Together at the Poles

Bipolar Disorder in Women

By Daniel Bader, Ph.D.


Unlike major depression, which is three times more likely in women than it is in men, bipolar disorder affects the sexes at roughly equal rates. However, just because bipolar disorder is just as likely to affect women as men does not mean that it affects women and men in quite the same ways. As a matter of fact, there are many differences, many of which relate to issues around fertility and children. On this page, I will discuss some of the issues that affect women uniquely, as well as introduce some of the strategies for dealing with these complications.

Variation in Overall Rates of Symptoms

Although bipolar disorder is just as prevalent in women as it is in women, the types of bipolar disorder from which men and women suffer actually varies widely. Specifically, women are more prone to having bipolar disorder 2 instead of bipolar disorder 1, and women are more prone to rapid cycling than men are.

Increased Rates of Bipolar 2

Woman Looking Out Window

Source: Beercha - CC BY 2.0

Women with bipolar disorder are more likely to be diagnoses with bipolar disorder 2 than with bipolar disorder 1. Bipolar disorder 2 is sometimes called the “less severe” form of bipolar disorder, but that isn’t quite accurate. Only manic symptoms are less severe. Depressive symptoms can actually be more severe:

  • Bipolar disorder 2 does not include manic episodes, but only less severe hypomanic episodes.
  • Bipolar disorder 2 includes more severe and long-lasting depressive episodes than bipolar disorder 1. In fact, though it is rare, some people with bipolar 1 have no depressive episodes at all.

In a way, this is consistent with the overall trend in diagnosis that women are more prone to depression than men. Even in bipolar disorder, which is equally diagnosed among men and women, it tends to manifest itself in more frequent and severe depressive episodes.

Just as women are more prone to major depressive disorder, women who have bipolar disorder are more likely to have bipolar disorder 2 rather than bipolar disorder 1. Bipolar disorder 2 is the variation that lacks manic episodes, instead only having hypomanic episodes. However, bipolar disorder 2 also has higher rates of depression than bipolar disorder 1. It is therefore quite consistent with the overall pattern of increased depression among women.

Increased Rapid Cycling

Someone is defined as having rapid cycling bipolar disorder if he or she has four or more mood cycles during a twelve-month period. Rapid cycling bipolar disorder is three times more likely in women than it is in men. Rapid cycling bipolar disorder can be significantly harder to treat, especially with respect to depression. People with rapid cycling tend to have more volatile reactions to antidepressants, and so are more dependent on mood stabilizers for handling depression, which are usually not quite as effective.

The reason for this increase in rapid cycling is not known. There are several hypotheses. One is that hormonal changes during the menstrual cycle destabilize episodes, causing them to not last as long or causing them to kick in when they might not otherwise do so. Another is that, because women are more prone to depression, women are more likely to be given antidepressants, which are known to potentially cause rapid cycling themselves. Finally, women are known to have increased rates of hypothyroidism, a condition in which the thyroid gland does not make enough of the thyroid hormone. Hypothyroidism has been linked in both men and women to increased rates of rapid cycling, so this increased rate of hypothyroidism may be the culprit.

Issues Related to Pregnancy

Issues related to pregnancy can be roughly broken down into two categories. First, there are the potential negative effects that bipolar medications may have on the fetus, causing birth defects. Second, there are the potential negative effects that hormones associated with pregnancy might have on the bipolar mother herself.

Medications and Birth Defects

Not all medications are tested on pregnant women for possible birth defects. Indeed, it is hard to imagine how such a test could be done ethically. However, there are still many medications that experience has shown are unsafe for the fetus or safe for the fetus. Then, there is a wide category of medications for which they have no idea, because they have never been properly tested on pregnant women.

Bipolar women should therefore speak with their psychiatrist before becoming pregnant. It might be a good idea to put together a pregnancy-friendly medicinal regime in advance, in order to make sure that it works well. Otherwise, the combination of new medications and hormonal changes in pregnancy might become overwhelming.

Hormonal Changes and Mood Episodes

The evidence for the interaction of bipolar disorder and pregnancy is very mixed. On the one hand, some studies have provided evidence that bipolar disorder actually becomes better during pregnancy. Most studies, however, have argued that bipolar disorder becomes worse during pregnancy, including both depressive and manic episodes.

The reason for the confusion around the data is that the data is very hard to sort out. Women already have a tendency to increased depression when they are pregnant, even if they are not bipolar. It is therefore difficult to establish whether or not a given depression is the result of bipolar disorder or whether it would have happened anyway as a result of the pregnancy. How one tries to answer this question will alter whether or not one thinks depression has gotten worse or better.

On the other hand, manic and hypomanic episodes do seem to get worse, especially among rapid cyclers. There are a number of reasons why this might be true:

  • Changing hormonal levels during pregnancy.
  • Changes in treatment in order to avoid birth defects where the changes aren’t working as well as the established regime.
  • An increase in “glomerular filtration rate”. This basically means that women who are pregnant excrete faster, meaning that medication is less effective.

Even so, the increased rate of hypomanic and manic episodes is usually fairly small, enough that some experts even deny that a change exists.

Overall, mood should be carefully monitored during pregnancy, especially for women with a history of rapid cycling. For some women at least, it appears that pregnancy can cause increased symptoms.

Post-Partum Issues

Like issues relating to pregnancy, post-partum issues can be roughly divided into those that affect the mother and those that affect the child. First, there are often severe emotional reactions to childbirth by bipolar women. Second, medications can be unsafe to use if you are breastfeeding.

Post-Partum Symptoms

Jules Dalou - Peasant Woman Nursing an Infant

Public Domain

Even women who do not have bipolar disorder are at a high risk of becoming depressed after childbirth. Women who have bipolar disorder are at an even higher higher risk of serious post-partum depression than women who do not have it. In fact, rates of post-partum depression among women who have bipolar disorder have been estimated at approximately one in three. Aside from their relative likelihood, post-partum depression is usually especially severe for women with bipolar disorder. Many bipolar women have post-partum depression that is so severe that it leads to psychosis, which can be dangerous both for the mother and the baby.

Depression is not the only danger after childbirth, however. Some women, usually those with bipolar 1 disorder, can have especially severe manias following childbirth. The delusions associated with these post-partum manias will often center around the child and beliefs that the child is somehow miraculous or otherwise special. Like depressive post-partum psychosis, this can be dangerous for the child and women with bipolar 1, and their family members should be aware of this possibility and be on the lookout for it.

For women with bipolar disorder, a psychiatrist should be involved to monitor fluctuations in mood that result from childbirth. Sometimes post-partum psychoses can be prevented by immediately resuming medication. If it is not prevented, care must be taken to protect both the child and the mother from potential harm resulting from an episode.

Breastfeeding

While we do not know not know very much about the dangers of many medications during pregnancy, we know even less about the dangers of those medications while breastfeeding. However, this does not necessarily mean that women with bipolar disorder will be unable to breastfeed. Breast milk is known to be superior for the health of babies than formula, which would be the only realistic alternative. So, women are often stuck between the unknown risks of medication and the known risks of formula.

The best thing may be to do some research yourself about the risks of breastfeeding with whatever specific medications you are taking, and then to speak with your physician about your particular situation. A good place to start for any information about breastfeeding, including medications, is La Leche League International. Another resource is a book called Medications and Mothers’ Milk by Thomas W. Hale, which has a comprehensive list of known information about the safety of medications for breastfeeding women (there will be a new edition of this available on June 15th that will be less expensive). Issues surrounding bipolar breastfeeding are complex, and will depend on which medications you are taking and your tolerance of and willingness to take other medications.

Conclusion

There are a lot of ways in which bipolar disorder affects women differently. Some of them are increased rates of various symptoms, but others are related to childbirth:

  • While women and men are equally likely to be bipolar, women are more likely to have bipolar 2 than men.
  • Women are three times more likely than men to have rapid cycling bipolar disorder.
  • Some medications are dangerous for a fetus, including the most common mood stabilizers. It is very important to speak to a physician before becoming pregnant.
  • The evidence about whether pregnancy itself exacerbates bipolar disorder is mixed.
  • There is a very real danger of post-partum depression, psychosis and mania. Having a psychiatrist involved immediately after childbirth can help offset these problems.
  • Some medications may be dangerous for a newborn baby if you are breastfeeding, but these risks need to be weighed against the superiority of breast milk itself.

Note: The primary source for the information on this page is Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition by Frederick K. Goodwin and Kay Redfield Jamison.

More Information:

12 Responses to Bipolar Disorder in Women

  • I was actually diagnosed after being pregnant, although it turns out I had been living with it since childhood, in hindsight. I don’t know if the hormonal changes had much to do with it, or were just the catalyst for the discovery, but either way there needs to be much, much more research done into earlier diagnosis.

    • Hi Bea,
      The problem seems to be that 1) people only go to a psychiatrist when they are sick (i.e. there are not standard “check ups”) and b) the symptoms of mental illness are largely invisible. This leads to 3) people not being diagnosed for years on end. Most of us end up diagnosed as the result of some sort of severe episode. If health insurance were to include psychiatric check ups, I think less of us would fall through the cracks.

      • Hi Daniel,

        That is certainly true, although in my case as a child I had actually been diagnosed with ADD. My poor mum tried every psychologist and counsellor to find out what was wrong with me, and it wasn’t until my mid 20s that I was finally diagnosed after a totally different psychologist I was seeing asked me if I had mental illness in the family. I’m not sure what the diagnostic process is in the US, but in Australia, we have to be referred by a GP before we can see one that is bulk-billed by Medicare. I have to admit, from what I understand of the US health system, we are indeed lucky to have the fairly universal health care we do in Oz, but having said that, unless you are bad enough to be hospitalised, in a lot of cases, its very expensive to see a psychiatrist or a psychologist who specialises in mental health, which doesn’t help AFTER you have been diagnosed!

        • Hi Bea,

          That sounds like an a frustrating catch-22 in the system. I’m in Canada, and we have something of the same problem. We can’t see a psychiatrist unless our GP refers us to one, but GPs aren’t psychiatrists, so they aren’t necessarily good at knowing when to do a referral. So, a lot of people slip through the cracks. I think it would be a good idea to have psychiatric check-ups every four or five years for people to alleviate this problem.

  • I am currently 19.5 weeks along, and still slowly lowering my medication.
    There is so much conflicting information out there (in fact my long-time GP/OB gave me completely opposite advice of what my medication leaflet stated). I have also had a hard time getting any kind of ongoing psych care (and I was not properly diagnosed until 7 years after my first major episode.) Before getting pregnant, I did a ton of research and found that most women, on the meds I was taking, did fine, and that there was a low chance of the baby being effected, except for the antidepressant, which should not be taken in the third trimester…well, now it’s completely different. I’m so confused mentally, emotionally and even physically, it seems – and scared out of my wits now that taking any meds will be disastrous, and that I have already caused harm to my baby by taking higher doses in early pregnancy.
    Also, in my situation, I had been trying for years to have a baby, undergoing treatments, and it was not possible to stay off my meds for such an indefinite amount of time, before pregnancy.
    I really wish that there was more (accessible) support out there.
    I am set on breastfeeding, but still uncertain about the safety of it. It has been verified that the Anti-psych I take DOES pass into breastmilk, but no one knows the long term side effects on the baby. And yes, since lowering my dose, I have been having mixed episodes and been rapid cycling (had a brief mania of only 2 days! – followed of course by depression and then more mixed states). I am attending a support group – but it seems that it’s not enough. Being Bipolar and Pregnant is turning out to be a bit of a nightmare.

    • Hi Nicole,

      I’m sorry to hear you’ve been having such a rough pregnancy. I don’t know all of the details of medication, but your OB should know the details of what is safe or not safe. Given that there is so much conflicting advice out there, having a professional on your team can be very helpful. For breastfeeding, I would suggest talking to La Leche League, as that is a part of their area of expertise.

      Best,
      Daniel

  • I am peri menapausal. I am diagnosed with bi polar 2 and am a ultra rapid cycler. I am trying to understand what is hormonal and what is bi polar mood change. I do wish this article had addressed older women and the hormonal changes involved and how this affects depression and labido.

  • We had tried for yrs to get pregnant, we thot that would make me happy. I was Bipolar Type 1 n didn’t know it…I knew I had mental problems but after about 3 months being psycho n depressed rapid cycling like never before I took a pregnancy test, positive, I started bleeding same day and Dr. said baby was dead. I know being pregnant was HORRIBLE for me and post-partum depression for bout 2 years. Being pregnant drove me into the mental hospital for the 1st time and made me wanna kill me and others, I tried. I wish I could have a family but I live alone at 40. I have made “incremental changes” because I have learned from my past. Bipolar can be great at times but thank God I have experience, medicine and counseling!!!

    • I’m sorry to hear that you had such a difficult experience, Jodee. I’ve also found that the combination of experience, medication and counseling have been helpful. What a great way to put it!

  • I was diagnosed with Bi-Polar II 2 years ago, after having a diagnosis of Major Depressive Disorder for 10 years (which followed a year long diagnosis of Post-Partum Depression). I had actually asked my first psychiatrist about having Bi-Polar after the birth of my 2nd child & he said he highly doubted it & it would take him 6 years to diagnosis it. It was a doctor at CAMH (Centre for Addiction and Mental Health in Toronto, as I’m sure you’re aware of) that diagnosed me after only 3 visits. It was also a doctor at CAMH that informed me that it’s very common for childbirth to trigger manic, or hypomanic, episodes in women with BD. I think the difficulty the first dr. had was that my hypomanic episodes were exhibited with extreme anger/rage. I suffered from mild delusions as well, but not really the grandiose behaviours. The symptoms were definitely worsened by taking multiple anti-depressants over the years. I have found that symptoms are worse at certain times throughout the month as well (very similar to Pre-Menstrual Dysphoric Disorder). Since I was only diagnosed after the birth of my 3rd (& last) child I have no experience with taking medication for Bi-Polar during pregnancy, only anti-depressants. Personally though, I’d do the same thing I did with those. I’d have to consider pros & cons of taking & not taking medication (in terms of safety of myself & the child).

    I’d like to think that my symptoms are improving since proper diagnosis, & with age, although it seems I’ve had more hypomanic episodes than I had before. Of course it could be that I’m just more aware of them now. My recent one started around July 23 (that I noticed anyway), & thankfully I see my dr. tomorrow. (On a side note, my mother was also diagnosed as having Bi-Polar, & my brother has a diagnosis of Schizo-Affective).

    • Thank you for sharing your experiences, Krystal. I’m sure that a lot of women will find it very helpful. As a side note, I was also diagnosed at CAMH.

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Psychotherapy from Daniel

Daniel Bader, Ph.D., RP (Qualifying), CCC

Daniel Bader, Ph.D., is a Registered Psychotherapist (Qualifying) and Canadian Certified Counsellor specializing in bipolar disorder, offering in-person psychotherapy in Kitchener, Ontario, and online and telephone psychotherapy within Canada.

To book an appointment with Daniel, please visit his Psychology Today profile.