Managing Bipolar Disorder During Pregnancy
Dr. Charles Bowden, a leading authority on bipolar disorder, spoke in a podcast about managing medications and balancing symptoms during pregnancy, as well as issues regarding communication between psychiatrist and patient.
Dr. Bowden began by saying that it's almost impossible to tell whether an individual woman will do well during pregnancy in terms of bipolar symptoms or her symptoms will worsen, so the initial strategy is the same in most cases: medication management.
There are three particular medications that have high risk of fetal abnormalities: valproate (brand names Depakote and Depakene), carbamazepine (brand name Tegretol), and Lithium. These three should be discontinued before pregnancy, if possible.
Thus it is important to tell your psychiatrist as soon as you know you are pregnant or as soon as you know you are trying to become pregnant.
Gynecologists prefer that their pregnant patients discontinue as many medications as possible, since so much is not known about their effects and interactions, and their default recommendation would be to discontinue everything. Of course, said Dr. Bowden, this is not always possible, giving the example of drugs that control physical conditions such as diabetes.
It is well known that abruptly stopping many psychiatric medications can have serious mental and physical effects. Thus for a pregnant woman with bipolar disorder, medications should always be tapered off. The psychiatrist needs to observe what happens during the tapering process. If no clinically significant symptoms appear, the tapering continues until the drug is stopped completely. If troublesome bipolar symptoms do occur, then doctor and patient need to reevaluate the strategy.
Dr. Bowden also mentioned that some women who've done well for several months start to show symptoms of depression toward end of pregnancy. The cause of this is unknown; some speculations are that it may be hormonal, or that the larger size of the fetus makes it more difficult for the woman to be comfortable in bed, thus disrupting sleep. In any case, women need to know possibility of this issue. In effect, these are symptoms of postpartum depression that may appear 4-8 weeks before birth.
Because of the need to monitor bipolar disorder symptoms closely, the frequency of a woman's visits to her psychiatrist during her pregnancy probably needs to be increased. But, said Dr. Bowden, "for most women pregnancy is a pleasant experience with bipolar disorder. The discussion here could make it sound as though it's almost worth avoiding pregnancy if one has bipolar disorder, and I think that would be a wrong take-home message either for professionals or for patients to have in regard to what's one of the most important and enjoyable part of a woman's and a couple's lives."
Dr. Bowden concluded by saying that nearly all of the data on managing bipolar disorder during pregnancy disorder comes from open, observational information, but the people who work in this area have been very careful in terms of the way the results have been presented.
I should add that the reason clinical studies on pregnant women taking bipolar disorder medications have not been done is simply that the risk to fetuses in such studies outweighs the benefits. Rather, data on birth defects is generally projected from animal testing, and then gathered by reviewing the data on birth defects caused by particular medications after the fact.
Charles Bowden, MD, is a clinical professor in the department of psychiatry at the University of Texas Health Science Center, San Antonio. He is a well-known authority on bipolar disorder. His research focuses on both the symptoms and biology of bipolar illness and on the effectiveness of drugs and how they affect the body.
- Podcast interview with Dr. Bowden, published on the Psychiatric Times website.
- Biography of Dr. Charles Bowden