Bipolar Disorder and Pregnancy (Part 1 of 2)

Today, I am publishing the first of a two-part interview with Dr. Amanda Itzkoff, MD, about bipolar disorder and pregnancy. I am often asked about this subject and, since I am not a doctor nor a woman, I decided it was a good idea to seek the knowledge of a trained medical professional.

How do you advise women when they ask about the possibility of passing bipolar disorder on to their children?

Bipolar disorder is heritable (passed on in genes) to some degree. But inheritance patterns are complex. Multiple genes appear to be involved and we don’t yet know all of them or how they increase the likelihood of developing the illness. Some of these genes don’t code for bipolar disorder specifically, but increase the likelihood of developing mood disorders (like depression). A child born of a parent (mother or father) who has bipolar disorder will have an increased risk of having a mood disorder (seemingly about 10% for bipolar and 50% for depression).

Though there is some discrepancy in data, it is understood that the more family members one has with bipolar disorder, and the closer the relative, the greater the risk.  Risks are greater when both parents have bipolar disorder.

When mothers with bipolar disorder are thinking of having a child, their illness is usually quite stable. If you have managed your own illness, you may have some unique advantages in detecting a mood disorder in your child and knowing what to do about it.

Once a woman chooses to have a baby, can she stay on her medication for bipolar disorder?

Her doctor will look at the medication the patient is currently taking (as that is likely the medication that has caused her to have the most stability) and then will review the risks the medication poses to an unborn child. Ultimately, the decision is up to the mother whether the risks outweigh the benefits.

Risk can often be mitigated by using the lowest effective dose of a medicine. For some medications (such as some traditional anti-epileptics) and for some mothers, risks may be deemed too great to take that medication during pregnancy, and switching to a medication that is lower risk will be undertaken to establish efficacy prior to conception.

I always recommend having a backup plan, so that if you should become symptomatic, you have already discussed your first and second choice treatment plans with your doctor. This will greatly reduce the risk of any treatment that you would not want being administered to you while pregnant from being selected if you should be in a compromised state and are less able to participate in your own care.
If your case is one in which the only successful management of your illness has been achieved via medication that confers unacceptable risk to an unborn child, and past attempts at switching to more acceptable treatments have resulted in severe decompensation, then you might choose third-party reproduction options, allowing you to maintain your health for when your baby comes home.

What additional challenges will a pregnant woman with bipolar disorder face during pregnancy?

Patients with any mood or anxiety disorder are at greater risk for peripartum (before, during, and for one year after pregnancy) exacerbation of their illnesses. You will want to be monitored closely by your psychiatrist, who may work with your obstetrician/gynecologist, and again, creating a backup plan before pregnancy is extremely useful.

Dr. Amanda Itzkoff, MD

Bipolar patients, in particular, need to be mindful of triggers to their illness that can be affected by pregnancy. Sleep can become difficult later in pregnancy and reduced sleep is a very common mania trigger. So you’ll want to get as much sleep as possible and closely monitor for any symptom emergence. Stress can be a trigger for many, and while pregnancy can be a very joyful time, it can certainly be a stressful time, too. Change in routine can also be a trigger, and all the appointments, body changes, etc. should be considered potential triggers.

Is the likelihood of a bipolar manic episode higher during pregnancy? A depressive episode?

Unfortunately, yes, but we make every effort to mitigate this by establishing a plan prior to becoming pregnant. Most women who are planning pregnancies have been stable for quite some time, which may be protective. The risk during pregnancy is actually the same as it is postpartum.

Will the stress and pressure of pregnancy on the body (hormonally) and in terms of fatigue trigger any of the old bipolar behavior?

The physical stresses and hormonal changes that accompany pregnancy can result in mood symptoms. This is another reason to work closely with your psychiatrist throughout your pregnancy. Ideally, this is taken into account during pre-conception planning and is another reason to have a backup plan. Some women may choose third-party reproduction if the risk in their cases is deemed too high or if they have become suicidal during prior pregnancies. This is not a reason that will necessarily prevent a woman with bipolar disorder from having a child.

How do women with bipolar deal with the anxiety of pregnancy? Is there medication or alternative treatment?

Some anxiety medications have acceptable risks to many mothers when taken during pregnancy. SSRIs in those who can take them, need to be carefully monitored in bipolar patients, but some have demonstrated stability [while taking medications].  We need to be careful when we talk about anxiety, so that we’re not missing what is really early mania or early depression in bipolar patients. Psychotherapy can be quite helpful and poses no risk to the pregnancy. I highly recommend this approach in expectant mothers. Alternative treatment for mild anxiety (like massage, acupuncture, and meditation) can be helpful, but again, we want to be very careful that we’re not missing early mania when talking about anxiety in bipolar patients.

Gabe Howard is a professional speaker, writer, and advocate who lives with bipolar and anxiety disorders. He has made it his mission to change the way society reacts to mental illness. He is an award-winning blogger and the creator of the official bipolar shirt. (Get yours now!) Interested in working with Gabe or learning more? He can be reached on Facebook, via email, or on his website, www.GabeHoward.com.  Don’t be shy — he’s not.