Medical Research on Bipolar Disorder and Pregnancy
People ask me about the research on bipolar disorder and pregnancy quite a bit. Now, I am not a doctor and nor do I claim to be one; moreover, this is a subject that I haven’t studied exhaustively so I tell these women to talk to their doctors. Unfortunately, that’s the best advice I have been able to give about bipolar disorder and pregnancy.
That said, I read a new paper on bipolar disorder in pregnancy and I thought I would take the time to summarize some of its recommendations regarding pregnancy and bipolar disorder. I’ll add my two cents here and there (clearly noted as just my opinion), but for the most part, this advice comes from the references following the article and not from me. If any of the below concerns or interests you, please check the references and discuss it with your doctor.
And I must remind you: even though I am referencing everything with a scientific source, there is no accounting for your particular situation and history. That means that, sometimes, you may decide to go against what the literature says because it is best for you. Only you and your doctors (probably an obstetrician and a psychiatrist) can make those kinds of decisions.
If I Have Bipolar Disorder, Will My Child Have Bipolar Disorder, Too?
Before we start, one thing I think every woman who is considering having a babe should know: if you have bipolar disorder and you have a child, your child has a 50% chance of having a serious mental illness (not necessarily bipolar disorder). Please, please think about this before having a child. More serious risks for a child with a bipolar parent are documented here.
Bipolar Disorder and Prepregnancy Treatment Planning Advice
One of the big things Optimizing the Treatment of Mood Disorders in the Perinatal Period advises is to make a treatment plan before you get pregnant. Really, it’s best to weigh all the pros and cons of treatment and risks during pregnancy before you are pregnant because that may affect your decision to get pregnant. This also gives you the chance to get genetic counselling at this time.
Of course, this isn’t going to happen with every woman, but, overall, I agree with the idea.
This prepregnancy treatment plan would include what to do preconception, postconception, during labor and postnatally. I would suggest this plan is particularly important in the event that something bad (such as postpartum bipolar psychosis) happens and you can no longer make your own treatment decisions.
Research on Pregnancy and Bipolar Disorder During Preconception
One paper recommends that some drugs, like valproate, should be avoided, if possible, in all women of childbearing age because it so dangerous to a fetus. Personally, I think that’s nice for a researcher to say, but not reasonable for most women. If valproate is the drug that works for you, it’s unlikely you’ll avoid it just because you happen to be under 40.
Additionally, it should be noted that if a woman has only experienced a mood disturbance in relation to pregnancy (say, postpartum depression), she is at less of a risk to relapse during pregnancy; if she does relapse, it will likely be postpartum again. If, on the other hand, mood disturbances are not only related to pregnancy then the woman is at a higher risk of relapsing during pregnancy as well as postpartum.
Research on Bipolar Disorder During Pregnancy
Making the decision to stop medications is a personal and difficult one. (You might want to also look at my article Can You Treat Bipolar Without Medication?) Again, it comes down to you, the severity of your episodes, the number of episodes and your personal circumstances as to what you will choose with your healthcare providers. Here are some things to keep in mind according to recent research:
- If you discontinue mood-stabilizing medication, there is double the chance of bipolar relapse and a shorter time to relapse.
- Anticonvulsants (mood stabilizers, unfortunately) like carbamazepine, lamotrigine or valproate all have negative impacts on the fetus (such as malformations, lower IQ and greater risk of autism spectrum disorder as seen with valproate) that can be seen all the way up to six years of age (I’m guessing beyond that, too, but studies have only run up to six, I believe; by the way, this data comes from women with epilepsy, but there is no reason to think the outcomes wouldn’t be the same for bipolar women). Lamotrigine may be the least harmful of the class.
- There is some evidence that use of lithium creates the risk of Ebstein’s anomaly, but evidence is conflicting on this point so some do consider lithium “safe” to use, specifically during the second and third trimesters.
- If you do decide to use lithium during pregnancy, you need to have your levels checked more frequently and one paper recommends it be stopped at the onset of labor and reinstated after delivery. This is considered “critical” due to the fluctuations in fluid status that occur during this period (and the fact that lithium is excreted through the urine).
- Atypical antipsychotics appear not to have the risk of malformation of the fetus but other risks are not known due to small study sizes.
- Recent studies have shown that antidepressants (selective-serotonin reuptake inhibitors, SSRIs in this specific meta-analysis) in pregnancy are associated with the risk of autism spectrum disorder in the fetus.
- While other risks, such as preterm birth, primary persistent pulmonary hypertension of the newborn, risk of autism spectrum disorder, attention-deficit/hyperactivity disorder, and cardiac effects, with antidepressant exposure appear small, concerns over them have been raised. The literature is inconsistent on some of these points.
- Benzodiazepines (typically for anxiety) are generally considered safe during pregnancy.
- Note that any drug used in pregnancy can result in withdrawal symptoms in the newborn but these are generally short-lived.
It should be noted very clearly that children born to mothers who are actively in a mood episode are also harmed, sometimes even long-term. For example, children born to depressed mothers show disruptive social behavior, depression, and changes in the period of sensitivity for language discrimination.
One paper points out that intensive therapy such as interpersonal therapy or cognitive behavioral therapy during this time is also an option for some people (instead of, of along with, medication).
Risks of Bipolar Disorder Postnatally
The big risk of getting pregnant with bipolar disorder is a relapse. This relapse could happen during the pregnancy (commonly in the third trimester) or it could happen postnatally. The odds against a woman are staggering.
- “Clinical and population registry studies are consistent in finding that bipolar women are at very high risk (at least 1 in 5, 20%) of suffering a severe recurrence following delivery. If episodes of nonpsychotic major depression are also included, women with bipolar disorder are at an even higher risk (approaching 1 in 2, 50%) of experiencing an episode of mood disorder in the postpartum period.”
- It is worth noting that these risks are higher for those with bipolar I over those with bipolar II.
- Women who have experienced a psychosis related to a previous pregnancy or who have a first-degree relative who has experienced pregnancy-related psychosis are at a greater than 50% risk of postpartum psychosis.
- About 4% of women with postpartum psychosis kill their child. This risk to child and mother is why it’s critical to treat postpartum psychosis as an emergency.
- Lamotrigine and valproate appear to be safe during lactation (not pregnancy).
These studies are not encouraging, I understand, but, remember, if half of all women with bipolar disorder experienced a relapse after birth then that means that half did not.
If you’ve stopped your medication because of pregnancy, you’ll want to discuss (preferably far ahead of time) whether you want to restart it now, during this high-risk period. Of course, if you do this, it will likely mean that you won’t be able to breastfeed (although not always), but that is a tradeoff worth making for many women who are considered at a high risk of relapse.
Some studies support lithium during this time period to prevent possible mood episodes; however, there are concerns regarding “fluid shifts at the time of childbirth and concerns about exposure during lactation, and therefore atypical antipsychotics are often used but without a solid evidence base for this specific indication.”
If you do experience postpartum mood episodes, your functioning can deteriorate rapidly and hospitalization is generally needed for postpartum psychosis. Of course, medications are normally used at this point to treat the episode but repetitive transcranial magnetic stimulation (if available) or electroconvulsive therapy (ECT) may be chosen because of the ability of the mother to continue breastfeeding. (Note: sometimes ECT is chosen because it’s, typically, the fastest acting treatment.) (Aside: if you’ve had ECT at any time, please take this very important, short and anonymous survey on patient perspectives of ECT.)
Please note that one of the big things that can affect whether you relapse or not is sleep. Most new mothers are heavily sleep-deprived, which is understandable, but this just may not be acceptable to a new mom with bipolar disorder. Rearranging things so that the partner or a family member feeds the baby at night may be an important part of remaining relapse-free.
Deciding on Whether to Get Pregnant with Bipolar Disorder?
I have decided not to have children, in large part due to bipolar disorder. This is not a judgement about those who choose differently. Not every person with bipolar is like me (obviously). If you’d like to read about my decision, you can read about it here:
- I Can’t Get Pregnant – I Have Bipolar Disorder
- Bipolar Disorder and Pregnancy: Bipolar Taking Away Choice
- Acute and long-term behavioral outcome of infants and children exposed in utero to either maternal depression or antidepressants: a review of the literature. Suri et al. 2014.
- Diagnostic Precursors to Bipolar Disorder in Offspring of Parents With Bipolar Disorder: A Longitudinal Study. Aselson et al. 2015.
- Fetal antiepileptic Drug Exposure and Cognitive Outcomes at Age 6 Years (NEAD study): a Prospective Observational Study. Meador et al. 2013
- Living with Uncertainty: Antidepressants and Pregnancy. Jones et al. 2014.
- Managing Your Own Mood Lability: Use of Mood Stabilizers and Antipsychotics in Pregnancy. Wichman. 2016.
- Mood Stabilizers in Pregnancy and Lactation. Grover et al. 2015.
- Optimizing the Treatment of Mood Disorders in the Perinatal Period. Meltzer-Body. 2015.
- Postpartum Psychosis: Detection of Risk and Management. Spinelli. 2009.
Other Bipolar Disorder and Pregnancy Resources
Note that these are not scientific resources but, rather, other resources or support groups. Please always consider the source of this information.
- Bipolar Disorder, Pregnancy and Childbirth by Bipolar UK
- Massachusetts General Hospital Center for Women’s Mental Health — A reproductive psychiatry resource
- Bipolar Mom Life — Note that this is a blog and only contains personal opinions.