Medication treatment for bipolar disorder during pregnancy and breast-feeding

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Bipolar disorder presents many challenges for women who want to have children, writes William R. Marchand, MD in his new book Depression and Bipolar Disorder: Your Guide to Recovery. "This is because of the severity of the illness as well as the fact that many medications used to treat this disorder are known to cause birth defects," writes the author. The following is an excerpt from the book, reprinted with permission from the publisher.

As with major depression, women with bipolar disorder have a high risk of relapse during pregnancy506 and after delivery.507, 508 But, these rates are similar to those among nonpregnant women, which suggests that pregnancy itself may neither increase nor decrease the risk of relapse. Unfortunately, the baseline risk of relapse after stopping medication is very high for bipolar disorders. Further, while treatment with psychotherapy alone may be effective in preventing relapse for some women with major depression, there is currently no evidence that this strategy is effective for bipolar disorder. The conclusion is that there may be no available option that is completely free of risk. On the one hand, stopping medication is associated with a risk of relapse of illness; on the other, taking medications may expose the child to some risk of adverse effects. So, advance planning is essential for those who have bipolar disorder and want to become pregnant. It may not be possible to eliminate risk completely, but you can develop a plan that minimizes risks for both you and your child.

Medication treatment for bipolar disorder during pregnancy and breast-feeding
Antidepressants are sometimes used for the treatment of bipolar depression (see Chapters 8 and 11 for more information). Please see the preceding section for information about using these medications when pregnant or nursing. Everything I said about using antidepressants for major depression applies to bipolar disorder. Current evidence indicates that individuals with bipolar disorder require ongoing treatment with a mood stabilizer to avoid relapse (see Chapter 11 for more information). Unfortunately, many medications that provide mood stabilization also are known to cause birth defects when taken by pregnant women.

Lithium is one of the most effective treatments for bipolar disorders (see Chapter 8 for more detailed information about lithium). The risk of birth defects has been thought to be very high with lithium, although some recent evidence suggests that the risk may be less than originally thought.510 Nonetheless, first-trimester exposure to lithium is associated with a greater relative incidence of cardiovascular malformations compared with that in the general population.505, 510 Several anticonvulsants are also effective as mood stabilizers (see Chapter 8 for more information). Among these, valproate and carbamazepine are known to increase the risk of birth defects during pregnancy, and there is some evidence that lamotrigine may as well.505 Finally, second-generation antipsychotics are also used for bipolar disorder. There is very limited evidence in regard to the potential risks associated with the use of these medications during pregnancy.505, 511 In regard to treatment during breast-feeding, lithium, valproate, carbamazepine, and lamotrigine are secreted in breast milk.509 Please discuss with your treatment team the risks and benefits of breast-feeding while taking these medications.

Recommendations
As I said earlier in this section, bipolar disorder presents many challenges for women who want to have children. Decisions about pregnancy and treatment are very complicated.

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In order to minimize risk, advance planning is critical. If you have bipolar disorder, please take precautions to avoid unplanned pregnancy. My strongest recommendation is to take your time and gather as much information as possible when considering pregnancy. Also, please do not make a decision based only on reading this book. Each woman’s situation is unique and the various options can be complicated. Talk to your treatment team, including your obstetrician, about your desire to have a child. Once you have gathered information and all of your questions have been answered, you can make a thoughtful and well-informed decision about pregnancy.

Premenstrual dysphoric disorder
Premenstrual dysphoric disorder (PMDD) is a mood disorder related to a woman’s menstrual cycle.512 The DSM-IV-TR (see Chapter 2 for more information about this manual) lists PMDD in an appendix as a disorder that requires further study.38 PMDD was placed in the appendix because the experts felt there was not enough evidence available to include it as an “official” disorder. The diagnostic criteria may be revised over time based on further research. Currently, PMDD is defined as a condition causing symptoms such as depressed mood, anxiety, loss of interest in activities, and rapid changes in emotional state (labile mood). These symptoms typically come on during the week prior to menses and disappear after the onset of menstruation. As currently defined, the diagnosis requires at least five of the symptoms listed in Table 12.5.38 These symptoms must be present most of the time during the week prior to menses, and at least one of the symptoms must be one of the first four on the list. Also, the symptoms must have occurred most months for at least twelve consecutive months. Finally, the symptoms must cause impairment in functioning. The DSM-IV-TR differentiates PMDD from more common minor premenstrual symptoms, commonly known as premenstrual syndrome or PMS, which may affect as many as 70% of women.

A number of disorders can result in symptoms similar to those of PMDD associated with menstruation and should be ruled out. These include autoimmune disorders, diabetes mellitus, anemia, hypothyroidism, dysmenorrhea, and endometriosis. Symptoms of both depression and bipolar disorder worsen prior to menses, so it is important to determine whether the condition is actually PMDD or another mood disorder.

The biological cause or causes of PMDD are currently unknown. The primary hypothesis at this time is that dysfunction in female sex hormonal changes related to the menstrual cycle underlie this condition. Abnormal function of the neurotransmitter serotonin has also been implicated. There is some evidence for an inherited increase in risk for developing PMDD. Finally, in regard to psychological factors, stress is associated with this illness.

Several treatment approaches may be beneficial for PMDD. Adopting a more healthy lifestyle may be helpful for some. Additionally, relaxation therapy and psychotherapy can lead to a reduction of symptoms. If medication is required, the SSRI antidepressants are frequently effective (see Chapter 8 for more about these medications). Finally, suppressing ovulation by controlling the usual hormonal fluctuations associated with the menstrual cycle can be effective.512 Oral contraceptives and other medications have been used for this purpose.

Excerpt from Depression and Bipolar Disorder: Your Guide to Recovery
William R. Marchand, MD
Copyright - 2012 by Bull Publishing Company
ISBN 9781933503998
Bull Publishing Company

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