Pregnant women with bipolar disorder (BD) have a high risk of illness relapse postpartum, including psychosis. Postpartum mood episodes occur in a psychologically sensitive phase of life and present significant implications for the mother, the infant and the father. Despite the high risk, there is a scarcity of studies regarding the perinatal impact and management of BD. In particular, there is a significant knowledge gap regarding the perceived needs of women with BD in the transition to motherhood and on mother-infant interactions in the context of maternal BD.
The aim of this thesis was to generate knowledge that may inform more comprehensive and psychologically oriented perinatal care for women with BD and their families that responds to the complex challenges of becoming a mother with an enduring severe mental disorder. The main objective of this thesis was to investigate the transition to motherhood, from a subjective and dyadic perspective, for women with BD. To fulfil this objective, we conducted a prospective mixed methods study, where women with BD and their infants were followed up from pregnancy/maximum three months postpartum to 12 months postpartum.
In Paper I, we chose a qualitative approach to investigate how perinatal women with BD relate to the risk of illness relapse postpartum. This approach enabled us to explore subjective experiences in an open and inclusive manner and to obtain detailed and rich information. We individually interviewed 13 primiparous and 13 multiparous women with BD in pregnancy or early postpartum. We explored the women’s concerns and how they prepared for the dual demands of mood episodes and motherhood. In Paper I, we thus describe the contents of women’s perinatal concerns as well as their perceptions of their resources and preparations. A main finding was that even if women with BD are aware of the postpartum risk, they relate to it differently, expressing low, moderate and high levels of concern, which in turn, impacts their perinatal deliberations and preparations.
In Papers II and III, we describe mother-infant interaction patterns in dyads in which the mothers have BD (N=26 in Papers II and III) compared to dyads in which the mothers have no mental disorder (N=30 in Paper II and N=28 in Paper III). We assessed maternal, infant and dyadic interaction behaviours. For these investigations, we employed a quantitative methodology with standardised assessments. In Paper II, we examined mother-infant interactions at three months postpartum and whether concurrent affective symptoms of mothers with BD were associated with interaction quality. In Paper III, we investigated the patterns and development of mother-infant interactions from 3 to 12 months.
The main findings of both papers were that there were difficulties with dyadic coordination and reciprocity in mother-infant interactions among the BD dyads. The mothers with BD and their infants experienced challenges in “finding” each other and sharing a positive “rhythmic dance”. Subdued expression of positive affect and mutual underinvolvement represented core challenges in maternal and infant behaviours. On the positive side, there was little expression of negative affect or tension in maternal, infant and dyadic behaviour, and some positive changes in infant behaviour from 3 to 12 months were observed. At three months postpartum, we could not find significant associations between maternal symptom load and interaction quality. The interactional findings suggest that mother-infant interaction patterns may enhance the developmental risk for bipolar offspring.
A conclusion, and the main clinical implication of this thesis, is empirical support for the importance of more comprehensive and psychologically oriented perinatal care for women with BD and their families. In perinatal prevention planning and counselling, women with BD ought to be given opportunities to share their thoughts, concerns and deliberations and should be encouraged and supported in making adaptive preparations for childbirth and the postpartum period. In postpartum follow up, early detection of maternal mood deviations is crucial, and mother-infant interactions need to be targeted to promote resilient infant development.