围产期双相障碍女性患者治疗决策较复杂

一项纳入了334例妊娠期和产后精神疾病女性患者的回顾性研究表明，围产期双相情感障碍女性患者的临床特征比接受其他精神疾病治疗的女性患者要严重得多，包括自杀行为史更多，物质滥用史更多；而且，在分娩和哺乳期间面临的困难也更大。

美国罗得岛州普罗维登斯Butler医院的Cynthia L. Battle医生及其同事对这类女性患者的临床病历进行了回顾性分析。患者的年龄范围为15~43岁，种族背景多样。该样本中只有不到一半的患者已结婚或者有固定伴侣(J. Affect. Disord. 2014;158:97-100)。产后患者占2/3，妊娠期患者占1/3。
 
研究者要求患者填写爱丁堡产后抑郁量表以及该治疗机构的日间医院筛查量表，以便患者报告包括双相情感障碍在内的精神疾病。

大约10%的患者被确诊为双相情感障碍，包括19例I型双相情感障碍，10例II型双相情感障碍，5例未注明分型的双相情感障碍患者。其中26%报告了双相情感障碍的情感高涨症状，76%报告了易激惹症状，且在过去1个月内至少持续4天。

作者指出：“妊娠期和产后双相情感障碍患者报告了更多的精神健康病史，包括既往接受过药物治疗和精神治疗，并且既往物质滥用的发生率也更高。”双相情感障碍患者报告了既往自杀行为或自杀意图的患者比例显著高于其他轴I障碍患者。在妊娠期患者中，双相情感障碍患者服用精神药物的比例高于其他精神障碍患者。在产后患者中，双相情感障碍患者出现分娩并发症和哺乳困难的几率也更高。

作者写道，虽然本项分析仅限于病历中记录的数据，但研究结果“反映了与围产期双相情感障碍相关的临床和人口统计学特征”，包括这些患者存在明显的功能受损。很多患者都自我报告了情感高涨和易激惹症状，“这说明对于妊娠期和产后双相情感障碍患者，很有必要对躁狂和轻躁狂进行持续评估”。

作者说，虽然双相情感障碍诊疗指南建议维持性药物治疗和辅助精神治疗，但“尚未针对这一人群制定个性化的精神社会干预措施……对于围产期双相情感障碍患者而言，以患者为中心的决策支持以及制定个性化的辅助精神治疗，可能会在帮助这些患者在妊娠期和产后坚持接受治疗方面起到关键作用”。

Battle博士及其同事也指出，这项研究存在一些局限性。例如，由于研究所用方法为回顾性分析，因此只能局限于使用患者病历中记录的数据。

该研究没有接受任何资助；一名作者接受了美国国立卫生研究院事业发展基金的部分资助。作者声明无相关经济利益冲突。

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By: KAREN BLUM, Internal Medicine News Digital Network

The clinical features of perinatal women with bipolar disorder are much more severe than those of women seeking care for other psychiatric conditions, including greater history of suicidal behavior and substance abuse, and more difficulties during childbirth and while breastfeeding, a retrospective study of 334 pregnant and postpartum women suggests.

Cynthia L. Battle, Ph.D., of Butler Hospital in Providence, R.I., and her colleagues reviewed the clinical records of the women, who sought treatment at a specialized partial hospitalization program that serves patients during pregnancy and the first postpartum year. Their ages ranged from 15 to 43 years, and they came from a range of ethnic backgrounds. Less than half of the women in the sample were either married or had partners (J. Affect. Disord. 2014;158:97-100). Two-thirds were postpartum, and one-third of them were pregnant.
 
The investigators asked the patients to complete the Edinburgh Postnatal Depression Scale and the facility’s Day Hospital Screener for self-reporting of psychiatric disorders, including bipolar disorder.

About 10% of women had a bipolar disorder diagnosis, including 19 with bipolar I disorder, 10 with bipolar II disorder, and 5 with bipolar not otherwise specified. Twenty-six percent reported bipolar disorder symptoms of elation, and 76% reported symptoms of irritability lasting 4 or more days within the previous month.

"Pregnant and postpartum women with [bipolar disorder] reported more extensive mental health histories, including prior use of pharmacotherapy and psychotherapy, as well as higher rates of prior substance abuse," the authors noted. Women with bipolar disorder were significantly more likely than those with other Axis I disorders to report prior suicidal behavior and attempts. A higher proportion of expectant mothers with bipolar disorder took psychotropics than did pregnant women with other disorders. Among postpartum women, mothers with bipolar disorder were more likely to report delivery complications and difficulties breastfeeding their babies.

Although analyses were limited to data recorded in the charts, the current findings "shed light on the clinical and demographic features associated with perinatal bipolar disorder," including a high level of functional impairment experienced by these women, the authors wrote. The high level of self-reported symptoms of elation and irritability "underscore the importance of consistently assessing for mania and hypomania during pregnancy and postpartum."

While bipolar disorder guidelines recommend maintenance pharmacotherapy and adjunctive psychotherapy, the authors say, "tailored psychosocial interventions have not yet been developed for this population. ... Patient-centered decision support and development of tailored adjunctive psychotherapies for perinatal [bipolar disorder] may play a key role in helping women with [bipolar disorder] remain engaged in treatment during pregnancy and postpartum."

Dr. Battle and her colleagues noted several limitations of the study. For example, because the methodology used was retrospective, their analyses were limited to data that had been recorded in the charts.

This study was unfunded; one author was supported in part through a National Institutes of Health mentored career development award. The authors reported no relevant financial conflicts of interest.