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Bipolar Disorder and Pregnancy: Asking the Right Questions

PregnancyBipolar disorder can present additional challenges when it comes to being pregnant. What medications are safe for the fetus? Would going without medication put the mother and fetus at even greater risk? How might medication disruptions harm the mother and child by inducing postpartum psychosis, which women living with bipolar disorder are 100 times more likely to experience? CNN attempts to strike a balance between the viewpoints of several women who have found different answers to these questions in the article “Do Pregnancy and Bipolar Disorder Mix?

The fact is, pregnancy and bipolar disorder do mix. An article for the Substance Abuse and Mental Health Services Administration by Nicholson, Bieber, et al., found that “68 percent of women living with severe and persistent mental illness are mothers, compared to 62.4 percent of women with no such disorder.” Yet, as CNN notes, “As recently as 10 years ago, doctors advised women with bipolar disorder not to have children.” While things have progressed since then, clearly more research is needed on the safety—for mother and child—of taking psychiatric medications during pregnancy.

“We found in our study that what predicted the greatest risk was stopping medication. It's almost as if stopping maintenance medication trumps everything else; it's such a powerful risk factor, it's hard to tease out whether pregnancy is a risk factor in itself.”

One of the challenges for a woman seeking to become educated about treatment during pregnancy is that research articles may be difficult to comprehend. The Massachusetts General Hospital Center for Women’s Health blog is a good destination for readable information on psychiatric medications and pregnancy. One of the doctors associated with the center, Dr. Adele Casals Viguera, is an authority on bipolar disorder and expectant mothers. In a 2005 interview with Medscape she said that out of a study group of women living with bipolar disorder, 45 percent were advised by clinicians to avoid pregnancy. By contrast Viguera says, “We found in our study that what predicted the greatest risk was stopping medication. It's almost as if stopping maintenance medication trumps everything else; it's such a powerful risk factor, it's hard to tease out whether pregnancy is a risk factor in itself.”

Some of the things every pregnant mother struggles with can be especially important for women living with bipolar disorder. For example, sleep disturbances, which are common during pregnancy, can be a risk factor for a manic episode. Mothers-to-be should monitor their sleep and be on the lookout for the signals of a mood shift—which may be heralded by certain thoughts, behaviors or even a piece of music they tend to listen to.

Depression is another frequent occurrence during pregnancy—some have estimated that between 14 and 23 percent of all women experience symptoms of depression while they are expecting. This is especially challenging for women living with bipolar disorder, as it is more difficult to treat bipolar depression. The STEP-BD studies sponsored by the National Institute of Mental Health found that therapy was more effective than antidepressants in treating the depressed phase of bipolar disorder. The STAR*D study by the National Institute of Mental Health was the largest clinical trial for depression and a good place to start looking for research about antidepressants.

Women who are considering taking medication during pregnancy should work closely with their doctors. The FDA organizes drugs in categories according to their proven safety for women and the developing fetus. Medications range from Category A—those which have been shown in human studies to have no negative effect on either mother or child—to Category X—which should never be used by a pregnant woman.

Many medications may pose a risk to the developing child, but women living with psychiatric conditions may receive different advice about the same medications compared with expectant mothers affected by other conditions. A recent article by Dr. Viguera found that anticonvulsants, medications like valproic acid and lamotrigine, which are used to prevent seizures and to treat bipolar disorder, were depicted by neurologists as being safer for mothers-to-be with epilepsy than they were by psychiatrists to their patients. This may be due to the larger body of research regarding mothers with epilepsy compared to pregnant women living with a psychiatric diagnosis.

If there little information about expectant mothers living with mental illness, the trend appears to continue after birth. Parenting with a Mental Illness: Programs and Resources cites a 2004 study by Biebel et al. which found that providers “may not even ask about a client’s family roles and responsibilities.” One organization seeking to redress this imbalance, the UPenn Collaborative on Community Integration, is an excellent resource for individuals who want to be better parents or need help navigating the legal system to reunite their family.

Parents living with mental illness are square pegs that do not fit into the current research and social services landscape. “Critical Issues for Parents with Mental Illness and Their Families,” a review of existing research by Nicholson, Biebel, et al., found that, “Policies and programs have not necessarily been developed with adequate information to meet the needs or goals of adults and mental illness as parents or the needs of their children.” There is a need for further education and advocacy regarding the many roles people living with mental illness play in the community. This might encourage more research about psychiatric treatment options during pregnancy. Learn more about bipolar disorder on NAMI’s website.

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