Bipolar Disorder and Pregnant Women
ABSTRACT & COMMENTARY
Source: Viguera AC, et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry 2000;157(2):179-184.
Bipolar disorder (manic-depression) affects 1-3% of the population. It is a life-long condition with an age of onset that frequently overlaps with the reproductive years. First trimester exposure to all of the established mood stabilizers (lithium, valproate, and carbamazepine) is associated with an increased risk of fetal malformations. As such, many women with bipolar disorder choose to discontinue these and all other medications during pregnancy and while trying to conceive.
However, recurrent acute illness (mania or depression) may pose an even greater threat to the fetus, and is certainly detrimental to the patient. Many patients and clinicians believe that pregnancy is protective. To address this important issue, Viguera and colleagues retrospectively compared recurrence rates for 101 women with bipolar disorder during pregnancy and postpartum or during equivalent time period for age-matched nonpregnant women, following discontinuation of lithium maintenance treatment. Rates of recurrence during the first 40 weeks after lithium discontinuation were similar for pregnant (52%) and nonpregnant women (58%). Recurrence rates were much lower for both groups in the year before lithium discontinuation (21%). Among women who remained stable during the first 40 weeks after lithium discontinuation, postpartum recurrences were 2.9 times more frequent in the nonpregnant women over the same time period (weeks 41-64), 70% vs. 24%. Recurrence rates were greater after rapid than gradual discontinuation.
Comment by Lauren B. Marangell, MD
Viguera and colleagues provide extremely important information that should be used to guide treatment decisions in collaboration with women with bipolar disorder who are planning to become pregnant. There is a common misperception that pregnancy is protective, which is clearly not the case in the current cohort. Although this was a retrospective review, an appropriate control group was included. Over the 64-week period following lithium discontinuation, recurrences occurred in 85.71% of the pregnant/postpartum women, and 67.80% of the nonpregnant women. The markedly high recurrence rate in the postpartum period is noteworthy. Many patients and clinicians understandably prefer to avoid fetal exposure to medications. However, the current data indicate that a careful risk-benefit analysis is imperative. For women with more severe episodes, the adverse consequences of recurrence may outweigh the risk of ongoing medication. Consistent with previous data, the recurrence rate with a gradual taper (15-30 days) was less than with abrupt discontinuation, but still 37.14%. When planning pregnancy, if the woman decides to discontinue medication, a gradual taper is recommended. Unplanned pregnancy is more of a challenge, and the decision regarding discontinuing medication, and if so how rapidly, should be made with consideration of gestational age. A nonteratogenic mood stabilizer is urgently needed.
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