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E- activity 2

REBECCA

Facts of this case-study

34 year old

4 children

3 have been previously removed from her care (9, 7, 6) due to DV and neglect

New baby, Krystal (16 week old female infant)

Hx of domestic abuse with Krystal’s father (Aaron)

Hx domestic abuse with other children’s father

Restraining order against Aaron, no longer in relationship nor allowed contact with Krystal

Family hx of schizophrenia

Rebecca c/o Bi-polar disorder (treated)

Krystal currently on CP plan

Rebecca on edge, unkempt, conversation erratic and giving false information about her whereabouts to professional involved in her care

DNA appointments for baby

Aaron states has been having contact with Rebecca and Krystal

Areas to research

Domestic Violence (in/out of pregnancy)

Bi-polar disorder (in/out of pregnancy)

Puerperal Psychosis

Safeguarding/ Child protection

Impact of infant development mental health/domestic violence (Adverse Childhood experiences-ACE)

Bi-Polar

A mental health disorder where someones mood swings from one extreme to the other. Either depression or mania. Formerly know as manic depression.

Signs and symptoms

MANIA/HYPOMANIA

Decreased need for sleep

Talking excessively

Racing thought

Easily distracted

Physical agitation

Increased sexual desire

Increased risk taking behaviours ie gambling, lavish purchases

Inappropriate behaviour

Irritable

Delusions

DEPRESSIVE EPISODE

Crying for no reason or prolonged periods of sadness

Feelings of guilt or hopelessness

Loss of interest in activities that usually give you pleasure

Extreme fatigue, including the inability to get out of bed

Loss of interest in health, nutrition, or physical appearance

Difficulty concentrating or remembering things

Sleeping excessively or difficulty sleeping

Suicidal thoughts or an impulse to self-harm

Bi-Polar in pregnancy/Postpatum

Pregnant women with a diagnosis of Bi-polar disorder should be under obstetric-led care.

Risks should be discussed about whether to continue or discontinue psychotropic medications… risk to fetus vs benefit to mum.

Evidence-base is lacking for the treatment of Bi-polar in pregnancy.

Psychotrophic drugs are not licensed for use in pregnancy due to the ethical complications of testing on pregnant women/fetus in utero.

Significant increased risk of psychotic episode during the postnatal period. Careful discussion around breast-feeding should be given to forward plan treatment/medications.

Important not to switch medications for breastfeeding. The amount of medication secreted into the breast milk is thought to be less than the utero-placental exposure.

Maintenance treatment is important throughout the pregnancy, as morbidity is increased with the abrupt discontinuation of medication.

There is a need for co-ordinated care/communication within the multidisciplinary team to ensure early recognition and intervention if there is a relapse or psychosis presents (Marsh, W and Viguera, A: 2012)

I found an interactive learning tool for health professionals. Unfortunately it is now out of action but will share when it is working again, but can be found here if you are interested.

https://www.ncmh.info/resources/online-tools/ National Centre for Mental Health (2021)

https://www.nice.org.uk/guidance/CG192 Antenatal and postnatal mental health: clinical management and service guidance (02/2020) NICE

https://www.rcpsych.ac.uk/mental-health/problems-disorders/postpartum-psychosis-in-carers

Domestic Abuse

Research shows that quality of inter-parental relationships and ability to resolve conflict have a substantial influence not only on parental mental well-being but also the long-term life chances for children.There is strong evidence to support the link between healthy couple relationships and improved outcomes for children.

Thoughts

My thoughts are that Rebecca may be having a psychotic episode following the birth. This in turn is leading to her partaking in risky behaviours, as such, being in contact with Aaron and putting herself and the baby at risk. As above, Rebecca is at very high risk of psychosis due her diagnosis of Bi-Polar disorder. I query if she is taking her regular medications.

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Shelley Brough

Rebecca -Activity 1.

Facts and observations –

Rebecca is a 34 year single mother

Has 16 week old daughter-Krystal -Child protection plan in place due to evidence of DV in late pregnancy from the father of the baby- Aaron.

Krystal observed to be meeting milestones

Supported to end the short relationship, restraining order in place, detailing no contact with mum and baby.

3 sons aged 9,7,6 – removed from Rebecca’s care and adopted due to severe DV and neglect

Family history of schizophrenia , diagnosis and treatment for Bi-polar

Professionals involved;

Family support and assessment worker, is aware of family/medical/social history

Health Visitor-telephone contact , weight clinic

Health, social care professionals

GP

Police

Aarons probation officer

Current/ evolving risks

Change in level of engagement with professionals- DNA weight clinic, hasn’t attended GPs for a few months?

Rebecca appears on edge /unsettled, unkempt, conversation jumping from one topic to another

Rebecca unable to explain rational for why she lied re non attendance at clinic

Probation officer states Aaron is having contact with Rebecca

Initial thoughts/issues

Need for integrated MDT response and communication to develop risk assessments and formal management plan. Are Perinatal services involved? Who is co-ordinating ?

Timely exploration /assessment and review of treatment re Bi-polar diagnosis –consider rapid onset of symptoms and associated risks, what are Rebecca’s relapse signatures? Is Rebecca compliant with medication? When was this last reviewed and by whom? Consider impact of stress, sleep deprivation and social isolation, risk of suicidality, risk to baby. What contingency planning is in place?

What is Rebecca’s experience of being parented? Did she experience any childhood adversity? How is she adjusting to motherhood? What support does she need re parenting? Consider bonding and attachment -possible impairments as well as strengths

What safety plans are in place re DV? Is Rebecca having face-to-face contact with Aaron? What does the contact look like, Is there an immediate risk to safety for mum/baby?

Does Rebecca have any family/friends that are supportive?

What is experience (consider through eyes of the child’ ? Safety Triangle, are all of her needs being met?

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Pregnancy can be a worrying time for women with Bipolar Disorder. The risk of experiencing postpartum psychosis (PP) or Postnatal Depression is higher than for women in the general population. In this section we draw together resources that could be useful during pregnancy or when considering pregnancy.

For information about the chances of experiencing PP or PND if you have Bipolar Disorder, see our FAQ Who is most likely to get postpartum psychosis? For advice about factors that could further increase or decrease your own individual risk, see this article written by our team ' The management of Bipolar Disorder in the perinatal period & risk factors for postpartum relapse'. (Copies of any articles written by members of the APP team can be requested from the APP office).

Specialist Advice Before & During Pregnancy

If you have Bipolar Disorder, accessing high quality advice before and during pregnancy is extremely important. Your GP or general psychiatrist should refer you to a specialist Perinatal Psychiatrist. A Perinatal Psychiatrist is someone who is specially trained and experienced in providing advice on the risks of pregnancy, how best to manage them, and on medications that can be used when planning pregnancy, during pregnancy, after having a baby, and whilst breastfeeding.

The care you can expect to receive prior to and during pregnancy is outlined in the NICE Antenatal and Postnatal Mental Health Guidelines. These guidelines were published in 2007 and are currently being revised. The Royal College of Obstetricians and Gynaecologists also published a guide to good practice in 2011.

Your GP or General Psychiatrist may have limited knowledge about best practice care for women with Bipolar Disorder in pregnancy, therefore you might have to guide them through what should happen. These guidelines represent advice on best practice; they are not enforceable in all health authorities. However, if they are not being followed in your local area, being armed with the guidelines provides you with ammunition to argue for a decent standard of care.

Even if you have been well for many years, it makes sense to plan as if an episode of PP will happen. But remember also that many women who have Bipolar Disorder do not become ill postnatally - and some experience only mild mood symptoms. If you are well-prepared and symptoms do occur, the evidence suggests that rapid expert intervention can prevent a full-blown episode from occurring.

Useful Resources

APP can offer you a variety of support and information during this time. Follow these links to written information, academic articles, personal stories, video resources and find out about ways you can talk to other women who have faced similar issues.

APP has produced a Bipolar Disorder, Pregnancy & Childbirth Guide, written in conjunction with the National Centre for Mental Health & the national charity, Bipolar UK. The guide contains information for women, partners & families & covers issues such as the importance of obtaining expert referral before and during pregnancy; decisions about taking medication; postnatal care plans; looking after yourself and managing your risk of illness.

We have also produced an Insider Guide about planning pregnancy for anyone at high risk of postpartum psychosis.

For information about recovery following a postnatal episode see our Insider Guide to Recovery.

You can watch our Pregnancy and Bipolar Disorder Podcast and Module produced in conjunction with Cardiff University.

APP Trustee and Chair of Bipolar UK, Clare Dolman, has written a personal account of her attempt to avoid having a second episode of PP, which is available here". The article details useful tips on staying well - such as reducing stress, managing sleep, limiting activities, paying attention to illness triggers, developing support networks and making the most of friends and family. In addition there are ideas for your personal care plan, such as asking for a postnatal room separated from other mothers and babies to help you get rest and sleep in the early postpartum period.

APP's peer support forum, , is a fantastic place for asking questions and getting support from other women who have faced similar situations. You can talk to other women about issues such as: what their care plans included; their experiences with medication; how they managed their anxieties during pregnancy; their experiences in the postpartum; and more. Here is a thread that has already been started that might be useful, 'what can one do to prevent the onset of PP in the first place?'

APP has produced an Insider Guide to postpartum psychosis for Partners, which includes information about the early warning signs of postpartum psychosis, and what to do should symptoms develop. An article about early symptoms is available from the APP office and here you can find information on Early Symptoms of postpartum psychosis.

On the positive side, a previous experience of Bipolar Disorder is likely to mean that you and your family are better equipped to identify early warning signs than those who develop PP 'out of the blue'. Clare Dolman writes about this aspect of PP in her piece 'Finding a Silver Lining'.

The help available in your area

NHS Services

Most Mother & Baby Units (MBU's) offer specialist preconception counseling for women with a Bipolar Disorder diagnosis for those who are thinking about having a baby. You can link to a map of the locations of UK Mother & Baby Units here".

Areas of the country without MBU's sometimes have specialist perinatal teams or individual Perinatal Psychiatrists. If your local GP or General Psychiatrist cannot locate one for you, you could post on our forum to ask one of APP's volunteer Regional Representatives for advice about what might be available locally. Alternatively the Royal College of Psychiatrists can provide information about where specialist Perinatal Psychiatrists are located. APP hosts the Maternal Mental Health Alliance (MMHA) which is an organization campaigning to end the current postcode lottery in maternal mental health services.

Expert Referral

If you are unable to gain specialist referral in your area, and you can get to Cardiff University, your GP or Psychiatrist can refer you for an appointment with APP's Chair, Professor Ian Jones. Ian is a Consultant Psychiatrist and an expert in the management of Bipolar Disorder in pregnancy and the postpartum period. He is able to offer preconception advice, medication review, and second opinion from his Cardiff University clinic. The service is free to you and free to your local health authority, but you will need a referral letter from your GP/mental health team. Further information about this service is available here".

Interviews with APP about PP

In this video Clare Dolman, Vice Chair, Bipolar UK and APP Trustee discusses the specific issues around pregnancy and childbirth for women with Bipolar Disorder.

Please get in touch with us via email, our forum, or Facebook for more information or to tell us your story.

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Pregnancy can be a worrying time for women with Bipolar Disorder. The risk of experiencing postpartum psychosis (PP) or Postnatal Depression is higher than for women in the general population. In this section we draw together resources that could be useful during pregnancy or when considering pregnancy.

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There are several variables in this case, presuming the reported contact Rebecca is having with Aaron is accurate there may be a reoccurrence of DA.
We know that Rebecca is extremely high risk for a relapse of bi-polar in the perinatal period including psychosis.
A recent article from Katie Hazelgrove 2021 considers the role of the immune response post partum and a potential link with psychosis for those with risks such as Bi-polar, Schizophrenia or previous psychosis this is increased.

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Abstract

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. The risk is particularly high for women with a history of bipolar disorder or schizoaffective disorder, or those who have suffered a previous episode of postpartum psychosis. However, the aetiology of the illness remains unclear. Pregnancy and the early postpartum are times of significant immunological change. Furthermore, alterations to the immune system have been implicated in the onset and course of various psychopathologies, both related and unrelated to childbirth. Emerging evidence, from studies on immune related disorders, immune cells and inflammatory markers, suggests that the immune system might also be involved in the pathophysiology of postpartum psychosis. Furthermore, recent research has also begun to explore the potential mechanisms underlying immune dysfunction in postpartum psychosis (e.g., disturbances in the Treg-CCN3 protein-(re)myelination axis). Nevertheless, more research is required to understand whether immune dysfunction is a cause or consequence of postpartum psychosis and to clarify the exact mechanisms involved. The aim of this short review is to present the current findings on immune system dysregulation in postpartum psychosis, discuss possible mechanisms underlying the association, highlight potential challenges and confounders and provide suggestions for future research.

Keywords: Postpartum psychosis, Immune system, Inflammation, Biomarkers, Perinatal period

1. Background

Postpartum, or puerperal, psychosis (PP) is the most severe psychiatric disorder associated with childbirth ( Meltzer-Brody et al., 2018; Jones et al., 2014). Symptoms can begin within days of the delivery and develop rapidly ( Heron et al., 2007, 2008), they can include both mania and depression, commonly in the form of fluctuating mood ( Jones, 2012; Oates, 2009), hallucinations, which can be present in all sensory modalities, and delusions, which are commonly of reference, persecution or grandiosity ( Spinelli, 2009; Paschetta et al., 2014). Many women with PP will also show signs of confusion and perplexity ( Jones et al., 2014; Rai et al., 2015).

PP is relatively rare, occurring in 1-2 per 1000 deliveries in the general population ( Jones, 2012). However, the risk is greatly increased for women with a diagnosis of bipolar disorder, schizoaffective disorder or a personal or family history of PP, with up to 50% experiencing an episode after giving birth ( Dean et al., 1989; Doyle et al., 2012; Jones and Craddock, 2001; Wesseloo et al., 2016; Di Florio et al., 2013b).

Despite the severity of PP, knowing that it has a clearly defined onset following childbirth and that women with certain pre-existing diagnoses are at increased risk, the exact causes of the illness remain unknown. Emerging evidence suggests the immune system might play a role. The aim of this short review is to discuss the current findings on immune dysregulation in PP.

2. The immune system and the perinatal period

Pregnancy and childbirth are times of dramatic immunological change. Indeed, it has been suggested that pregnancy represents a unique period of immunomodulation, characterised by increased recognition, communication, trafficking and repair ( Mor et al., 2011; Racicot et al., 2014). This unique and highly dynamic immune response is essential for establishing and maintaining pregnancy, with the maternal immune system promoting tolerance towards the semi-allogenic foetus, whilst also providing protection from pathogens. To achieve this, it has been proposed that pregnancy involves three distinct immune stages, characterised by both pro- and anti-inflammatory states ( Mor et al., 2011; Racicot et al., 2014). The first stage is necessary for successful implantation and placentation. Immune cells, including natural killer (NK) cells, dendritic cells and macrophages, infiltrate the decidua and surround the invading trophoblasts. However, rather than rejecting the blastocyst, these immune cells instead play a supportive role, repairing and restructuring uterine tissue ( Mor et al., 2011, 2017; Maguire et al., 2020; Leff-Gelman et al., 2016; Sherer et al., 2018). The first and early second trimester of pregnancy are, therefore, characterised by a T helper (Th) 1-type proinflammatory response, necessary to repair damaged tissue and remove cell debris ( Mor et al., 2011, 2017; Maguire et al., 2020; Dutta and Sengupta, 2017). Following successful implantation and placentation, there is a period of rapid foetal growth and development, which lasts from pregnancy weeks 13-27 ( Mor et al., 2011, 2017). In order to maintain pregnancy, and prevent miscarriage or preterm birth during this phase, there is a switch from the Th1 proinflammatory environment to a predominantly Th2-type anti-inflammatory state ( Mor et al., 2011, 2017). In addition to promoting immune tolerance towards the foetus, anti-inflammatory responses in this stage also promote uterine growth and foetal development ( Mor et al., 2017; Sherer et al., 2018; Dutta and Sengupta, 2017). Thus, the second immunological stage provides a supportive immune environment in which symbiosis is established between maternal and foetal physiology ( Mor et al., 2011, 2017; Maguire et al., 2020; Dutta and Sengupta, 2017). Once foetal development is complete, the final immunological stage of pregnancy occurs in preparation for the delivery. Following the onset of labour, immune cells migrate into the myometrium resulting in a shift back to a proinflammatory state. This proinflammatory milieu promotes uterine contractions and the subsequent expulsion of the baby and placenta ( Mor et al., 2011, 2017; Maguire et al., 2020). Finally, pre-pregnancy immune function is not thought to return for up to several months post-delivery ( Groer et al., 2015).

Whilst essential for the pregnancy and for foetal development, it is suggested that these changes in immune physiology during the perinatal period can contribute to maternal perinatal psychopathology, particularly in women with an existing vulnerability ( Yim et al., 2015). Research has indeed shown immune system dysregulation in women with perinatal depression. For example, our group recently showed elevated immune markers (Interleukin (IL)-6, IL-10, Tumor Necrosis Factor (TNF)-α and Vascular Endothelial Growth Factor) in pregnant women with a diagnosis of major depressive disorder, compared with healthy pregnant controls ( Osborne et al., 2018). Furthermore, there is some evidence to suggest that a heightened proinflammatory response, including increased IL-6, IL-1β and TNF-α, is associated with postnatal depressive symptoms ( Maes et al., 2000; Boufidou et al., 2009; Corwin et al., 2008; Liu et al., 2016).

3. The immune system and PP

3.1. Immune-related disorders and PP

Emerging evidence for the role of the immune system in PP has come from studies examining immune-related disorders in women with PP. In an observational study of primiparous women, Bergink and colleagues examined the association between autoimmune thyroid dysfunction and first-onset PP ( Bergink et al., 2011a). The authors found that autoimmune thyroid disease (AITD) was more prevalent in women with first-onset PP than postpartum women from the general population, at both 4 weeks' (prior to initiation of antipsychotic and mood stabiliser treatment) and 9 months' postpartum. Furthermore, the authors reported a faster and greater progression to clinical thyroid dysfunction in women with PP and AITD, when compared with the postpartum control group ( Bergink et al., 2011a).

These findings are consistent with an earlier case report, which documented the simultaneous onset of postpartum thyroiditis and PP in a 29-year-old woman with no past history of psychiatric or general medical disorders ( Bokhari et al., 1998). Simiarly, a previous study of thyrotoxicosis and hypothyroidism in postpartum women found evidence of PP-like symptoms in the women with postpartum thyroid dysfunction. The authors reported that the psychotic symptoms improved when the women became euthyroid again ( Amino et al., 1982).

More recently a nationwide register-based cohort study examined the bidirectional association between first-onset AITDs and first-onset psychiatric disorders, including PP ( Bergink et al., 2018). The study found that, after adjustment for covariates, women with first-onset postpartum AITDs were at increased risk of experiencing a first-onset psychiatric disorder compared with those who did not have postpartum AITDs and vice versa (i.e., first-onset postpartum psychiatric disorders were associated with an increased risk of AITDs). Furthermore, high comorbidity was found between first-onset AITDs and psychiatric disorders in the postpartum period ( Bergink et al., 2018). Given the autoimmune aetiology of AITD, these findings provide evidence to support the hypothesis that immune dysfunction plays a role in the pathophysiology of PP.

Simiarly, in another population-based cohort study, Bergink and colleagues examined whether pre-eclampsia, considered a disease of immunological maternal-foetal incompatibility, is a risk factor for postpartum psychiatric episodes ( Bergink et al., 2015). The study found that pre-eclampsia increased the risk of a psychiatric episode, including PP, in primiparous women without a psychiatric history. This is in line with earlier findings by Bergink and colleagues, who reported a higher incidence of pre-eclampsia during pregnancy in women who subsequently developed an episode of PP compared with postpartum controls ( Bergink et al., 2011b). However, a more recent population-based cohort study, examining the association between pregnancy and obstetric-related complications and risk for different types of first-onset postpartum psychiatric disorders, found no association between pre-eclampsia and PP ( Meltzer-Brody et al., 2017). Given these mixed findings, additional research is needed to confirm whether pre-eclampsia increases the risk of PP.

3.2. Immune cells and PP

Evidence of immune system dysregulation in PP also comes from studies examining the status of various immune cells. For example, Bergink and colleagues carried out a comprehensive analysis of immune cells in women with first-onset PP compared with healthy postpartum and non-postpartum women ( Bergink et al., 2013). They found that, compared with non-postpartum controls, postpartum controls showed elevated T cells, present across various T cell subsets (including Th1, Th17 and natural Regulatory T cells (Tregs)). On the other hand, women with PP did not show this typical postpartum increase in T cells, but instead had significantly lower T cells (both total T and Th1 cells) compared with healthy postpartum women ( Bergink et al., 2013). More recently, examining subpopulations of T cells, Kumar and colleagues found that women with PP had lower naïve CD4 and CD8 cells, but higher activated CD8 and memory Tregs, compared with healthy postpartum women ( Kumar et al., 2017). Taken together, these findings suggest that increases in T cells are part of normal immune function during the postpartum period and the inability of women with PP to show these typical postpartum increases appears to emphasise the role of various T cell subsets in the pathophysiology of the disorder.

Monocyte levels have also been found to be altered in women with PP. Indeed, Bergink and colleagues found increases in total monocyte levels, as well as upregulation of monocyte gene expression, in the women with first-onset PP, compared with both healthy postpartum and non-postpartum women ( Bergink et al., 2013). Kumar and colleagues on the other hand examined subtypes of monocytes and found that women with PP showed a decline in non-classical monocytes compared with healthy postpartum women ( Kumar et al., 2017). Further evidence for the relevance of monocyte alterations in PP comes from research showing downregulation of microRNA (miR)-146a and miR-212 expression in the monocytes of women with PP. Interestingly, miR-146a expression was decreased in the monocytes of women with first-onset PP, while miR-212 was decreased in the monocytes of women with PP and a history of bipolar disorder, possibly signifying an inherent difference between episodes of PP limited to the postpartum period and those occurring in the context of a diagnosis of bipolar disorder ( Weigelt et al., 2013). Weigelt and colleagues also found that downregulation of miR-146a expression in monocytes was associated with reduced natural Tregs in women with PP ( Weigelt et al., 2013), which further fits with the findings of a reduction in T cells in women with PP (e.g., Bergink et al., 2013; Kumar et al., 2017).

As well as altered T cell and monocyte levels, Kumar and colleagues found that, compared with healthy postpartum women, women with PP showed alterations in NK cells ( Kumar et al., 2017). The authors reported a marked decrease in cytotoxic NK cells, which they propose is suggestive of a possible defect in normal postpartum immune restoration. They also found a significant increase in regulatory NK cells, which are thought to be involved in NK cell cytotoxicity suppression during the postpartum period ( Kumar et al., 2017). Finally, dendritic cells have also been implicated in PP. Kumar and colleagues found a reduction in myeloid dendritic cells in women with PP when compared with healthy postpartum women ( Kumar et al., 2017). Taken together the findings suggest PP is characterised by immune dysregulation, involving both pro- and anti-inflammatory processes.

3.3. Inflammatory markers and PP

More recently, research has also examined levels of inflammatory markers (e.g., cytokines) in PP. Indeed, Sathyanarayanan and colleagues investigated cytokine and chemokine changes in women with first-onset PP compared with healthy postpartum and non-postpartum women ( Sathyanarayanan et al., 2019). Interestingly, IL-6 was found to be elevated in both the women with PP and the healthy postpartum women, compared with those in the non-postpartum group. The authors propose that this could indicate that increased IL-6 is part of a normal postpartum biological response. In line with this finding, our own research group found no difference in levels of IL-6 between women with PP, those at risk (because of a diagnosis of bipolar disorder, schizoaffective disorder or a history of PP) who were well in the postpartum period and healthy postpartum controls ( Aas et al., 2020), supporting the idea that IL-6 does not represent a pathophysiological marker for PP.

On the other hand, Sathyanarayanan and colleagues found elevated levels of IL-8 in women with PP, compared with healthy postpartum women ( Sathyanarayanan et al., 2019). Furthermore, the authors found that healthy postpartum women had similar levels of IL-8 to those in the non-postpartum control group, suggesting that IL-8 might be a characteristic of immune system dysfunction in PP ( Sathyanarayanan et al., 2019). Additionally, our research group found that women with PP had increased high sensitivity (hs) CRP (a more precise measure, which can detect lower levels of CRP) when compared with healthy postpartum women. Interestingly, we found that women at risk of PP who were well in the postpartum period had hsCRP levels that were intermediate between those of women with PP and healthy postpartum women, suggesting that hsCRP might represent a trait marker for severe postpartum mental illness, which is then exacerbated in those women who become unwell after giving birth ( Aas et al., 2020). Of note, a recent systematic review and meta-analysis of 21 studies found that elevated CRP was associated with increased risk of suicidality, and particularly suicidal ideation, in individuals with psychiatric disorders, including those with affective and non-affective psychoses ( Miola et al., 2021). This is particularly relevant given that PP is associated with an increased risk of suicide, which remains one of the leading causes of maternal death ( Jones et al., 2014).

In addition to IL-8 and hsCRP, previous research has reported increased expression of Monocyte Chemoattractant Protein (MCP)-1 levels in women with first-onset PP, compared with both healthy postpartum and non-postpartum women ( Bergink et al., 2013), suggesting that MCP-1 might also be a marker of immune dysregulation in the illness. However, this finding was not replicated in subsequent studies ( Sathyanarayanan et al., 2019; Aas et al., 2020). Given this inconsistency in findings, the association between MCP-1 and PP requires further investigation.

provides an overview of the three immune molecules found to be associated with PP (i.e., IL-8, CRP and MCP-1), including an outline of their function and associations with other psychiatric disorders, both related and unrelated to gestation.

4. Immune system dysregulation as a predictor of PP

The above research provides support for the hypothesis that PP is associated with immune dysfunction. However, the majority of studies conducted to date have used cross-sectional designs, which cannot determine the direction of the association, i.e., whether immune system alterations are a cause or a consequence of PP. Longitudinal studies, which can disentangle directionality, are therefore needed to address the question of cause and effect in the association between immune system dysfunction and PP. Establishing whether immune dysfunction is present prior to illness onset could help predict which women are most likely to become unwell in the postpartum period.

Our research group recently attempted to investigate this in a prospective longitudinal study of women at risk of PP (because of a diagnosis of bipolar disorder, schizoaffective disorder and/or a previous history of PP). Women were recruited in pregnancy and followed-up to 4 weeks' postpartum, in order to ascertain who did and did not have a psychiatric relapse in the postpartum period. Immune markers were assessed in the 3rd trimester of pregnancy ( Hazelgrove et al., 2021) (also discussed in Hazelgrove (2021)). Contrary to what we expected, women at risk of PP who went on to have a psychiatric relapse in the first 4 weeks' postpartum did not differ from the women at risk who remained well in the postpartum period in their levels of antenatal inflammatory markers (including, IL-1β, IL-6, IL-8, TNFα or hsCRP). In fact, we found that both at-risk groups had similar mean cytokine levels as healthy pregnant women. This finding is perhaps surprising given the accumulating evidence of immune alterations in women with PP. Given that previous research has been conducted in women who had already developed an episode of PP, one possible explanation is that while immune system dysregulation might be a characteristic of PP, it is not necessarily present prior to illness onset. It is, however, important to note that we used a broader definition of PP (i.e., psychiatric relapse), which captured relapse of all affective symptoms in the immediate postpartum (including depressive symptoms). It is, therefore, possible that immune dysfunction, while not a marker for more broadly defined postpartum episodes in women at risk of PP, could be predictive of full-blown PP. However, given that PP is a polymorphic clinical entity, characterised by various symptoms, including depression and mania, it is possible that we would not have found differences even if full-blown PP had been assessed. Whilst it was not possible to explore this in our research, it warrants further investigation.

Interestingly, we did find that MCP-1 levels in the third trimester of pregnancy were lower in women at risk of PP who relapsed following delivery, compared with women at risk who remained well. Although only reaching a trend for significance, this might suggest that MCP-1 has a 'protective' effect on the risk of postpartum relapse in women at risk of PP. This would appear to contradict previous findings of increased MCP-1 in women with PP ( Bergink et al., 2013). This could be because we measured MCP-1 levels during pregnancy before illness onset, whereas Bergink and colleagues assessed women in the postpartum period during an acute illness state ( Bergink et al., 2013). However, as discussed, other studies have not found altered MCP-1 in women with PP ( Sathyanarayanan et al., 2019; Aas et al., 2020). On the other hand, our findings are in line with the literature on treatment-resistant depression, which found depressed patients who did not respond to pharmacological treatment had lower levels of MCP-1 at baseline than responsive patients ( Carvalho et al., 2013). However, given that MCP-1 was the only inflammatory marker to differ between the women at risk who relapsed and those who remained well, and that the difference only reached a trend for significance, it is important to interpret the finding with caution. Additional research in larger samples is recommended to gain a better understanding of the role of MCP-1 in the development of PP.

5. Mechanisms underlying the association between immune system dysregulation and PP

It has been suggested that immune system dysregulation could play a role in the onset of psychotic disorders via both direct pathways (e.g., autoimmunity or infection) and more complex, immune-mediated, pathways (for review see Bergink et al. (2014)). While the exact mechanisms underlying the association between immune dysregulation and PP remain unclear, one hypothesis recently proposed by members of our group is that immune system involvement in PP may occur through immune system-mediated myelination processes, namely disturbances in the Treg-CCN3 protein-(re)myelination axis ( Dazzan et al., 2018). Specifically, the authors propose that women at risk of PP are more likely than healthy women to show disturbances in Treg activity and/or abundance, which in turn could be associated with altered CCN3 protein expression and subsequently with reduced (re)myelination in cortical and limbic brain regions ( Dazzan et al., 2018).

The exact mechanisms by which peripheral disturbances in Treg activity and/or abundance lead to altered CCN3 expression, and by which CCN3 expression might influence (re)myelination processes, remain unclear. Dazzan and colleagues suggest that it could be possible for Tregs to enter the brain through permeabilization of the blood-brain barrier, possibly facilitated by increased expression of MCP-1 ( Dazzan et al., 2018), which enhances blood-brain barrier permeability ( Yadav et al., 2010; Yao and Tsirka, 2014). Indeed, immune dysfunction has been found to be associated with blood-brain barrier compromise, leading to an influx of unwanted immune cells and inflammatory molecules into the brain ( Lee and Giuliani, 2019; Huang et al., 2021). Nevertheless, additional research is needed to confirm whether disturbances in the Treg-CCN3-(re)myelination axis play a role in the aetiology of PP and, if so, the precise mechanisms underlying these processes.

6. Potential challenges and confounders

It is of course important to consider the findings outlined above considering the potential challenges and confounders associated with studying the immune system in postpartum women, and particularly those affected by psychiatric illness.

Firstly, given that there are changes to the immune system over the postpartum period, with 'normal' non-pregnant immune state thought to return around 3-4 months' post-delivery ( Groer et al., 2015), the time (i.e., number of days/weeks/months) postpartum at which immune function is assessed could influence findings. Several of the studies discussed above have reported between group differences in number of weeks after delivery at the time of assessment. For example, in the study by Sathyanarayanan and colleagues, women with PP were recruited up to 6 weeks' postpartum, whilst healthy postpartum women were recruited up to 12 weeks' postpartum ( Sathyanarayanan et al., 2019). There was also a difference in time post-delivery in our recent research by Aas and colleagues, with women with PP assessed significantly later than healthy women or those at risk of PP ( Aas et al., 2020). However, after controlling for number of weeks post-delivery Aas and colleagues found that women with PP continued to have increased hsCRP compared with healthy postpartum women, suggesting that time post-delivery could not fully explain the immune findings (i.e., elevated hsCRP in women with PP) ( Aas et al., 2020). Nevertheless, it is important for future studies examining immune function in PP to consider the possible influence of time post-delivery.

It is also important to consider breastfeeding status, which is thought to influence immune function. For example, a study by Groer and colleagues found a heightened immune activation in postpartum women, which was further enhanced in those who exclusively breastfed ( Groer et al., 2005), whilst a study by Ahn and Corwin found lower levels of IL-6 at 6 months' postpartum in women who were primarily breastfeeding, compared with those who primarily bottle fed ( Ahn and Corwin, 2015). Furthermore, exclusive breastfeeding might be more likely in healthy postpartum women than those with PP. Indeed, in their study of immune system function in PP, Bergink and colleagues found that postpartum controls were significantly more likely to breastfeed than women with PP ( Bergink et al., 2013). Simiarly, the studies by Kumar and colleagues and, more recently, Sathyanarayanan and colleagues reported that whilst all women in the healthy postpartum group exclusively breastfed, those in the PP group gave a mixture of breast- and formula-feeding ( Kumar et al., 2017; Sathyanarayanan et al., 2019). However, despite these differences in breastfeeding status, Bergink and colleagues found no association between breastfeeding and T cell or monocyte activation in their study ( Bergink et al., 2013). Nevertheless, most studies of immune function in PP do not appear to have examined the relationship between breastfeeding and immune function. Thus, it is not possible to rule out the influence of breastfeeding on immune status in PP.

Another perinatal-specific factor shown to be associated with immune function is mode of delivery. Indeed, Bergink and colleagues found women with PP who had a cesarean section had increased MCP-1 levels, whilst healthy postpartum women who had a cesarean section had elevated percentages of Th1 and Th2 helper cells, compared with those who had a vaginal delivery ( Bergink et al., 2013). The authors also reported group differences in mode of delivery, with healthy postpartum women being more likely to have had a cesarean section than those with PP ( Bergink et al., 2013). Interestingly, the studies by Kumar and colleagues and Sathyanarayanan and colleagues found that a higher percentage of women with PP had a cesarean section (25% of women with PP, compared with 5% of healthy postpartum women) ( Kumar et al., 2017; Sathyanarayanan et al., 2019). Future studies in PP should, therefore, control of the effects of mode of delivery on immune function.

Finally, research has shown psychotropic medication to have an impact on immune function, including evidence of both pro- and anti-inflammatory effects of various psychotropic treatments ( Baumeister et al., 2016). Despite this, not all studies investigating the immune system in PP have controlled for psychotropic medication use, potentially limiting the interpretation of the findings. Of the two studies that did consider medication use, neither found it to be associated with altered immune measures ( Bergink et al., 2013; Aas et al., 2020). However, one of the studies reported that most women with PP had only been taking medication for a few days at the time of the assessment ( Bergink et al., 2013), making it difficult to draw firm conclusions about the impact of longer-term medication use on immune function in PP.

7. Conclusion and future directions

There is growing evidence to suggest that immune dysfunction is a core feature of PP. However, the research to date provides little evidence to suggest that these alterations in immune function are present prior to the onset of PP and, therefore, predictive of the illness, particularly in women at risk. Nevertheless, the majority of studies have examined immune function in women with PP, thus more research in large prospective samples is needed to understand whether immune dysfunction represents a biological marker for PP. On the other hand, there is evidence to suggest that episodes of PP limited to the postpartum period might be biologically distinct from those occurring in the context of bipolar disorder (e.g., Weigelt et al., 2013). This could provide information relevant to the diagnosis and treatment of PP and, therefore, merits further investigation. Finally, hypotheses around the potential mechanisms linking immune dysfunction to PP have also been proposed (e.g., disturbances in the Treg-CCN3 protein-(re)myelination axis ( Dazzan et al., 2018)). However, more research is required to clarify the precise mechanistic processes involved. Ultimately, understanding the biological underpinnings of PP has important implications for both potential treatments (e.g., the ability to develop targeted treatments) and early identification of those most at risk (e.g., closer monitoring of primiparous women who experience pre-eclampsia or AITD).

Funding

This work was supported by the UK Medical Research Foundation [grant number C0439]. The research was also in part supported by the UK Medical Research Council [grant number MR/s003444/1, e-BRAIN Study] and the UK National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London. The funding sources played no role in writing the article or in the decision to submit the article for publication.

Declaration of competing interest

The author declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Biography

Dr. Katie Hazelgrove is a postdoctoral research associate in the Section of Perinatal Psychiatry in the Stress, Psychiatry and Immunology (SPI)-Lab, at the Institute of Psychiatry, Psychology and Neuroscience, King's College London. She received her PhD from the Institute of Psychiatry, Psychology and Neuroscience in 2018. Her thesis, entitled 'The Neurobiology of Postpartum Psychosis: Maternal Stress and its Effect on the Infant', examined the role of maternal psychobiological stress on maternal and infant outcomes in women at increased risk of postpartum psychosis. Since completing her PhD, she has been involved in a longitudinal research study investigating the effects of antenatal depression on stress reactivity, behaviour and development in children aged 6-8 years and a clinical trial examining the effectiveness of music therapy for postpartum depression. She is also currently working on a follow-up to her PhD research, which aims to explore the potential longer-term impact of postpartum psychosis on maternal and child outcomes. Through her research she hopes to help advance knowledge and understanding of the risk and resilience factors for severe maternal perinatal mental illnesses.

References

Aas M., Vecchio C., Pauls A., Mehta M., Williams S., Hazelgrove K. Biological stress response in women at risk of postpartum psychosis: the role of life events and inflammation. Psychoneuroendocrinology. 2020;113 doi: 10.1016/j.psyneuen.2019.104558. [[PubMed] [CrossRef] Google Scholar]

Hazelgrove K. Postpartum psychosis: does stress play a role in relapse? [Internet]. 2021 [cited 2020 May 21] https://www.inspirethemind.org/blog/postpartum-psychosis-does-stress-play-a-role-in-relapse Available from:

Hazelgrove K., Biaggi A., Waites F., Fuste M., Osborne S., Conroy S. Risk factors for postpartum relapse in women at risk of postpartum psychosis: the role of psychosocial stress and the biological stress system. Psychoneuroendocrinology. 2021;128 doi: 10.1016/j.psyneuen.2021.105218. [[PubMed] [CrossRef] Google Scholar]

Knight M., Bunch K., Tuffnell D., Jayakody H., Shakespeare J., Kotnis R. National Perinatal Epidemiology Unit; Oxford: 2018. MBRRACE - UK Report: Saving Lives, Improving Mothers' Care, 2014-16. [Google Scholar]

Maguire J., McCormack C., Mitchell A., Monk C. In: Handbook of Clinical Neurology. Steegers E.A.P., Cipolla M.J., Mille E.C., editors. 2020. Neurobiology of maternal mental illness; pp. 97-116. [Google Scholar]

Miola A., Dal Porto V., Tadmor T., Croatto G., Scocco P., Manchia M. Increased C-reactive protein concentration and suicidal behavior in people with psychiatric disorders: a systematic review and meta-analysis. Acta Psychiatr. Scand. 2021 doi: 10.1111/acps.13351. Advance online publication. [[PubMed] [CrossRef] Google Scholar]

Pereira A.C., Oliveira J., Silva S., Madeira N., Pereira C.M.F., Cruz M.T. Inflammation in bipolar disorder (BD): identification of new therapeutic targets. Pharmacol. Res. 2021;163 doi: 10.1016/j.phrs.2020.105325. [[PubMed] [CrossRef] Google Scholar]

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The role of the immune system in postpartum psychosis

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Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. The risk is particularly high for women with a history of bipolar disorder or schizoaffective disorder, or those who have suffered a previous episode of postpartum psychosis. However, the aetiology of the illness remains unclear.

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https://www.app-network.org/what-is-pp/getting-help/bipolar-disorder-pregnancy/finding-a-silver-lining/

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As someone who has had many conversations with women who have had a postpartum psychosis - some of whom, like me, already had a diagnosis of bipolar disorder - I can say that the experience is very different in one very important respect.

If - as a woman with no previous history of mental illness - you have a postpartum psychosis (PP), the effect is devastating. It is a bolt from the blue: none of the books about childbirth on 'getting to know your baby in those first few magical months' and 'how to be a Supermum' gave you the slightest inkling that your baby might instill nothing but fear in you; or that you might be spending those early weeks in a psychiatric hospital.

As APP's research study on PP support needs illustrated, women for whom it was their first experience of mental illness "felt overwhelmed by the psychological enormity of the event" (Heron et al. 2012). If, on the other hand, you approach childbirth as a woman with bipolar disorder, you possess a distinct advantage: something similar to this has happened to you before.

Even if you are unlucky enough to be unaware of the much higher risk of PP for women with Bipolar, when it starts to happen to you in the days after the birth you won't wonder 'What on earth is happening to me?' You'll probably think 'Am I having a bipolar episode - this is a bit like being high (talking too much and staying up all night) and a bit like being low (feeling anxious and irritable and maybe paranoid)? Or if you are too ill to have insight into your condition, your partner or family may recognize aspects of behavior they have seen before - and know that you need psychiatric help.

That is what happened to me and when I was told after a week that I needed to go into hospital, I was obviously sad and perhaps worried, but -overwhelmingly - I remember feeling relieved. Relieved that I would at last be able to sleep and not feel responsible for my baby and anxious that I wasn't up to caring for her properly (I was fortunate to know she would be very well looked after at home).

Better still, if you have a treatment plan in place, you and those around you will know exactly what to do and what your wishes are. Being well-prepared is the best way of ensuring you stay calm in the run-up to the birth: hopefully it will help prevent you from getting ill and, if not, at least you can feel reassured that the professionals around you will know how to act quickly.

So although it is daunting for women with this condition to face all the decisions and potential risks of having children, one advantage we have is that we do not usually have to face the additional huge psychological burden of coming to terms with having a mental illness (and at such a vulnerable time) and all the stigma that brings with it. Most of us faced up to that challenge to our sense of self when we were first diagnosed with bipolar disorder and accepted that we needed the help of medication to control our moods, probably a few years before.

When I met with a group of APP members all of whom had been free of mental health issues before childbirth, it struck me how lucky I was to already have dealt with the shock of being looked at as no longer 'normal' but someone who was mentally ill. I had already had time to come to terms with the affront to my sense of self, the assault on my self-confidence and the injustice of being branded in some way a lesser human being (I'm in no way saying I accepted this description, just that it takes time to rise above society's stigmatizing attitudes). They, on the other hand, were completely traumatized by 'being seen as a mental patient' and adjusting to the idea that not only were they not 'the perfect mum' they'd intended to be, but they were now part of that marginalized and often ostracized group of 'people who have been in a psychiatric hospital' (no longer able to sit on a jury and - in my case - despised at NCT meetings for not breastfeeding).

Obviously mental health discrimination is something that we are all trying to fight against, especially at APP, but it would be foolish at this point to say that it isn't a massive additional problem for women trying to recover from the trauma of PP. So perhaps the half of us who have suffered a postpartum psychosis but who have already coped with having bipolar can help the other half of our sisters to deal with the corrosive effects of stigma now - and do our best to help diminish them in the future.
Heron J, Gilbert N, Dolman C, Shah S, Beare I, Dearden S, Muckelroy N, Jones I, Ives J (2012) Information and support needs during recovery from postpartum psychosis. Archives of Women's Mental Health:1-11 Back to Bipolar Disorder & Pregnancy page"

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As someone who has had many conversations with women who have had a postpartum psychosis - some of whom, like me, already had a diagnosis of bipolar disorder - I can say that the experience is very different in one very important respect.

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https://www.app-network.org/what-is-pp/books-references/

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The Association for Post-natal Illness (PNI) and the Royal College of Psychiatrists publish leaflets about postpartum psychosis (PP). Links to these websites are available on our Useful Links page.

Postpartum Psychosis for Carers

This information leaflet is for partners, family and friends of any woman with postpartum psychosis, as well as for Psychiatrists, mental health team members and other health professionals (such as Health Visitors and GPs) who care for women with postpartum psychosis. APP Trustee, Clare Dolman, also helped to develop this leaflet.
Click to view the leaflet"
Perinatal Mental Health Toolkit

This toolkit is a set of relevant tools to assist members of the primary care team to deliver the highest quality care to women with mental health problems in the perinatal period. As well as offering a diverse collection of resources, the Perinatal Mental Health Toolkit gives details of additional learning for individual practitioners.
Click to view the Toolkit"
Support after suicide

'The Support after Suicide Partnership (SASP) is the UK's national hub for organisations and individuals working across the UK to support people who have been bereaved or affected by suicide. We passionately believe that everyone bereaved or affected by suicide should be offered and receive timely and appropriate support.'
Click to visit the website" s upportaftersuicide.org.uk
Carer's Survival Guide

A thorough Carer's Survival Guide containing excellent tips and advice for carers. It is written by Craig Allatt whose partner experienced PP. Please note, it is aimed at an Australian audience and some of the health care procedures may differ in the UK.
Click to Download"
Bipolar, Pregnancy & Childbirth

Psychiatrist Professor Ian Jones talks to Clare Dolman, Chair of Bipolar UK, about how bipolar can affect women, particularly during pregnancy and after birth. This podcast was produced in partnership with the Royal College of Psychiatrists to mark the first Bipolar Awareness Day. To listen to the podcast

This module covers the risks of becoming unwell in pregnancy and the postpartum, issues around medication in pregnancy and breastfeeding, and about passing on a vulnerability to bipolar disorder to children. It forms a part of the psychoeducation programme called Beating Bipolar and has been developed, and currently reviewed, as part the BEPC project.Click here" to view the module.

Midwives On-line Tool

Maternal Mental Health: A learning Programme for Midwives isan on-line tool to help midwives identify & treat new mothers at risk of severe mental illness was officially launched by the Chief Nursing Officer for Wales, Professor Jean White at the St David's Day Conference of the Royal College of Midwives in Cardiff.

Textbooks & Factual Resources

- reviewed by Jackie Benjamin:

Understanding postpartum psychosis: A Temporary Madness by Teresa Twomey
Support International provides information about the features and treatment of PP. Readers should note that it is aimed at a US audience and legal issues and health care procedures differ in the UK.

Perinatal Mental Health - a sourcebook for health professionals by Diana Riley
Published 1995 by Radcliffe Medical Press, Oxford. This is very readable and gives extensive references.

Motherhood & Mental Health by Ian Brockington. Published in Hardback 1996 by Oxford University Press, (Paperback edition available) This is extremely thorough and authoritative but quite technical and difficult for a lay person to follow. You can download reviews of the book by Carol Sue North MD and by Miriam B. Rosenthal, MD. You will need Adobe Acrobat Reader to view these files. To download the reader Click here"

Mood & Anxiety Disorders During Pregnancy by Cohen & Nonacs
In five concise, well-written chapters, the authors offer invaluable guidance in treating women during pregnancy and the postpartum period.

Psychiatric Drugs Explained by David Healey. Published by Elsevier Churchill Livingstone
Now in its 5 th Edition - I have the 4 th Edition of this book and also had the 2 nd and 3 rd as, although it is aimed at a professional audience, I have found this fairly approachable but detailed enough to be useful. I struggled with medication side effects when my sons were born and wasn't given much information so didn't always know what was caused by my illness and what was due to medication. When I was ill a third time, this book helped me to be much informed and to make real choices about my treatment. Not everyone wants so much information, some people take the attitude that that is the doctor's job. I feel more confident talking to my doctor and psychiatrist with the benefit of this kind of information so that I share the decision making with them. Be warned, though, that David Healey has quite strong views against the drug industry and you need to take that into account.

Out of me by Fiona Shaw
Out of Me is a personal, engaging and extremely readable account of severe postnatal illness, the author's process of trying to understand and recover from the illness, and of coming to terms with her psychiatric admission and treatment.

Beth: A story of postpartum psychosis by Shirley Cervene Halvorson
This short book is written by a mother who lost her daughter to PP. It tells the story of Beth and how the family coped following her tragic suicide in 1986.

A Mother's Climb Out of Darkeness by Jennifer Hentz Moyer

In this honest, real and heart-wrenching story of a mother battling postpartum psychosis, there are accounts of some of the most difficult experiences a mother could face. There are also uplifting accounts of a mother's bond to her baby, success in going back to work and building a strong family unit. Some parts may be hard for women currently experiencing PP to read due to her complete and honest accounts of psychosis and experiences. Jennifer explores the importance of caring for yourself physically and emotionally, and how a woman's spiritual side may also play a part in recovery. including having doctors listen to her, communicate with her and involve her in care plans. It therefore lends itself as a fascinating account for health professionals and students in mental health who want an insight into the impacts on every aspect of a woman's life. Jennifer's account is both heart breaking and inspirational. Click here" to read an interview with the author.

Fictional & Biographical Accounts of PP

- reviewed by Jess Heron

The Yellow Wallpaper by Charlotte Gilman Perkins
Written in 1890, this is the most famous early fictional account of puerperal psychosis. The short story, originally published in the New England Magazine, was informed by her own experience of postnatal illness, and her struggles with ambition and duty. It is now a text studied by English scholars as feminist literature, but contains good descriptions of a woman 'losing her mind' after the birth of her baby, an ineffective 19th century medical system, and of a husband not knowing what to do.

The Shutter of Snow by Emily Holmes Coleman
The Shutter of Snow is a fictional description of the postpartum psychosis of Marthe Gail, who after giving birth to her son, is admitted to a 19th Century psychiatric hospital. The story describes the passage of Gail's mind through the fog of her illness; the other patients and caretakers; and describes the immense support provided by her husband as she sorts through her delusions and behaviours. Written in 1931, the book is based on the experiences of the author and takes an unusual form that is very difficult to read. It is probably only for the most dedicated and persistent reader!

Surviving Post-Natal Depression: At Home, No one hears You Scream by Cara First published 2000 by Jessica Kingsley Publishers Ltd. This contains the personal accounts of 10 women who had various degrees of postnatal illness, including PP with other chapters on partners, the professional view, practical advice and The Light at the End of the Tunnel. This book is easier to digest than some as it is broken down into smaller chunks and you can pick and choose the parts that seem most relevant to you.

Hillbilly Gothic: A Memoir of Madness & Motherhood by Adrienne Martini
A personal and sometimes humorous account of postpartum psychosis, with a wonderful first line: "My family has a grand tradition. After a woman gives birth, she goes mad. I thought that I would be the one to escape."

Eyes without Sparkle by Elaine Hanzak
Eyes without Sparkle is a powerful personal account of a journey through motherhood & mental illness. Elaine now gives talks to educate professionals about the experience, stigmas & difficulties faced by women with young children who experience an episode of mental illness.

Saving Grace by Grace Sharrock
Saving Grace is published by one of our APP members. Grace gave birth to her daughter Ellie 8 years ago & suffered a postpartum psychosis. This book describes her experiences & her process of recovery. We send Grace our best wishes as she has just given birth to twins, without a recurrence of PP.

Blackmoor by Edward Hogan
Edward Hogan's debut novel Blackmoor was shortlisted for the Sunday Times Young Writer of the Year Award. As I was reading this compelling story set in a close-knit conservative Derbyshire mining village in the 1980s, I was surprised to find a character with an episode of puerperal psychosis in her historyI talked to Ed about the source of his inspiration. Click here" to read the interview with Edward Hogan.

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The Association for Post-natal Illness (PNI) and the Royal College of Psychiatrists publish leaflets about postpartum psychosis (PP). Links to these websites are available on our Useful Links page. This information leaflet is for partners, family and friends of any woman with postpartum psychosis, as well as for Psychiatrists, mental health team members and other health professionals (such as Health Visitors and GPs) who care for women with postpartum psychosis.

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https://soundcloud.com/bipolaruk/bipolar-disorder-pregnancy-and/s-cZcU7

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published on

Psychiatrist Dr Ian Jones talks to Clare Dolman about how bipolar can affect women, particularly during pregnancy and after birth. This podcast was produced by Bipolar UK and the Royal College of Psychiatrists to mark the first national Bipolar Awareness Day on 27 June 2012. For more information please visit: Bipolar UK: www.bipolaruk.org Royal College of Psychiatrists: www.rcpsych.ac.uk Action on Postpartum Psychosis: www.app-network.org Bipolar Scotland: www.bipolarscotland.org.uk

Genre

Mental Health

License: all-rights-reserved

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Bipolar Disorder, Pregnancy and Childbirth by Bipolar UK

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Psychiatrist Dr Ian Jones talks to Clare Dolman about how bipolar can affect women, particularly during pregnancy and after birth. This podcast was produced by Bipolar UK and the Royal College of Psychiatrists to mark the first national Bipolar Awareness Day on 27 June 2012.

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Laura Spence - What happens in the Womb can last a lifetime

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Laura Spence - What happens in the Womb can last a lifetime

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https://www.youtube.com/watch?v=LToZPa702Tk

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What Happens In The Womb Can Last A Lifetime - Begin Before Birth

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https://www.youtube.com/watch?v=pJQehbByKLY

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Fetal programming -- medicine starts before birth | Eduard Gratacós | TEDxBarcelona

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https://www.nice.org.uk/guidance/CG192

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Overview | Antenatal and postnatal mental health: clinical management and service guidance | Guidance | NICE

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This guideline covers recognising, assessing and treating mental health problems in women who are planning to have a baby, are pregnant, or have had a baby or

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https://www.ncmh.info/resources/online-tools/

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Access a range of online tools and resources which can be used to help manage or monitor a number of mental health conditions.

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Online tools

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Rebecca  - case study 2   (charlotte Hough)

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Rebecca  - case study 2   (charlotte Hough)

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Facts – Rebecca – case study 2

-          34 year old single mother

-          Three older children who have been removed and have been adopted

-          Previous domestic violence and evidence of neglect

-          Family history of schizophrenia

-          Diagnosed and receives treatment for bipolar disorder

-          New short relationship with infants’ father and domestic violence again

-          Restraining order in place for Krystal’s father

-          Krystal placed on a child protection plan

-          Krystal is now 16 weeks old and meeting milestones

-          Rebecca did not attend a weight clinic as planned

-          Rebecca appears on edge and unsettled upon visit

-          Probation officer discloses that Aaron and Rebecca have had contact

What would I want to know/issues for consideration?

-          Is Rebecca receiving any CMHT/PMH input? And is Rebecca actively engaging?

-          Concordant with bipolar medication?

-          Rebecca may be “unsettled and on edge” due to previously having her older children removed from her care and worries this may reoccur?

-          What kind of contact have Rebecca and Aaron had?

-          Drugs and alcohol involved? Or hx of?

-          Was Rebecca’s bipolar treatment altered during pregnancy, mood stabilisers? And if so could this be reviewed? As might not be having the same effect

-          What has the health visitor reported from earlier visits/appointments? And any extra support arranged?

-          What does the CP state?

-          Support network?

-          Lying to professionals, does Rebecca know the implication of doing this in regard to the CP?

-          Could Rebecca be encouraged to “open up “to CPN/health visitor specialist in PMH who has a good rapport with Rebecca to identify key factors/issues?

-          Postpartum psychosis? High prevalence within individuals with pre-existing bipolar disorder.

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I don't know if I have been very fortunate or very sheltered during my training and career so far. I have had minimal involvement with safeguarding issues and have not directly looked after women with CP plans in place or attended meetings, so this is a huge knowledge gap for me. I have found the child law advice website to be helpful!

Child Protection Conference & Plan (childlawadvice.org.uk)

34 year old single parent to 16/52 female infant conceived during short relationship.
evidence of domestic violence near end of pregnancy. Supported to end relationship, police involvement and restraining order in place. IDVA? PMHT/CMHT care co-ordinator?

3 older boys removed and adopted 5 years ago due to a history of domestic violence and evidence of neglect.

H/o schizophrenia and a diagnosis of bi-polar which is treated.  - High risk for postpartum psychosis

Child protection plan in place. - What does the plan state? - what support has been put in place to enable Rebecca to care for her baby appropriately?

Female infant meeting milestones. - Positive

DNA weight clinic appointment and Health visitor unable to contact. - Correct phone number? messages left? previous attendance?
Unannounced visit today - Rebecca on edge, reports had GP appointment so unable to attend weight clinic. - Medication compliance?

GP surgery report no attendance from Rebecca in months - Rebecca did not like being challenged on this. No explanation given on where she was or why she lied. - is she scared of repercussion? Outside influence? Did she genuinely forget her appointment at the weight clinic, but feel embarrassed to admit this?

Rebecca on edge at care group meeting, appears unkempt and her conversation jumps with no clear pathway. - CMHT / PMHT, psychiatric review, medication review.

Ex partners probation officer in attendance - reports Aaron states he is in contact with Rebecca and Krystal. Has this been reported as a breach of restraining order?
Does Rebecca feel safe? Does she want the contact? Refuge? IDVA?

Restraining Orders - Section 5, Protection from Harassment Act 1997 | The Crown Prosecution Service (cps.gov.uk)

https://doi-org.hallam.idm.oclc.org/10.1111/bdi.13060

community-mental-health-framework-for-adults-and-older-adults.pdf (england.nhs.uk)

the-perinatal-mental-health-care-pathways-pdf-4844068237 (nice.org.uk)

Catherine

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This page explains Child Protection Conferences, including information on who is able to attend and what will likely be discussed, as well as information regarding child protection plans and their function.

What is a Child Protection Conference?

A Child Protection Conference is a meeting between family members, the child (where appropriate), and professionals involved with the family about a child's future safety, health and development.

The Child Protection Conference is designed to look at all the relevant information and circumstances to determine how best to safeguard the child and promote their welfare. A Child Protection Conference may be held following an investigation under section 47 Children Act 1989 (a child protection investigation).

The conference will hear information about the family and concerns which have been expressed. There will be a discussion about whether or not the child is at risk of significant harm and whether the child should be placed on a 'child protection plan'. If it is decided that a child protection plan is necessary, the child's name will be placed on the child protection register - also known as the 'at risk' register.

Guidance on Child Protection Conferences is contained in Working Together to Safeguard Children. This is guidance published by the Department of Education and is designed to ensure that there is a coordinated and child-centered approach to safeguarding.

Who goes to a Child Protection Conference?

The meeting is attended by professionals who know the family and can provide relevant information. This could include the child's health visitor, teacher, doctor, other health and education workers and specialist police officers. There are other people who may be invited to attend because they have specialist information or knowledge relevant to the child.

Professionals will be required to submit a written report to the Chairperson beforehand.

Parents and carers are encouraged to attend and participate as it is recognised that they have an important part to play in the conference. The social worker and Chairperson both have obligations to help parents and the child understand the conference process and what to expect.

The Chairperson can exclude certain persons from the conference in some situations, for example, where there has been domestic violence. The excluded person should still be allowed to submit their views in writing.

Can a parent bring a friend or relative with them for support?

A parent can request that another person attend the conference if it will help them to express their views. However, this person must be trustworthy as information regarding the family must remain confidential.

It is important that a parent is able to express his or her views at the conference.

A parent is entitled to take their solicitor with them, but the solicitor cannot speak on the parent's behalf.

The parent should inform the social worker if they have learning difficulties or an issue which affects their ability to communicate effectively. An interpreter can be arranged to attend the conference if English is not the parent's first language.

Can the child attend the Child Protection Conference?

The child who is the subject of the conference is not required to attend but they can do so if they wish. The Chairperson can refuse to allow the child to attend if it has been determined that their attendance could cause harm or if they are not old enough to understand what is happening.

A child may wish to have the assistance of an advocate or friend to help them express their views and wishes at the meeting. A child can have their legal representative attend the meeting if they are mature enough to instruct a solicitor.

If it is determined that the child should not attend the conference, the child can write to the conference and express their views about the situation. The social worker involved with the case should be able to assist the child with this.

See our page on Advocacy for more information on obtaining an advocate.

Will I be able to be present during the whole Child Protection Conference?

This will depend on the protocol of the relevant local authority. Parents can generally stay throughout the discussion, however they may be asked to leave the conference to allow the professionals involved in the case to seek legal advice.

Local authorities should make available their policy and protocol on child protection conferences.

What happens if I cannot attend the Child Protection Conference?

If the parent cannot attend the conference or chooses not to, he or she can write to the child protection co-ordinator explaining their views or ask the social worker to relay their views to the conference.

Can I see the minutes of the Child Protection Conference?

A parent is able to request the minutes of the Child Protection Conference, but these are confidential and should not be shared with anyone other than the parent's legal representative. If you have difficulty in obtaining this information you are able to contact the Information Commissioner's Office on 0303 123 1113.

I am not happy about what happened at the Child Protection Conference, what can I do?

If a parent is not happy about the outcome of a child protection conference or about how the conference has been conducted, they may have a right to appeal dependent upon the policy of the relevant local authority. We would advise the parent to check whether this is available in such circumstances.

If a parent is not happy about how children's services have acted, they are entitled to make a complaint. A parent should put their concerns in writing to the chair of the Child Protection Committee. See our How to Guide on Complaints against Children's Services for more information.

What is a Child Protection Plan?

A Child Protection Plan should:

assess the likelihood of the child suffering harm and look at ways that the child can be protected;

decide upon short and long term aims to reduce the likelihood of harm to the child and to protect the child's welfare;

clarify people's responsibilities and actions to be taken; and

outline ways of monitoring and evaluating progress.

When will a child come off of a Child Protection Plan?

A child will no longer be under a Plan:

when it is judged that the child is no longer continuing to or believed to be suffering significant harm;

where the child and family have moved permanently to another Local Authority area - the new Local Authority should arrange a Child Protection Conference within 15 days of being notified of the move;

when the child has reached 18 years old - the LA should conduct a review around the time of the child's 18th birthday when the plan can be ended;

if the child has died; or

if the child has permanently left the UK.

Going further

If you wish to initiate a complaint against Children's Services, detailed information can be found in our How-to Guide. Please note that a fee is charged for this service.

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This page explains Child Protection Conferences, including information on who is able to attend and what will likely be discussed, as well as information regarding child protection plans and their function. A Child Protection Conference is a meeting between family members, the child (where appropriate), and professionals involved with the family about a child's future safety, health and development.

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Relationship of bipolar disorder with psychiatric comorbidity in postpartum period

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Bipolar disorder in pregnancy and birth - a sytematic review of outcomes

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Facts:

34 year old para 4

Hx bipolar disorder and fx schizophrenia

3 sons removed, now adopted, due to domestic abuse and neglect in previous relationship, no contact with father now

16 week old daughter Krystal, father is Aaron who was a perpetrator of domestic abuse in relationship, restraining order now in place

Previously engaged with CP plan for Krystal who was meeting milestones

DNA’d HV weigh in clinic for Krystal, said was at GP, GP records showed this to be false

Rebecca’s appearance has been noted to have become unkempt

Rebecca’s behaviour appears to have deteriorated, became agitated at unannounced home visit and showed signs of manic thinking at core group meeting

Probation officer states Aaron claims to have been having contact with Rebecca and Krystal

Issues for consideration:

Bipolar disorder is known to have a high risk of recurrence postnatally

Risk of spiralling into psychotic episode

What has happened to cause Rebecca to relapse, is it related to her bipolar disorder, involvement with Aaron, a combination of events or something new

Could Aaaron be lying about having contact with Rebecca in an effort to manipulate her or cause her distress

Any hx of drug or alcohol misuse?

Is Rebecca currently able to act as a protective factor to Krystal? Risk taking behaviours are often linked to periods of mania.

Parental capacity

Questions!:

Has Rebecca had contact with Aaron, if so why and what did it involve?

Were mood stabilisers discontinued during the pregnancy and what medication if any is she taking now? Does this need reviewing?

What is the risk of infanticide related to bipolar / schizophrenia?

Could targeted support from a CPN/perinatal nursery nurse help?

Any specialist charity/organisation that could help/provide 1-2-1 peer support?

What is the plan from children’s services going forward in light of Aaron having broken the restraining order?

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Facts:

·       Single mother – 34 years old

·       Bipolar - medicated

·       Family hx of Schizophrenia

·       3 boys aged 9, 7 and 6 all removed from Rebecca’s care 5 years ago due to neglect and DV relationship

·       16 week old daughter, Krystal

·       Recent DV relationship with father of Krystal. Restraining order in place

·       On CP plan

·       Krystal reaching her milestones

·       Recently missed HV apt and lied about where she was

·       Aaron’s probation officer aware that Rebecca and Aaron are seeing each other again

What would I want to know / what are the issues:

·       Is Rebecca still taking her medication for Bipolar?

·       Is she under a mental health team? Women with Bipolar are high risk of postpartum psychosis, would fit the criteria for support with a Perinatal Mental Health Team.

·       What is the interaction between Rebecca and Aaron? Is he visiting her home? Spending time with Krystal? Living with her?

·       Is Rebecca aware of ACE’s and the impact this has on a child’s development.

·       Is Rebecca bonding with Krystal? What is her parent – infant interaction / relationship like? Is she meeting Krystal’s emotional needs?

·       What family support does Rebecca have?

·       What did the DV consist of? Has Rebecca got an IDVA?

·       What are the rules of Aaron’s restraining order? Will the probation officer pursue the break in these rules and look at prosecuting?

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Leanne

Rebecca activity 1

Facts:

34 year old single mother.

Has 3 boys that were removed from her care and adopted 5 years ago, due to severe DV and neglect.

H/O schizophrenia and bi polar.

Has a 16 week old daughter named Krystal, following a new short relationship with Aaron, which ended due to DV.

Krystal on child protection plan.

Aaron placed on restraining order and to have no contact with Rebecca or Krystal.

Appears on edge and unsettled when Margaret arrived unplanned to her home.

Lied about why she didn’t attend clinic.

At core meeting Rebecca still appeared on edge, looked unkempt and conversation jumped from one thing to another with no clear path.

Aarons probation officer was in attendance at the core meeting and reports that Aaron has stated he has been having contact with Rebecca and Krystal.

Questions/Thoughts:

Is Rebecca taking her medication?

Is Rebecca experiencing symptoms of bipolar?

How is she adjusting to mother hood/being a single parent?

Has Rebecca’s change in appearance/mood impacting her ability to care for Krystal?

Is Aaron having contact with Krystal/Rebecca and if so what form of contact?where is this taking place if face to face? how long for? and is there DV/coercive control?

If found to be true, how will the breach of restraining order be dealt with?

What are Rebecca’s thoughts and feelings?

What support is Rebecca receiving from other services?

Does she have friends and family support?

Is she isolated?

Lying to professionals.

What does child protection plan state.

Vulnerable.

Starting to avoid engaging with professionals.

Areas to develop:
Schizophrenia

Bipolar

Domestic violence

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Nicola Dyke.

Thoughts and questions.

Unable to prioritise the care of her previous children which led to them being removed from her care due to neglect.

Rebecca is a vulnerable adult.

Not in a stable relationship.

Previous severe domestic abuse.  Possible current domestic abuse and coercion.

What was the plan from MARAC?

Which professionals are offering support to Rebecca? What is the child protection plan?

Any adverse childhood experiences for Rebecca? Does she understand the impact of adverse childhood experience for her baby?

Aaron and Rebecca not compliance with restraining order.

Reducing engagement with professionals.

Mental health concerns. Is Rebecca engaging with mental health support?

What support is the Health Visitor offering?

Has bonding between Mum and baby been assessed?

Is GP aware of lack of engagement with professionals? Is Rebecca medicine compliant?

Is personal appearance changing?

Conversation jumping and lying to professionals.

Is Rebecca isolated?

Does Rebecca have a support network in place?

Are all of Krystels needs being met?

Is Rebecca being heard by anybody?

Areas to develop:

Bipolar and schizophrenia.

Domestic abuse.

Coercive relationships.

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Rebecca – Activity 1

Facts

·      34-year-old single mother.

·      Diagnosed bi-polar, family history of schizophrenia.

·      16 weeks postpartum, daughter Krystal.

·      On Child Protection Plan due to severe domestic violence.

·      3 sons aged 9,7 and 6. Removed from her care and adopted 5 years ago due to severe domestic violence and neglect. Left their father 2 years ago, no contact since.

·      Left recent partner, Aaron, near the end of this pregnancy, he has no contact with Rebecca or Krystal. Restraining order in place.

·      Stopped seeing GP, missing appointments for Krystal. On edge, unkempt, lied about seeing Aaron.

·      Conversations jumping from one thing to another, seems agitated, lying to professionals.

·      Krystal is 16 weeks old and meeting milestones.

·      Lying about missing appointments, does not like to be challenged on this.

·      Core group meeting: Aaron’s probation officer attended and disclosed that Rebecca and Krystal have had contact with Aaron.

Thoughts

·      What other professionals are involved? Assuming due to the Child Protection Plan that there is a multi-disciplinary support network in place. With the limited information available, it is apparent that Rebecca has a social worker, support worker and a health visitor as part of this support network.

Consider any further support that could be offered, such as:

1.     Local domestic abuse organisation.

2.     Peer support groups for survivors of domestic abuse.

3.     Programmes / courses relating to moving on from abuse and healthy relationships.

https://www.ted.com/talks/leslie_morgan_steiner_why_domestic_violence_victims_don_t_leave?utm_campaign=tedspread&utm_medium=referral&utm_source=tedcomshare

Many victims return to their abuser, high risk victims can return 2-3 times on average before they leave permanently.

https://safelives.org.uk/policy-evidence/about-domestic-abuse/how-long-do-people-live-domestic-abuse-and-when-do-they-get

·      At 16 weeks postpartum, Rebecca could be feeling down, lonely or isolated. Does Rebecca have any mother and baby groups to attend? Does she have any friends or family for support? Could she be feeling isolated?

https://www.frontiersin.org/articles/10.3389/fgwh.2020.00001/full

·      Is Rebecca still receiving treatment for bi-polar? We know she has not engaged with her GP for a few months.

Previous mental health conditions, including bi-polar, increase the risk of postpartum psychosis. As Rebecca is presenting agitated, unkempt and is starting to avoid engaging with professionals, which she was previously doing well, this could be a concern.

https://www.rcpsych.ac.uk/mental-health/problems-disorders/postpartum-psychosis

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Facts:
34y/o female with 4 children. 3 previously relinquished 1 in her care.
Dx of BiPolar disorder.
Family hx of Schizophrenia.
2 x relationships with DA.
Last partner known to probation.
named on CP plan.
Presenting different to her norm.
Recent none attendance causing concern to the HV.
Lied about her reason for this.

Issues:
Safeguarding - of mother and of baby. Assuming this had been heard at MARAC what was their plan with probation and police to support and safeguard both mother and baby. Why has the probation officer not shared the information sooner about the contact? What are they doing about this as it is a breach? Will this escalate to a non-mol order or is it reasonable to support with supervised contact? what are the risks ? Is mum at risk from further abuse - highly likely and possible cause for her deterioration. Its never good to assume, but i would hope a Claires Law had been submitted under CP and the information given to Mum. If not this needs doing asap. Police markers on the property need to be reactivated and checked. Is there an IDVA working with mum ? If not this needs to be offered and explored. There may be support needing navigating through the CP plan and legal world associated to this.

Mental health - is this CMHT or SPCMHT ? Who is the care co and what is there plan? Has this lady been following pathway 2 of the perinatal care pathways knowing she has a severe and enduring mental illness? When was her last medical review? are we concerned about PPP? Women with bipolar are the highest risk of Post Partum Psychosis. What is her medication? Has she been compliant ?

- To be continued - having to sign off to attend to my own children.......

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This case would require a robust multi-disciplinary approach. Midwifery, Safeguarding/SS, GP, MH services, HV.
Rebecca is obviously a vulnerable woman with psycho-social difficulties, a vulnerable women's midwifery team if available would be beneficial for someone in these circumstances.
My concerns and questions would be:
Is this a relapse of her Bi-polar symptoms?
Is she compliant with her care plan/medications?
Is she being abused by her ex Aaron?
What services can be pulled together to support?
Are Krystal's needs being met?
What is Rebecca saying?
What about Aaron?

I would want to arrange the following.
Complete an assessment of risk - safeguarding consultation
Mental health services consultation
MDT meeting - MH, SS, HV, Midwifery, probation.

https://www.bipolaruk.org/faqs/leaflets-bipolar-disorder-pregnancy-and-childbirth

NICE CG 192 Overview | Antenatal and postnatal mental health: clinical management and service guidance | Guidance | NICE

Recommendations for Bi-Polar in pregnancy
1.8.20 If a pregnant woman with bipolar disorder develops mania while taking prophylactic medication:

check the dose of the prophylactic medication and adherence

increase the dose if the prophylactic medication is an antipsychotic

suggest changing to an antipsychotic if she is taking another type of prophylactic medication

consider lithium if there is no response to an increase in dose or change of drug and the woman has severe mania

consider electroconvulsive therapy (ECT) if there has been no response to lithium. [2014]

https://pubmed.ncbi.nlm.nih.gov/29083536/

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Bipolar disorder, pregnancy and childbirth

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A leaflet about bipolar disorder in pregnancy for people who who are considering having a baby.

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This case study was really interesting. In terms of concerns and issues, Rebecca's behaviour is worrying, given her diagnosis of bipolar disorder, and initial thoughts are whether she is experiencing a symptomatic episode.  Women with BD are at increased risk of a psychotic episode (puerperal psychosis) in the postnatal period, so this is also something to be aware of.  Rebecca is very vulnerable and there are significant safeguarding issues for Krystal if Rebecca's mental health declines to a level that impacts on her ability to care for her and keep her safe.
At this point, we don't have a broad enough picture to assess the situation and the level of risk.
There are definitely some things we need to know
- what is Rebecca's treatment regime and has she stopped taking medication?
- is Aaron having contact with them (against the restraining order) and, if so, is there DV and coercion?
- is Rebecca having a recurrence of BP symptoms or is she experiencing a psychosis?
The case study highlights the critical importance of multi-disciplinary working as there are numerous agencies involved in Rebecca's and Krystal's care - psychiatry, health visiting, social services, perhaps more.
It also brings up some thinking around the stigma of mental illness and potential ethical and moral issues around decision-making, and the need to meet the needs of both Rebecca and Krystal.
It is very important to hear Rebecca's voice - how she feels, what she thinks - and to know who is around her to support her - family, friends, professionals.

I came across a couple of articles by mothers, describing their experiences of parenting with BD -

https://www.mind.org.uk/information-support/your-stories/the-challenges-of-being-a-mum-with-bipolar/

https://www.tommys.org/pregnancy-information/pregnancy-news-blogs/lucys-road-becoming-mum-and-managing-bipolar-disorder

An area of further interest is the impact of BD on the mother-infant relationship and child development and how families can be supported to have the best experiences and outcomes.  Here's a recent study -https://www.frontiersin.org/articles/10.3389/fped.2021.646985/full

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I am a mummy to two little people. I also have rapid cycling bipolar disorder. These are not two things that complement each other well. I cannot count the number of times I have stopped and wondered how much damage my illness causes to my beautiful children. Hopefully none.

Hopefully they will learn from it, learn understanding, acceptance, patience, gratitude, how to love, how to be there for others. But the voice of doubt, the niggling fear suggests otherwise.

"To think that there may have been times when they could have felt unsafe, doubted my love and commitment to them, blamed themselves, breaks me a little more every day."

This is the hardest thing to live with. To know that seeing me live with bipolar has caused them pain, hurt, upset, fear, anxiety; to think that there may have been times when they could have felt unsafe, doubted my love and commitment to them, blamed themselves, breaks me a little more every day.

Rapid cycling bipolar disorder means swinging between hypomania and depression regularly. I wake up unsure of where I will be today - manic, depressed or functioning normally. I have to constantly censor my behaviour.

As with everything, there are ups and downs, good days and bad days. But never days where bipolar is not there with me, sitting on my shoulder haunting me as I play with my children, bath my babies, read my eldest a bedtime story.

Every day is a battle.

As with every battle, no two days are the same. Not all days end in disaster. Some days there are victories. For me, those victories are the little moments where my youngest toddles over to me and asks for a cuddle, or my eldest looks at me and says 'Mumma I love you.' These are the moments I treasure, but there are many more that cause me sadness and pain.

I take medication every day for my condition rapid cycling bipolar disorder. Each morning when I wake up, I take these tiny little pills that are supposed to make it all better. They don't. They help lessen the extremes. But I still have to fight every day to maintain balance.

For the most part, I enjoy the hypomania stage. The energy it gives me, the love for life and enthusiasm for everything. My little people love it too, at first. They enjoy my energy and enthusiasm. They thrive off my love for life and enjoy the endless hours of carefully constructed play and learning opportunities I provide for them.

"When I become too much my children become overwhelmed and exhausted, then unsettled and finally apprehensive about being near me."

Until it becomes too much. Until I become too much. They become overwhelmed and exhausted, then unsettled and finally apprehensive about being near me. On occasions maybe even slightly afraid of me because by now the hypomania isn't fun for any of us anymore. I have become obsessive and demanding, everything must be done exactly as and when I need it to be. My expectations become unrealistic, and I expect them to react and behave in the ways I anticipate.

Eventually, I become angry that things are not how they should be, that I can't control everyone and everything around me. I become irrational and snappy when they make a minor mistake such as spilling a drink at the dinner table because they won't sit still or falling and hurting themselves after I have given warnings. And then, at those times when they most need my love and comfort, they get my anger, my irrationality and my coldness.

No sooner has this occurred then I want to take it back. But it is done. Of course, they forgive and forget. I apologise and explain. But it does not change it or fix it.

Next comes the fall from hypomania. The need to be alone, the anger that no one understands, the feelings of worthlessness and self-hatred. Sometimes I go out on my own and walk in the dark. Sometimes I drink too much. Sometimes I hurt myself. I am crying out for help but no one can hear me.

After this, the depression kicks in. I complete day to day tasks but there is no engagement, no enthusiasm, no feeling. I don't give my little people the attention or love they deserve. I care for them, but I can't connect with them. Again, I reach out for help but as I cannot bring myself to actually ask for help outright, I am left to fight alone. But I have found a friend who has many similarities to myself and who I have found a huge strength. Without my friend I probably could not cope. Knowing that I have a friend who I can confide in and who can confide in me, someone who I can just ask for a hug from, go for a walk with, be in companionable silence with or talk about general rubbish with, is a great comfort.

It does get better though, sometimes quickly, sometimes slowly, sometimes after what seems like an eternity. Occasionally it gets worse first and I don't want to carry on anymore. But it does get better.

"The one thing that never falls short is how much love I have for my two little people and how I would give my everything to them."

Then I can be OK for a while - still facing situations that trigger me every day, but coping. It is during these times where I give my absolute all to my children, trying to be the best parent I can be. Every day I set my parenting expectations so high. On some of my good days I may meet them, on others I fall short. But the one thing that never falls short is how much love I have for my two little people and how I would give my everything to them. I just have to hope and pray that this is enough.

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The challenges of being a mum with bipolar

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I am a mummy to two little people. I also have rapid cycling bipolar disorder. These are not two things that complement each other well. I cannot count the number of times I have stopped and wondered how much damage my illness causes to my beautiful children. Hopefully none.