The Importance of Screening for Bipolar Disorder Before Prescribing Antidepressants in the Perinatal Period
By Julie Paul, DNP, PMHNP-BC, CNM, PMH-C, FACNM, Head of Psychiatric Services at FamilyWell
The perinatal period, encompassing both pregnancy and the first year postpartum, is a critical time to pay special attention to maternal mental health. The American College of Obstetricians and Gynecologists (ACOG) recently updated its guidelines, emphasizing the importance of screening for bipolar disorder before prescribing selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs) during this period. This update is crucial for preventing the misdiagnosis and improper treatment of mood disorders in perinatal individuals, which can lead to significant complications for both the mother and the baby.
The Perinatal Mental Health Challenge
Perinatal depression affects approximately 20% of women, making it one of the most common complications of pregnancy and childbirth (ACOG, 2023). SSRIs and SNRIs are often the first-line treatment for depressive symptoms due to their efficacy and safety profile. However, these medications may not be suitable for all patients, particularly those with undiagnosed bipolar disorder. Misdiagnosing bipolar disorder as unipolar depression and treating it with SSRIs or SNRIs alone can trigger manic or mixed episodes, exacerbating the condition and increasing the risk of harm (Demers et al., 2022).
Understanding Bipolar Disorder in the Perinatal Period
Bipolar disorder, characterized by alternating episodes of mania and depression, can be challenging to diagnose, especially during pregnancy and postpartum when hormonal changes can mimic or mask symptoms. Women with bipolar disorder are at a heightened risk of relapse during the perinatal period, necessitating careful screening and tailored treatment approaches (Demers et al., 2022).
ACOG's Updated Screening Guidelines
ACOG's 2023 guidelines highlight the necessity of comprehensive mental health screening, including specific assessments for bipolar disorder, before initiating SSRI or SNRI treatment. The guidelines recommend using standardized screening tools such as the Mood Disorder Questionnaire (MDQ), in addition to other screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) (ACOG, 2023). These tools help healthcare providers distinguish between unipolar and bipolar depression, ensuring appropriate treatment strategies are employed.
What is the MDQ?
The Mood Disorder Questionnaire (MDQ) is a 15-item self-report screening tool that can be used to identify clients most likely to have bipolar disorder. In fact, it is the most widely used screening instrument for bipolar disorder in the world, and has been translated into 19 languages. The MDQ specifically assists in distinguishing bipolar disorder from other mood disturbances, which is crucial for early detection and treatment. It takes about 5 minutes for a patient to complete.
Best Practices and Benefits of Using the MDQ
Utilizing the Mood Disorder Questionnaire (MDQ) in the perinatal period offers significant benefits for both healthcare providers and patients. Firstly, it improves diagnostic accuracy by tailoring the screening tool to the unique symptoms of bipolar disorder during pregnancy and postpartum, ensuring better differentiation from unipolar depression. This accuracy is crucial for informed treatment decisions, allowing for appropriate medication management that caters specifically to bipolar disorder, and facilitating holistic care planning that addresses the distinct needs of each individual. Furthermore, accurate diagnosis and tailored treatment plans enhance patient outcomes by effectively managing symptoms, improving overall mental health, and reducing relapse rates, thereby promoting sustained mental health throughout the perinatal period (Millan et al., 2023).
The Risks of Inappropriate SSRI Prescription
Prescribing SSRIs and SNRIs to women with undiagnosed bipolar disorder can have severe consequences. SSRIs can induce mania or rapid cycling in bipolar patients, leading to increased morbidity. In the perinatal period, this risk is particularly concerning due to the potential impact on maternal-infant bonding, breastfeeding practices, and overall family dynamics (Demers et al., 2022). Therefore, accurate diagnosis is critical to avoid these adverse outcomes and provide the most effective care.
A Case for Collaborative Care
To enhance the identification and treatment of bipolar disorder, depression, and other perinatal mood and anxiety disorders (PMADs), collaborative care that includes mental health professionals in prenatal and postpartum care teams is essential. A collaborative approach ensures that women and birthing individuals receive comprehensive, individualized treatment plans and perinatal mental health services in a timely manner.
Specifically, the collaborative care model (CoCM) is a proven, evidence-based approach with over 90 randomized control trials establishing its validity across multiple medical specialties, including in obstetrics. This model not only improves outcomes for the birthing person, but also promotes healthier family environments (Demers et al., 2022).
By leveraging the collaborative care model, FamilyWell equips Obstetric providers to integrate perinatal mental health services into their practices – and generate revenue from commercial payers and Medicaid. Learn more here.
Conclusion
The updated ACOG guidelines underscore the importance of screening for bipolar disorder before prescribing SSRIs during the perinatal period. By implementing thorough screening protocols and integrated care models, obstetric providers can prevent the misdiagnosis and inappropriate treatment of mood disorders, ultimately safeguarding the health and wellbeing of both mothers and their infants.
Want more support implementing these new guidelines and integrating perinatal mental health services into your practice? Contact us.
References
Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4:. Obstetrics & Gynecology 141(6):p 1232-1261, June 2023. | DOI: 10.1097/AOG.0000000000005200
Demers, C. J., Walker, R., Rossi, N. M., & Bradford, H. M. (2022). Management of bipolar disorder during the perinatal period. Nursing for Women's Health. https://doi.org/10.1016/j.nwh.2022.11.001
Millan, D. M., Clark, C. T., Sakowicz, A., Grobman, W. A., & Miller, E. S. (2023). Optimization of the Mood Disorder Questionnaire in identification of perinatal bipolar disorder. American Journal of Obstetrics & Gynecology MFM, 5(1), 100777.
