ORIGINAL ARTICLE

ONLINE FIRST

Psychiatric Disorders With Postpartum Onset

Possible Early Manifestations of Bipolar Affective Disorders
Trine Munk-Olsen, PhD; Thomas Munk Laursen, PhD; Samantha Meltzer-Brody, MD, MPH;
Preben Bo Mortensen, DrMedSc; Ian Jones, PhD

Context: Childbirth has an important influence on the

onset and course of bipolar affective disorder, and it is
well established that there may be a delay of many years
before receiving a diagnosis of bipolar disorder following an initial episode of psychiatric illness.
Objective: To study to what extent psychiatric disor-

ders with postpartum onset are early manifestations of

an underlying bipolar affective disorder.
Design: Survival analyses were performed in a registerbased cohort study linking information from the Danish Civil Registration System and the Danish Psychiatric Central Register.
Setting: Denmark.
Participants: A total of 120 378 women with a firsttime psychiatric inpatient or outpatient contact with
any type of mental disorder excluding bipolar affective
disorder.
Main Outcome Measures: Each woman was followed up individually from the day of discharge, with
the outcome of interest being an inpatient or outpatient
contact during the follow-up period with a first-time diagnosis of bipolar affective disorder.

Author Affiliations: National

Centre for Register-Based
Research, Aarhus University,
Aarhus, Denmark
(Drs Munk-Olsen, Laursen, and
Mortensen); Department of
Psychiatry, UNC Center for
Womens Mood Disorders,
University of North Carolina at
Chapel Hill (Dr Meltzer-Brody);
and Department of
Psychological Medicine and
Neurology, Medical Research
Council Centre for
Neuropsychiatric Genetics and
Genomics, Cardiff University,
Cardiff, Wales (Dr Jones).

Results: A total of 3062 women were readmitted or

had an outpatient contact with bipolar affective disorder diagnoses. A postpartum onset of symptoms within
0 to 14 days after delivery predicted subsequent conversion to bipolar disorder (relative risk = 4.26; 95% CI =
3.11-5.85). Approximately 14% of women with firsttime psychiatric contacts during the first postpartum
month converted to a bipolar diagnosis within the 15year follow-up period compared with 4% of women
with a first psychiatric contact not related to childbirth.
Postpartum inpatient admissions were also associated
with higher conversion rates to bipolar disorder than
outpatient contacts (relative risk=2.16; 95% CI=1.273.66).
Conclusions: A psychiatric episode in the immediate
postpartum period significantly predicted conversion to
bipolar affective disorder during the follow-up period.
Results indicate that the presentation of mental illness
in the early postpartum period is a marker of possible
underlying bipolarity.

Arch Gen Psychiatry. 2012;69(4):428-434.

Published online December 5, 2011.
doi:10.1001/archgenpsychiatry.2011.157

HILDBIRTH HAS AN IMPORtant influence on the onset and course of bipolar

affective disorder,1 and
studies have shown that
episodes of postpartum psychosis are often best considered as presentations of bipolar affective disorder occurring at a time
of dramatic psychological and physiological change.2 Despite diverse presentations,
the specific link between childbirth and bipolar disorder is well documented in a range
of different studies including populationbased register studies,3 family studies,4,5 and
genetic studies.6
It is also clear, however, that a high number of women presenting with the new on-

ARCH GEN PSYCHIATRY/ VOL 69 (NO. 4), APR 2012

428

set of a psychiatric disorder in the immediate postpartum period do not receive a

diagnosis of bipolar disorder. In a previous
study, we showed that the relative risk (RR)
of having a first-time inpatient psychiatric
admission with bipolar disorder during the
first 30 days post partum was 23.33 (95%
CI, 11.52-47.24).3 However, among the total
of more than 1100 women with first-time
psychiatric admissions 0 to 12 months post
partum, only 44 were diagnosed with bipolar disorder. This may, to some extent,
be due to specific puerperal diagnostic categories being applied to women with bipolar episodes but clearly not all postpartum
cases fall into the bipolar spectrum, and
childbirth may be a trigger for a range of psy-

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chiatric diagnoses. It is also possible, however, that a significant proportion of postpartum episodes that receive another diagnosis do in fact occur in women with underlying
bipolar illness. This may result from misdiagnosis if, eg,
features of high mood in a mixed episode are missed.
It is well known that there are difficulties in diagnosing bipolar disorder, with often a considerable delay in
an accurate diagnosis being made.7-9 In the Bipolar Comprehensive Outcomes Study, individuals with bipolar disorder showed an average of 9 years between the first episode of major depression and diagnosis.10 Similarly, this
study revealed an average 5-year delay in receiving a bipolar diagnosis following the first symptoms of a manic
episode. Depressive episodes occur in patients with both
unipolar and bipolar disorder. For all individuals presenting with depression, there is therefore a risk of subsequent episodes of high mood and a diagnostic conversion from unipolar disorder to bipolar disorder. A study
by Angst et al11 has quantified this risk and found a diagnostic change from unipolar major depression to bipolar I disorder in 1% of patients per year and to bipolar
II disorder in about 0.5% of patients per year.
Although a diagnostic shift to bipolar disorder is more
unusual than for other initial diagnoses, it can occur. For
example, there are issues in the diagnostic stability of a
first psychotic episode, with the later emergence of affective features resulting in a revision from a nonaffective psychosis to bipolar or schizoaffective disorder in a
proportion of patients.7,9
Given these diagnostic challenges and the very strong
relationship between childbirth and bipolar disorder, we
hypothesized that a postpartum onset of psychiatric illness could help in the difficult task of diagnosis with the
triggering of illness by childbirth being a marker of underlying bipolarity. We aimed to study to what extent nonbipolar postpartum episodes convert to bipolar affective
disorders over time using registry data in a longitudinal
study based on data derived from the entire Danish population.
METHODS

STUDY POPULATION
We established a population-based cohort using information
from the Danish Civil Registration System.12 The register was
established in 1968 and holds information on sex, date of birth,
and parents Civil Registration System numbers and is updated daily on vital status and migration. All citizens in Denmark are assigned a personal identification number (Civil Registration System number), which is used in all registers and
makes linkage between and within registers possible. We included all women with records of 1 psychiatric contact who
were born in Denmark from January 1, 1950, until December
31, 1991, who were alive on their 15th birthday (N=120 378)
of which 2870 had their first psychiatric contact within the first
year after delivery of their first child.

PSYCHIATRIC DISORDERS
Data on psychiatric disorders came from the Danish Psychiatric Central Register, which holds information on all admissions to psychiatric hospitals in Denmark since 1969. Further-

130 208 Women having at least 1 psychiatric

contact between January 1, 1970, and
December 31, 2006, were included

Exclusion:
1727 Women with bipolar affective
disorder diagnoses at initial
contact. Among these
women, 38 had first onset
within 0-30 d post partum,
27 had onset within 31-365 d
post partum, and 1662 had
onset at other points
8103 Women discharged after end
of follow-up period, died,
emigrated, or had first
psychiatric contact before
age 15 years

Inclusion:
120 378 Women (of 120 378 included)
at risk of subsequent
psychiatric contact with
bipolar affective disorder
diagnoses
2870 Women had their initial
psychiatric contact within
0-12 mo after delivery of
first live-born child

3062 Women were readmitted or

had subsequent psychiatric
outpatient contact with
first-time diagnoses of
bipolar affective disorder
132 Women (of 3062) had their
initial psychiatric contact
within 0-12 mo after delivery
of first live-born child

Figure 1. Flowchart illustrating the identification of the study population.

more, it contains records of psychiatric contacts at outpatient

clinics since 1995. At present, the register holds information
on more than 725 000 persons and 3.25 million contacts. From
1969 to 1993, the diagnostic system used in the registries was
the Danish adaption of the International Classification of Diseases, Eighth Revision (ICD-8)13 and ICD-10 from 1994 and onward.14 The study population and their parents were linked to
the register to obtain information on mental illness to study
psychiatric disorders in both the probands and presence or absence of psychiatric disorders in their families. Women and their
parents were classified as having a psychiatric disorder if they
had records of either inpatient or outpatient contacts at a psychiatric hospital with any type of mental illness (main diagnoses only). For the women in the study, diagnoses were grouped
as follows: bipolar affective disorders (ICD-8 codes 296.19,
296.39, and 298.19; ICD-10 codes F30 and F31), unipolar affective disorders (ICD-8 codes 296.09, 296.29, 296.99, 298.09,
300.49, and 300.1x; ICD-10 codes F32, F33, F34.1, F38.8, and
F39.0), schizophrenia-like disorders (ICD-8 codes 295.xx,
297.xx, 298.39, and 301.89; ICD-10 code F2x.xx), adjustment disorders (ICD-8 codes 307.xx and 308.4x; ICD-10 code
F43.xx), personality disorders (ICD-8 code 301.xx minus 301.83;
ICD-10 codes F60 and F61), puerperal disorders not elsewhere classified (ICD-8 code 294.49; ICD-10 code F53.xx), and
other disorders (remaining diagnoses). Parents of the women
in the study were categorized by their history of psychiatric
disorders in the following way: history of psychiatric contact
with bipolar affective disorder (ICD-8 codes 296.19, 296.39,
and 298.19; ICD-10 codes F30 and F31), history of psychiatric contact with any type of mental illness excluding bipolar
disorder (remaining diagnoses), and no history of psychiatric
contacts.

STUDY DESIGN
Based on information from these registries, we studied the largest possible homogenous population for which we had sufficient information. The study population consisted of women
born in Denmark from 1950 to 1991 who were alive and had a
history of a first-time psychiatric contact with any type of psychiatric disorder excluding bipolar affective disorder
(N=120 378) (Figure 1). Data derived from the registries were

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Table 1. Timing of First Psychiatric Contact and Conversion

Rates to Bipolar Affective Disorder a
Timing of First
Psychiatric Contact,
d Post partum

No. of
Cases

Rate per
1000
Person-years

RR (95% CI)

0-14
15-30
31-90
91-365
Other points

39
21
20
52
2930

11.19
6.95
3.39
2.74
2.63

4.26 (3.11-5.85)
2.65 (1.72-4.07)
1.31 (0.84-2.03)
1.04 (0.79-1.37)
1 [Reference]

Abbreviations: CI, confidence interval; RR, relative risk.

a Adjusted for age and calendar period.

Table 2. Timing of First Psychiatric Contact and Conversion

Rates to Bipolar Affective Disorder Excluding the Group
of Patients With Puerperal Disorders at Initial Postpartum
Psychiatric Contact a
Timing of First
Psychiatric
Contact, d
Post partum

No. of
Cases

Rate per
1000
Person-years

RR (95% CI)

0-14
15-30
31-90
91-365
Other points

15
16
18
51
2915

6.86
6.92
3.40
2.77
2.62

2.64 (1.59-4.38)
2.66 (1.63-4.35)
1.32 (0.83-2.10)
1.06 (0.80-1.40)
1 [Reference]

Abbreviations: CI, confidence interval; RR, relative risk.

a Adjusted for age and calendar period.

handled and analyzed prospectively, and follow-up started on

January 1, 1970, or at age 15 years, whichever came last. Specifically, women 15 years and older were followed up individually from date of discharge of first inpatient or outpatient contact. Follow-up ended on the date of first-ever psychiatric
inpatient or outpatient contact with bipolar affective disorder,
death, or emigration or by December 31, 2006. The outcome
of interest was incident psychiatric contacts (defined as inpatient or outpatient contacts at psychiatric hospitals) with a bipolar affective disorder.
We excluded women from the study who had bipolar affective disorder diagnoses at their initial contact (first-time contact at either an inpatient or outpatient psychiatric facility).
Women diagnosed with bipolar affective disorder during a psychiatric contact immediately following the first contact (discharge and readmission within 24 hours) were also excluded
from the study together with women younger than 15 years at
first psychiatric contact (Figure 1).

STATISTICAL ANALYSES
Each woman was followed up individually during the specified follow-up period using survival analysis techniques. Data
were analyzed using Poisson regression with the logarithm of
the person-years as an offset using SAS version 9.1 (SAS Institute Inc). This method approximates a Cox regression.15,16 The
main outcome measures were number of new cases per period
(1000 years), ie, incidence rates of first psychiatric contacts with
bipolar affective disorder diagnoses. Age, calendar period, and
psychiatric disorders in parents of the women were treated as
time-dependent variables, whereas the remaining variables were
treated as time-independent variables.17 When comparing in-

cidence rates between 2 groups, the outcome measures were

incidence rate ratios, which can be interpreted as RRs. KaplanMeier plots were made to illustrate the conversion rates to bipolar affective disorders in women having initial psychiatric contact within the first months after delivery, between 2 to 12
months post partum, or at other points.17
The study was approved by the Danish Data Protection
Agency. Informed consent from the women in the cohort was
not required for use of registry data in this type of research.
RESULTS

During 1970 to 2006, 120 378 women had an initial psychiatric contact (admission or outpatient contact) with
any type of psychiatric disorder excluding bipolar affective disorder. A total of 2870 of these women had their
first psychiatric contact within the first year after delivery of their first child. During follow-up, 3062 of the
120 378 women received diagnoses of bipolar affective
disorder at a subsequent psychiatric admission or outpatient contact, of which 132 had their initial psychiatric contact 0 to 12 months post partum (Figure 1).
Women having a first-ever psychiatric contact within
the first month post partum demonstrated an increased
probability of converting to bipolar affective disorder at
a later stage: initial contact 0 to 14 days post partum,
RR=4.26 (95% CI=3.11-5.85) and initial contact 15 to
30 days post partum, RR = 2.65 (95% CI = 1.72-4.07)
(Table 1). This was compared with the reference category, which was women with initial psychiatric contacts at other points excluding the first year after delivery. A total of 47 women specifically received a diagnosis
of mental and behavioral disorders associated with the
puerperium, not elsewhere classified (ICD-8 code 294.49;
ICD-10 code F53.XX). Since these disorders are restricted to an onset within the first 6 weeks post partum, women with these diagnoses will, by necessity, at
subsequent nonpostpartum psychiatric contact receive
an alternative diagnosis. We have therefore conducted
additional analysis (Table 2) excluding the women with
an initial diagnosis of puerperal disorders in which a similar pattern of results were observed.
As discussed earlier, the rates of subsequent conversion to bipolar disorder are likely to differ depending on
the initial diagnosis and it is well established that a family history of bipolar disorder predicts higher rates of bipolar affective disorders in offspring.18 Therefore, we conducted multivariate analyses to adjust for these and other
potential confounders. After taking first diagnoses and
family history of psychiatric illness into account, conversion rates to bipolar disorder were still significantly
predicted by the timing of initial contact. Although reduced compared with the results presented in Table 1,
there was a significantly higher conversion rate to bipolar affective disorder in women having their initial psychiatric contact within the first postpartum month: initial contact 0 to 14 days post partum, RR = 2.53 (95%
CI=1.57-4.07) and initial contact 15 to 30 days post partum, RR = 1.82 (95% CI = 1.07-3.10) (Table 3). Additionally, there is evidence that the severity of the initial
postpartum episode may be important because inpatient admissions were associated with a higher conver-

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ORIGINAL ARTICLE

ONLINE FIRST

Psychiatric Disorders With Postpartum Onset

Possible Early Manifestations of Bipolar Affective Disorders
Trine Munk-Olsen, PhD; Thomas Munk Laursen, PhD; Samantha Meltzer-Brody, MD, MPH;
Preben Bo Mortensen, DrMedSc; Ian Jones, PhD

Context: Childbirth has an important influence on the

onset and course of bipolar affective disorder, and it is
well established that there may be a delay of many years
before receiving a diagnosis of bipolar disorder following an initial episode of psychiatric illness.
Objective: To study to what extent psychiatric disor-

ders with postpartum onset are early manifestations of

an underlying bipolar affective disorder.
Design: Survival analyses were performed in a registerbased cohort study linking information from the Danish Civil Registration System and the Danish Psychiatric Central Register.
Setting: Denmark.
Participants: A total of 120 378 women with a firsttime psychiatric inpatient or outpatient contact with
any type of mental disorder excluding bipolar affective
disorder.
Main Outcome Measures: Each woman was followed up individually from the day of discharge, with
the outcome of interest being an inpatient or outpatient
contact during the follow-up period with a first-time diagnosis of bipolar affective disorder.

Author Affiliations: National

Centre for Register-Based
Research, Aarhus University,
Aarhus, Denmark
(Drs Munk-Olsen, Laursen, and
Mortensen); Department of
Psychiatry, UNC Center for
Womens Mood Disorders,
University of North Carolina at
Chapel Hill (Dr Meltzer-Brody);
and Department of
Psychological Medicine and
Neurology, Medical Research
Council Centre for
Neuropsychiatric Genetics and
Genomics, Cardiff University,
Cardiff, Wales (Dr Jones).

Results: A total of 3062 women were readmitted or

had an outpatient contact with bipolar affective disorder diagnoses. A postpartum onset of symptoms within
0 to 14 days after delivery predicted subsequent conversion to bipolar disorder (relative risk = 4.26; 95% CI =
3.11-5.85). Approximately 14% of women with firsttime psychiatric contacts during the first postpartum
month converted to a bipolar diagnosis within the 15year follow-up period compared with 4% of women
with a first psychiatric contact not related to childbirth.
Postpartum inpatient admissions were also associated
with higher conversion rates to bipolar disorder than
outpatient contacts (relative risk=2.16; 95% CI=1.273.66).
Conclusions: A psychiatric episode in the immediate
postpartum period significantly predicted conversion to
bipolar affective disorder during the follow-up period.
Results indicate that the presentation of mental illness
in the early postpartum period is a marker of possible
underlying bipolarity.

Arch Gen Psychiatry. 2012;69(4):428-434.

Published online December 5, 2011.
doi:10.1001/archgenpsychiatry.2011.157

HILDBIRTH HAS AN IMPORtant influence on the onset and course of bipolar

affective disorder,1 and
studies have shown that
episodes of postpartum psychosis are often best considered as presentations of bipolar affective disorder occurring at a time
of dramatic psychological and physiological change.2 Despite diverse presentations,
the specific link between childbirth and bipolar disorder is well documented in a range
of different studies including populationbased register studies,3 family studies,4,5 and
genetic studies.6
It is also clear, however, that a high number of women presenting with the new on-

ARCH GEN PSYCHIATRY/ VOL 69 (NO. 4), APR 2012

428

set of a psychiatric disorder in the immediate postpartum period do not receive a

diagnosis of bipolar disorder. In a previous
study, we showed that the relative risk (RR)
of having a first-time inpatient psychiatric
admission with bipolar disorder during the
first 30 days post partum was 23.33 (95%
CI, 11.52-47.24).3 However, among the total
of more than 1100 women with first-time
psychiatric admissions 0 to 12 months post
partum, only 44 were diagnosed with bipolar disorder. This may, to some extent,
be due to specific puerperal diagnostic categories being applied to women with bipolar episodes but clearly not all postpartum
cases fall into the bipolar spectrum, and
childbirth may be a trigger for a range of psy-

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15
Other points
31-365 d Post partum
1-30 d Post partum

14
13

13.87%
(95% CI = 10.00-17.58)

12
11
10
9

8
7
6

4.69%
(95% CI = 3.47-5.90)

5
4
4.04%
(95% CI = 3.88-4.21)

3
2
1
0
0

10

11

12

13

14

15

Time Since Discharge, y

Figure 2. Kaplan-Meier curves illustrating conversion rates to diagnoses of bipolar affective disorder during a 15-year follow-up period. CI indicates confidence
interval; Other points, women having their initial psychiatric episode before giving birth to their first live-born child or later than 12 months after giving birth to
their first live-born child; 1-30 d Post partum, women having their initial psychiatric episode within the first 30 days after giving birth to their first live-born child;
and 31-365 d Post partum, women having their initial psychiatric episode from 31 to 365 days after giving birth to their first live-born child.

affective disorder, whereas psychiatric contacts later in

the first postpartum year did not show an increased risk
of conversion.
Severity of Episode
Inpatient admissions in the postpartum period were associated with a higher conversion rate to bipolar disorder than outpatient contacts.
CLINICAL IMPLICATIONS
Despite improvements in reliability over recent decades, the diagnosis of psychiatric disorders, particularly of first episodes, is often unclear and needs to be
revised as the illness develops. Although conversion from
bipolar disorder to another diagnosis may be rare, a conversion to bipolar disorder is more common. The findings of this study present further evidence that the onset of psychiatric illness in the early postpartum period
is of potential diagnostic importance. Postpartum onset
should be added to the list of features in the presentation of depression that raise the likelihood of latent bipolarity. These include early age at onset, the presence
of psychosis, atypical features, and an abrupt onset.19 In
addition, our work demonstrates that an early postpartum onset of illness has prognostic implications and raises
the chance of subsequent conversion to a diagnosis of
bipolar disorder. This does not apply merely to women

with postpartum unipolar depression (RR = 2.88; 95%

CI=1.53-5.43) but also to women with nonaffective psychosis/schizophrenia-like disorders (RR = 2.57; 95%
CI=1.19-5.57) (Table 3).
The results of this study provide further evidence linking childbirth-related episodes and bipolar disorder, building on our previous studies that have demonstrated a
strong and specific link.3-5,20 Despite the strength of this
association, the proportion of new postpartum episodes
receiving a diagnosis of bipolar disorder was relatively
low since many other disorders can have their onset after childbirth. Figure 1 illustrates that 38 women had their
first-ever psychiatric contact with a bipolar diagnosis 0
to 30 days post partum, 27 had initial bipolar contact 31
to 365 days post partum, and 1662 had their initial contact with bipolar disorder at other points. All these women
were excluded from the study, as their first psychiatric
contact was specifically recorded as a diagnosis of bipolar affective disorder. Our results suggest, however, that
at least some of the women receiving other diagnoses following childbirth have an underlying bipolar spectrum
illness and, moreover, that this is considerably more common than for first episodes occurring at other times.
Because of the specific link between childbirth and bipolar affective disorder, it is critically important to conduct a comprehensive assessment of women presenting
in the postpartum period. In particular, the clinician
should pay careful attention to symptoms of hypomania

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or a mixed episode because the misdiagnosis of a bipolar spectrum disorder can have serious consequences. For
example, the prescription of antidepressants is exceedingly common in the treatment of unipolar major depression but can cause or exacerbate manic symptoms
in bipolar spectrum disorders.21 The Mood Disorder Questionnaire was recently shown to be a useful screening instrument for bipolar disorder in the postpartum period, 22 and there are other screening tools (both
semistructured interviews and self-report measures) for
bipolar disorder in general that can be used following
childbirth.23
We speculated that severity of illness could predict conversion to bipolar disorder. For this reason, we studied differences in conversion rates between those women who received treatment at outpatient services vs those requiring
inpatient hospitalizations at their first psychiatric contact.
Interestingly, type of first contact did predict conversion
to bipolar disorder since women having inpatient treatment were more likely to convert than women having outpatient treatment (RR=2.16; 95% CI=1.27-3.66). These
results can most likely be explained by the severity of firstever psychiatric contacts, with inpatient admissions being
markers of more severe episodes vs milder episodes, which
will be treated at outpatient clinics.
IMPLICATIONS FOR CLASSIFICATION
At a time when revisions to the DSM and ICD classification systems are being considered, our findings are very
relevant to the debate about how postpartum disorders
should be treated. Previous work has demonstrated that
a postpartum onset has important prognostic implications; women with an episode in relation to childbirth
are at considerably higher risk of a postpartum recurrence following future pregnancies.24 Our work provides evidence that the relationship of the onset of symptoms to childbirth has diagnostic significance as well. A
postpartum episode of a mood disorder or nonaffective
psychosis is a marker that raises the possibility of both a
current and a subsequent bipolar diagnosis. This study
adds to the evidence for retaining the postpartum onset
specifier for mood disorders in DSM-5, and even expanding its application to psychotic diagnoses.
METHODOLOGICAL CONSIDERATIONS
Using population-based registers for conducting research offers both advantages and limitations. The present study uses data from registers that cover the entire
Danish population where all people have free access to
health care. It included a large study population with low
attrition rates and prospectively recorded information on
exposures and outcomes, minimizing both recall and selection bias. To study diagnostic paths among women with
first-time psychiatric contacts within the postpartum period requires large study populations because severe postpartum mental disorders necessitating admission are rare.3
Long follow-up periods are also needed to fully map conversion rates to bipolar disorder, and population registers are ideal for conducting these types of epidemiologic studies.

The present study has some limitations. First, the episodes studied were psychiatric inpatient and outpatient
contacts, which restricts analyses to only those women
who sought psychiatric care. Consequently, we can make
no comment on less severe episodes of illness in which
patients do not present to psychiatric services. It is possible that women in the postpartum period who have increased contact with health professionals are more likely
to have milder episodes of illness identified and therefore referred to psychiatric services. If, as seems likely,
women with less severe episodes of a mood disorder are
less likely to go on to receive a bipolar diagnosis, we may
have underestimated the true difference in conversion
rates. Second, our study may have underestimated the
true rate of conversion to bipolar spectrum disorders because a number of women may have developed significant bipolar symptoms but did not present to mental
health services. This may account for the lower rates of
conversion to bipolar illness we observed when comparing with studies involving follow-up of participants with
a research interview focused on bipolarity.11 This issue
applies equally across all the groups studied, both those
with a postpartum and a nonpostpartum onset, and it is
the substantial and significant difference between groups
that is the important finding of our study rather than the
absolute conversion rate. Third, in the registers we defined a postpartum contact as the date of psychiatric inpatient or outpatient treatment and the true onset of symptoms is likely to have been before this date. In addition,
some patients may have had a prepartum onset with exacerbation or symptoms after the delivery. Fourth, lifetime conversion rates to bipolar disorder could not be
established since women in the cohort were aged up to
57 years. Furthermore, the classification of specific psychiatric diagnoses was based on clinical diagnoses in the
registry rather than research diagnostic criteria. However, previous validation studies have found high agreement between clinical and research diagnoses.25,26
Last and most importantly, from the available data it
was not possible to study if women with subsequent bipolar diagnoses were misdiagnosed at initial contacts during the postpartum period or developed the disorder during the follow-up period. It is possible that the perinatal
context has important influences on the presentation of
mood and psychotic episodes and those features of severe postpartum psychiatric disorders. Perplexity and a
rapidly changing clinical picture make it more difficult
to make a correct diagnosis of the underlying clinical condition. Alternatively, it is possible that there are no differences in the accuracy of diagnosis in postpartum and
nonpostpartum episodes and that the differences in subsequent conversion rates are real. We are unable to differentiate between these possibilities but whatever the
balance between the two, the main implication for clinical practicethat a postpartum onset should raise the
suspicion of an underlying bipolar disorderwould remain unchanged.
The present study confirms the well-established link
between childbirth and bipolar affective disorder and specifically adds to this field of research by demonstrating
that initial psychiatric contact within the first 30 days post
partum significantly predicted conversion to bipolar af-

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fective disorder during the follow-up period. This was

compared with both women with first psychiatric contact in the later part of the postpartum period and women
with nonpostpartum initial contacts with psychiatric illnesses. The perinatal context of current or previous episodes is an important element to consider in psychiatric
assessment, with both diagnostic and prognostic implications.
Submitted for Publication: May 11, 2011; final revision
received September 5, 2011; accepted October 7, 2011.
Published Online: December 5, 2011. doi:10.1001
/archgenpsychiatry.2011.157
Correspondence: Trine Munk-Olsen, PhD, National Centre for Register-Based Research, Aarhus University, Taasingegade 1, Aarhus, 8000 Denmark (tmo@ncrr.dk).
Author Contributions: Drs Munk-Olsen and Laursen had
full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of
the data analysis.
Financial Disclosure: None reported.
Funding/Support: Dr Munk-Olsen receives financial support from the Danish Medical Research Council (reference number 09-063642/FSS). Drs Laursen and Mortensen
are funded by the Stanley Medical Research Institute. Dr
Meltzer-Brody is funded by National Institutes of Health
grant K23MH85165-3.
Role of the Sponsors: The sponsors had no role in the
design of the study, analysis and interpretation of the data,
or writing of the manuscript.
REFERENCES
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