evenness as much as possible, you know, while keeping the environment safe. So there is some degree of that that is in my comfort zone, but it's nothing like a two-year-old. I mean, don't get me wrong.

SPEAKER_02 28:34

Well, we will have you come back and do a whole series in a couple of years about how to survive the taller years as a reproductive psychiatrist would, because I mean, you are gonna be golden and I think it's going to provide just a lot of insight, and we're cheering you on as like we're cheering all our listeners. We're all moms, we're all in this together. Yeah, no matter what our day job is, we all are gonna have that park situation where our kid thinks we're ending their their whole entire joy.

Resources And Closing

SPEAKER_00 29:01

Yes, absolutely.

SPEAKER_02 29:03

Well, Claire, we adore you, we thank you, listeners. Go back if you've not listened to any of my episodes with Claire before, because we get tons of good information. We realize there's not a lot of Claire's around, but a good education piece who shares our podcast, bring it to your provider, Postpartum Sport International. I'll link that. Advocate for yourself and don't let anybody label you as bipolar. I think that's a great takeaway from today.

SPEAKER_00 29:31

Yeah.

SPEAKER_02 29:31

Thank you. All right, Claire. Thanks, listeners. I'll be back next week.

SPEAKER_01 29:37

Maternal mental health is as important as physical health. The Preview Alliance podcast was created for and by moms dealing with postpartum depression and all its variables like anxiety, anger, and even apathy. Hosted by CEO, founder Sarah Parkhurst, and licensed clinical social worker Whitney Gay, each episode focuses on specific issues relevant to pregnancy and postpartum. Join us and hear how other moms have overcome mental health challenges as well as access tips and suggestions on dealing with your own challenges as moms. You can also browse our podcast library and listen to previous episodes at any time. Please know you're not alone on this journey. We're here to help.