In Women with Bipolar Disorder, Loss of Sleep Related to Childbirth Increases Risk for Postpartum Psychosis

Women with bipolar disorder (BD) are at increased risk for postpartum psychosis (PP). While previous studies have indicated that sleep disruption is a risk factor for postpartum depression, we have less information on the impact of sleep disruption on risk of postpartum psychosis. Clinically, we observe that most women with postpartum psychosis present with significant sleep disruption; yet, it is not clear if sleep disruption precedes and acts as a trigger for postpartum psychosis, or if sleep disruption is a symptom of the disorder. 

A recent study from Perry and colleagues analyzes data from a longitudinal study of pregnant women with bipolar disorder in order to examine whether sleep disruption during the perinatal period–either poor sleep quality late in pregnancy or sleep deprivation related to childbirth–is associated with postpartum psychosis. Participants were recruited as part of the UK Bipolar Disorder Research Network Pregnancy Study and included 76 pregnant women with a diagnosis of DSM-5 bipolar I disorder or schizoaffective-BD before pregnancy. Participants were followed prospectively from week 12 of pregnancy to 12 weeks postpartum. 

Demographic information was collected, and lifetime psychopathology was assessed at baseline using a semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry). Participants reported on mood and sleep disruption in the third trimester and at 12 weeks postpartum. Data were supplemented by clinician questionnaires and review of the medical record. In this cohort, 44/76 (58 %) of the women used a mood stabilizing medication prophylactically during the postpartum period.

Impact of Sleep Loss at the Time of Labor and Delivery

Women who reported missing at least one complete night of sleep at the time of labor and delivery were significantly more likely to experience PP compared to women who did not miss any complete nights of sleep (44.8% v 14.3 %). After controlling for prophylactic use of mood stabilizers (initiated before or at the time of delivery), the researchers calculated that the loss of at least one complete night of sleep was associated with a fivefold increase in the odds of experiencing PP (OR 5.19, 95 % CI 1.45–18.54). 

In contrast, sleep quality reported during late pregnancy was not associated with PP. In addition, sleep disruption during pregnancy was not associated with increased risk postpartum depression.

Episodes of PP among those who reported one or more missed nights of sleep typically occurred early, with 92% of the episodes occurring within the first two weeks following delivery. In contrast, episodes of PP among women who did not report sleep loss were more widely distributed across the postpartum period, with onset occurring up to 5 weeks postpartum.

Clinical Implications

Sleep disruption is common during pregnancy and the postpartum period and may pose significant risks in women with a history of psychiatric illness. In non-pregnant individuals with bipolar disorder, sleep disruption is a risk factor for relapse of illness. The current study indicates that sleep disruption associated with labor and delivery is a potent risk factor for postpartum psychosis:

• In women with bipolar disorder, loss of at least one night’s sleep at the time of labor and delivery was associated with increased risk for postpartum psychosis.
• Women with BD who lost more than one night of sleep during labor and delivery had a 5-fold increase in risk for postpartum psychosis compared to women with BD who reported less than one night of sleep loss.
• In women with sleep loss, 92% of episodes occurred within two weeks of delivery.
• Sleep disruption during pregnancy was not associated with increased risk for postpartum psychosis or postpartum depression in women with BD.

When examining the impact of sleep disruption on risk of psychiatric illness, we have typically focused on sleep disruption that occurs as a function of taking care of a new baby. This study is distinct in that it focuses on sleep disruption that occurs at the time of labor and delivery. Because postpartum psychosis occurs very early, typically within the first two weeks and sometimes within the first 48 to 72 hours, it is not surprising that sleep loss associated with childbirth is a risk factor for postpartum psychosis in women with BD. 

As mental health providers, we must educate our patients with bipolar disorder about their risk for postpartum psychosis and the impact of sleep disruption associated with labor and delivery. We also need to inform obstetric providers that women with BD who experience significant sleep disruption at the time of delivery should be flagged for early follow-up. This is especially important for women with BD who have discontinued their medications during pregnancy and thus may not be in regular contact with their mental health providers.

Ruta Nonacs, MD PhD

References
Perry A, Gordon-Smith K, Lewis KJS, Di Florio A, Craddock N, Jones L, Jones I. Perinatal sleep disruption and postpartum psychosis in bipolar disorder: Findings from the UK BDRN Pregnancy Study. J Affect Disord. 2024 Feb 1;346:21-27.