The impact of reproductive events on women with severe mental illness: we need more research and professional awareness

Howard et al's masterful review of women's reproductive mental health1 highlights how neglected this essential component of women's lives has been, and how much gender discrimination and stigma have hampered research on the development of much-needed treatments and preventive strategies. As a mental health researcher with lived experience of bipolar disorder and postpartum psychosis, my work has focused on women with severe mental health conditions and the times of their lives when they are most likely to experience episodes of illness. These times are frequently related to their sexual and reproductive life: menarche, menstruation, sexual activity, pregnancy and childbirth, and peri-menopause. It is at these times that their mental health problems are often triggered or exacerbated, though disappointingly little research has been done on this. As someone involved with four maternal mental health char- ities, I have heard several accounts of women who had been sta- ble for many years and then were suddenly admitted for long hos- pital stays around the time of menopause. Or others who had a post- partum psychosis 25 years earlier, becoming desperately ill and suicidal completely out of the blue. Yet clinicians seem ignorant of this risk. Why? Because so little research has been done into it. Premenstrual triggering or exacerbation of mental disorders has received little attention until recently. The research which has actually been done has shown that reproductive cycle-associated mood symptoms are commonly reported in women with major depressive disorder and bipolar disorder2. In a US sample of 2,524 women, 67.7% of those with mood disorders reported premenstrual mood symptoms, compared to only 33.7% of women without a psychiatric diagnosis. A systematic review of 35 prospective studies concluded there was clear evidence of premenstrual symptom exacerbation for most serious mental disorders, hypothesizing that there may be a sizeable subgroup of hormonally sensitive individuals who are affected3. From women's point of view, the stigma around talking about “periods” (especially for some minority communities) deters them from asking for help with what can often be extremely difficult symptoms. For example, in a survey conducted by the Bipolar UK charity (including over 1,000 women with bipolar disorder), 65% reported that premenstrual syndrome significantly worsened their mood, with increased irritability and anger, and yet over half said that they had not told their doctor. If women do ask for help, they are often denied it. One woman said: “I track my mood. It's very clear that 7 days before my period starts my mood is badly affected. I've tried to highlight this with my mental health nurse and psychiatrist. I feel it's been ignored or dismissed”4. The lack of research on the psychiatric effects of hormonal fluctuations encourages clinicians to ignore the problem. An illustration of this was provided by the answer to the UK Bipolar Commission's question: “Has anyone in your health care team ever given you information about how hormones can affect your bipolar disorder?”. Eighty-five percent of women answered “No”4. Many women with severe mental illness experience a similar lack of information and treatment for hormone-related problems in the menopausal transition. Recent evidence documents that a link exists between peri-menopause and a worsening of mood symptoms as well as an increased risk of new-onset mood disorders. In a population-based UK Biobank study5 with 128,294 female participants, the first-onset rates of bipolar disorder and major depression significantly increased in the four years around menopause. Bipolar I disorder showed the largest effect (an 112% increase), while the increase was 30% for major depression. No association was found for schizophrenia-spectrum disorders. This lends weight to observational studies reporting a higher risk of relapse in these conditions at peri-menopause6. It is essential that women with serious mood disorders, some at risk of suicide, are made aware of these dangers. When the UK Bipolar Commission asked women with bipolar disorder if they knew that peri-menopause could be a time at higher risk of relapse, only 35% said they did4. Another area which is largely ignored by clinicians and researchers, but which causes a huge amount of suffering to women with severe mental illness, is that of hypersexuality. This is particularly a problem for people with bipolar disorder, and especially for women, who report increased vulnerability to rape (28%) and sexual assault (42%)7. This was highlighted in a recent report8, drawing attention to the fact that diagnostic classification systems do not recognize the seriousness of this problem and its often devastating consequences: unwanted pregnancies and abortions, marriage breakdown, job loss, and exacerbation of mood swings. Partly because women behaving in a sexually uninhibited and proactive way is socially frowned upon, there is a reluctance to talk about this issue and, according to survey evidence gathered by Bipolar UK, clinicians are similarly reluctant to enquire about it. Many women thus suffer in silence for decades, crippled by shame and guilt at how “their illness” made them behave (often before they had received a diagnosis or learnt that such behavior was characteristic of their condition). Many report that this problem increased their poor sense of worth and exacerbated their depression7. It is dismaying that very little research has been done on this issue. Only one small qualitative study9 has investigated the experience of three women and two men. No research has looked at the consequences of this behavior, whether any patients are offered psychological treatment or, crucially, why this behavior occurs in mania and hypomania. Many people believe that this is a manifestation of manic high energy, self-aggrandisement and recklessness. Dopaminergic pathways in the brain have also been implicated. Some women report that this behavior “takes them over” at particular stages of their menstrual cycle, so sex hormones may also be implicated. Research focusing on possible biological causes may potentially lead to preventive interventions. Now that it is more acceptable to talk about “periods” and “menopause”, perhaps the research community can begin to more deeply investigate the relationship between women's hormonal fluctuations and their brain chemistry. For those of us who live with severe mental illness, and struggle to adapt our lifestyles to reduce the risk of relapse, greater knowledge about how hormones impact our mental health would be invaluable. Just as research into the level of postnatal risk faced by a woman with bipolar disorder arms her with the knowledge of how best to prepare for that risk, so research on how hormonal changes at other times in the life course affect severe mental illness would potentially give women more control over the condition that blights their lives.