In part one of this sharepost on women and bipolar, I highlighted the fact that gender differences exist most notably in the significantly higher rate of rapid-cycling in women. In addition to hypothyroidism and gonadal steroid effects, a third risk factor exists that may predispose women to rapid-cycling. It is well established that antidepressant medication can precipitate manic episodes. At face value this would seem to suggest an avoidance of antidepressants, but the picture is less clear. Leibenluft (1998) points out that manic episodes caused by mono-amine oxidase inhibitors (MAOI's) are much milder than those caused by tricyclics or SSRI's such as fluoxetine (prozac). A state of deep depression could very well merit the use of MAOI antidepressants.
Some experts have suggested increasing mood stabilizing medication but this seems to result in more severe depression. Rapid-cycling certainly can be reduced in this way but, as Leibenluft states, "bipolar patients may prefer a rapid-cycling course to a severe, lengthy (and frequently suicidal) depression". Clearly the development of an antidepressant that would not result in mania would be a significant step forward.
The trade-off between the use of antidepressant medication and mood stabilizers is just one of the problems that confront women with bipolar. Another significant issue is pregnancy. It is known, for example, that lithium can cross the placenta and result in fetal defects. Mood stabilizers are also associated with polycystic ovarian syndrome, heart disease and cancer of the uterus. After the birth of a child women with bipolar are at greater risk of severe postpartum depression. Michael Aronson, MD, a clinical psychiatrist and consultant for the website WebMD states, "The interesting thing is, sometimes pregnancy by itself will stabilize someone with bipolar disorder. At other times, it can destabilize them. The best alternative for someone who is pregnant, who is having problems with depression or mania and cannot be placed on an adequate dose of medication, is using ECT. It's very effective and it's safe."
This sharepost has just scratched the surface of an immensely complex set of issues. It seems clear that while some progress has been made there is a long way to go before research can fully unpick the very particular issues associated with women and bipolar.
Leibenluft, E. (1996) Women With Bipolar Illness: Clinical and Research Issues. American Journal of Psychiatry. 153: 2. 163-173
WebMD Bipolar Disorder Guide (2008) Women With Bipolar Disorder. http://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-women