Mixed mania associated with cessation of breastfeeding

Abstract

BackgroundThis case chronicles the unique presentation of psychotic mixed mania in a female 5 months after parturition and 1 week following breastfeeding discontinuation, highlighting a rarely recognized mania risk factor that is temporally delayed from parturition: breastfeeding discontinuation.Case presentationA 25-year-old G1P1 female with a past psychiatric history of a depressive episode in adolescence presented to the Emergency Department with her 5-month-old daughter, fiancée, and family 1 week after breastfeeding cessation. She endorsed sleep-deprived energy enhancement, unfulfilled goal-oriented productivity, hyper-talkativeness, hyper-sexuality and increased nicotine use. Concurrent depressive symptoms included hopelessness, worthlessness, poor concentration, lack of appetite, and ego-dystonic intrusive thoughts that she may kill herself or her child. She exhibited pressured speech, affective lability, expansiveness, distractibility, and tangential, grandiose, delusional self-referential content. Transient thoughts of self-harm and harm to her child were not associated with intent. Her family history was significant for a deceased mother who had bipolar I disorder. The patient was hospitalized for 5 days and diagnosed with bipolar disorder, type I, current episode manic with psychotic features with a mixed-feature specifier. Olanzapine and lithium were initiated and the patient’s acute episode of mania resolved prior to discharge.ConclusionsThis case extends the limited literature on mania following weaning and highlights the role of rapid serum dopamine rise following breastfeeding cessation in mania.

Weaning and Mixed Mania—A Case Report

“…The symptoms resolved quickly following treatment with lithium and olanzapine, and the patient was discharged from hospital 5 days later. There are distinct differences between this case and the case described by Schmidt et al (2016), such as the presence of substance abuse with Schmidt et al's patient. However, there are some definite similarities between the two cases, including maternal family histories of bipolar disorder, onset of mood episodes during adolescence, and breastfeeding/weaning female infants.…”

“…There was no previous history of psychiatric illness, but the patient had a depressive episode following the first manic episode that remitted spontaneously 4 or 5 months later. Recently, Schmidt et al (2016) reported the case of a primiparous woman with a past history of depression who had first onset of a mixed episode 1 week after the cessation of breastfeeding. The symptoms resolved quickly following treatment with lithium and olanzapine, and the patient was discharged from hospital 5 days later.…”

“…He also argued that the rapid and significant decline in the prolactin level might trigger puerperal psychosis in predisposed women; however, the breastfeeding-related increase in prolactin levels might delay the onset of mania until cessation of breastfeeding. It has also been suggested that soporific effects of prolactin and oxytocin as well as reduced dopamine tone during lactation may delay the onset of mania (Schmidt et al, 2016). Evidence in support of the protective effect of breastfeeding comes from a large population-based study from Australia that reported a reduction in the risk of psychiatric hospitalization for women with bipolar disorder who were breastfeeding.…”

“…Interesting to note, the contemporary literature on lactational mania is limited to only a few case reports. A Medline search of the literature yielded only two case reports (Joyce, Rogers, & Anderson, 1981; Schmidt, Palmer, & Frye, 2016) and a letter to the editor (Abou-Saleh, 1982).…”

Cortisol, Prolactin, and Breastmilk Volume; A Promising Pattern for Reducing Postpartum Depression

“…At the end of breastfeeding, there is a reversal control of dopamine tonic inhibitors [50], [51]. In breastfeeding mothers with a history of depression in adolescence when high dopamine levels trigger symptoms of manic depression and psychosis [52]. Mothers with a history of depression who weaned prematurely were more likely to have a more severe depressive disorder.…”