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.
Research on Bipolar Disorder Postnatally
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
References
- 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.
I realize the topic of this post is about pregnancy, but I think the decision to have children is just as important for men as it is for women. Obviously the men don’t have the same health concerns as women during and after pregnancy, but men can pass on mental illness to their children as well.
I have had bipolar disorder since I was a teenager; I have a daughter with disabling schizoaffective disorder, and a son with periodic depression. I have had to deal with feelings of guilt because I have felt like it is my fault they have grown up with mental illness. I realize it no one’s fault, we simply lost the genetic lottery. I just didn’t know the risks at the time.
I was adopted as a baby, and I did not find my biological family until my mid-thirties. It turns out there was a family history of significant mental illness and addiction which I did not know about. If I had this information 20 years ago, I may have chosen to not have kids.
I hope my own kids will be very mindful if they decide to have children. I will share with them all the information I can find, including this post.
I would like to weigh in with a success story on this topic. I “discovered” my bipolar at the beginning of my pregnancy. I participated in a study at Northwestern University for the usage of lamotrigine during pregnancy (I was already on it) under the care of a wonderful psychiatrist who taught me so much about how lamotrigine is metabolized during preg. Non- pregnant I take 200mg per day. While preg I went as high as 600mg. Your blood volume increases massively while preg, therefore you metabolize drugs much faster, and therefore need higher doses to maintain the same level in your blood system. As she explained to me, lamotrigine is considered very safe and has a longer research history than other drugs because it’s been around for decades (since it’s an anti-epileptic). Throughout pregnancy it was a constant catch up game to keep my doses in line with my symptoms. I was a miserable non-functioning suicidal mess. I had to quit my job. Once we did catch up with meds around 7months, I did amazingly well and continued to do so post-partum.
Of course these things are a case by case decision. In mine, the benefits greatly outweighed the risks. The psychiatrist’s name is Crystal Clark, MD at Northwestern University so you can look up her publications. She regularly speaks to obstetricians about treating bipolar during pregnancy, of whom many have little or no experience handling it.
Thank you for an informative article. I know you don’t mean to frighten people, but they absolutely should be frightened by the possibilities that come with bipolar disorder and pregnancy…and not just the medication aspect of it. I think a good thing to do if you have bipolar disorder and are thinking of getting pregnant is to look at your relatives. I was not told anything about the mental illnesses in my family….my parents avoided “that side” of the family. Had I known what was lurking in my genes, I would have thought much longer and harder about having children, rather than being so eager to have a baby right after getting married. Not only did my mild depression explode into bipolar disorder after having kids, my kids both have multiple problems. Autism, bipolar disorder, ADD, anxiety, OCD, panic disorder, eating disorder. I had a tubal ligation immediately when I found out my son was autistic 15 years ago, and boy am I glad I did. Things got so much worse after that, and adding another child to the two we had… it would have been the worst thing we could have done. My life is not easy, and I break down constantly from stress, even though I am permanently disabled and don’t work outside the home. We have managed to do pretty well with our kids, but I did not expect my life to be like this. Constant financial strain from medical bills and my husband having to take so much FMLA, a near-divorce, my husband breaking down completely from stress, constant fighting the school system because they don’t want to deal with a “problem” child, and friends and relatives who are only there when you don’t talk about how complicated your life is. I just had my uterus and ovaries removed because pre-menopause was affecting the bipolar so badly I was consistently physically collapsing from rapid cycling. And the tiny bit of respite care we had for years was recently cut by our state government. I’m a pretty cheerful person who tends to look on the bright side, but even I have periods where I just despair that I will ever have a break or any peace in life. If I knew anyone who had bipolar disorder and who was thinking of having children, I would point out that my life could easily become their life. You have to have a massive amount of strength to keep going.
I have bipolar 2 . I had both my daughters before I knew that is what I had. I was unmedicated during pregnancy. I felt great during both pregnancies, surprisingly euthymic . My kids are now adults. One of them has bipolar 2 and is doing extremely well on meds. The other has no mood disorder and has always done very well. Both are successful independent adults who are understanding and compassionate. My understanding of mood disorders helped my bi-polar daughter handle hers. They are spectacular people , and I could not be prouder of them. Would I have had them if I had known the extent of my own problems? I’m not sure. It’s a tricky question, but my kids did well, and I am very glad they exist!
Thank you for posting this. I’ve been in turmoil over whether to get pregnant, and having these resources help.
Hi Wendy,
That’s great to hear. That was my goal — to help women make the best decisions for themselves.
– Natasha Tracy
Any pharmaceutical medication or any other substance that you consume while pregnant.. will have likely (not always, but likely) adverse effects on the fetus. It matters not whether it is mood stabilizers, anti-psychotics, anti-epileptics (often used as mood stabilizers) or anti-depressants. It could also be any other med for any other condition.
Being we are in the society that we are now… anything can be diagnosed as something and there are meds and substances galore for all of them.
If you are taking any type of medication for any type of condition, be it mental or otherwise (cause it really is either/or), and you inadvertently become pregnant or purposefully become pregnant… talk with your doctor and research ALL pros and cons.
Way back in the day – many civilized societies – oh say 40 years and further back…
many with mental illness, women primarily cause well really, were forcibly sterilized in an attempt to not replicate the madness, so to speak. Whether many of those many women (not all, many) ACTUALLY had mental illness, remains to be seen (since it can be so misdiagnosed). Yet, they were forcibly sterilized and/or their children removed from their care and thus, were labeled “unfit”. This, of course, furthered the stigmatization of those with mental illness… do not allow them to spawn madness into future generations.
The women of which this occurred to, were stripped of their choice. Those who actually had children, many of them saw the loss of their children due to removal… again, stripped of their choice.
If you are diagnosed with mental illness of any kind…. and you become pregnant or want to become pregnant… talk at great length with your professional support team, your family, your partner/spouse (really, nowadays, ya don’t need one but if you have one)… do research and come to your own decision.
Not all spawn replicates. Many, who have children, have fairly decent respectable human beings as adults who go on to lead fairly decent lives.
Side note: I am 1 of 3 daughters born to a woman diagnosed back in the early 70’s. I am the only 1 of the 3 children birthed who has had mental illness diagnosed time and again.
My mother was one of 4 children birthed to a woman who likely had Recurring Major Depression. My mother was the only 1 of the 4 children ever diagnosed with mental illness.
One of my mother’s siblings… has a granddaughter who has been diagnosed since she was 5 (she is now 21). That person is one of 2 children born to the same mom.
So… Of my grandmother…. cause she is as far back as I can go:
she had 10 grand-children (I am one) and 11 great-grandchildren.
out of 22… only 2 have been, so far, diagnosed with an actual mental illness. I note actually diagnosed as having an actual mental illness. Which leaves 20 humans beings within same family… who have not, so far.
Talk with your professional support network, talk with your family… research… make an informed decision. If you have personal misgivings and feel you are personally unable to handle the demands of raising a child and/or children… then give even more thought.
You have a choice, do not allow others to fear you out of or to strip away… your choice.
If it merely you are afraid of replicating…. there are many who are in the foster care system and the adoptive system. There are also many who are in mentoring programs of which you can mentor a child for however long you desire.
There are other avenues of which you can “parent” without actually being… a parent.
Hi Tabby,
I want to be clear that this isn’t about scaring women. This is about medical research and the facts. This is what women _should_ know to be informed when making decisions about their lives. I fully support a woman’s right to do what she wants but I also think she should walk into any situation armed with accurate information.
– Natasha Tracy
Hope you don’t mind, Natasha, my sharing a link to my Huffington Post article about postpartum bipolar disorder (bipolar, peripartum onset) a.k.a. childbirth-triggered disorder.
I wish I knew I had bipolar disorder when I was pregnant or before I decided to become pregnant, but unfortunately that was not the case.
http://www.huffingtonpost.com/dyane-leshinharwood/postpartum-bipolar-disorder-the-invisible-postpartum-mood-disorder_b_9419484.html#comments
Thanks so much for writing this excellent post!
Dyane
Well done Natasha for taking time to research and précis this info for Bp folk thinking about or finding themselves pregnant . Always tricky putting info out there when there is always someone who will disagree( sometimes in a loud way!). Useful addition to consider for any clients that might come to me with similar. Thank you
Kind regards
Julia
Hi Julia.,
Thank you so much. I get asked about pregnancy and I’ve been wanting to write something like this for a long time for those people. But, as you said, it takes quality research. So, people can argue loudly, if they like, but I know that everything in this article is accurate and current according to the literature. That’s the best I can do.
– Natasha Tracy
Very good article. I want to mention an excellent (but more general) resource run by Sick Kids in Toronto: http://motherisk.org
They have articles on various medical risks in pregnancy, as well as a call centre available for Canadians and their health care providers to answer questions about particular situations, including good coverage of mental health medications and illnesses.
In the US, http://mothertobaby.org provides a comparable resource.