Bipolar disorders: special diagnostic and treatment considerations in women

Bipolar disorder in women presents special diagnostic and treatment challenges to the clinician. The presentation of female bipolar may resemble depressive disorders, comorbid Axis I disorders, Axis II personality disorders, behavioral dysregulation, or general medical disorders; thus, it is critically important for clinicians to assess for a history of hypomania or mania when determining diagnosis in any woman presenting with psychological symptoms. Several gender differences may exist in the epidemiology and symptomatology of bipolar disorder, and each must be kept in mind during assessment. Rapid cycling and mixed states have been associated with female gender and may present diagnostic challenges as each often presents as major depression. Symptoms of postpartum psychosis tend to differ from the symptoms typically seen in bipolar mania; therefore, if postpartum psychosis is actually a manifestation of bipolar disorder, accurate diagnosis depends upon a knowledge of these differences. Special treatment considerations for bipolar disorder in women involve interactions between the illness and the female reproductive cycle. A risk of fetal malformation exists when some mood-stabilizing agents are used during conception and/or during the first trimester of pregnancy. Neurobehavioral teratogenicity and neonatal toxicity is also possible. Careful treatment management is necessary to reduce the risks to the fetus/infant and to effectively manage bipolar disorder in the mother. In treating women with bipolar disorder, clinicians should discuss the issue of pregnancy and associated risks of treatment versus no treatment with every patient of reproductive age. Further studies are needed on gestational timing and exposure to mood-stabilizing agents, especially newer agents recently approved or currently being considered for the treatment of bipolar disorder.