Bipolar Disorder in women who are pregnant or in women after the birth of a baby requires
- early treatment if not previously diagnosed
- early review of medications if already diagnosed and under treatment
Untreated mental health challenges and disorders can be very serious for both mother and baby. There is a possible risk for the mother of
- low levels of prenatal and postnatal care because of difficulty in attending appointments
- involvement in risky behaviors, including substance use and smoking
- inability to carry out daily activities, including looking after the baby’s needs
- difficulties in bonding with the baby, affecting the baby’s own development
- increased risk of suicide and infanticide (although this is very rare)
Treatment for women with existing Bipolar Disorder
A woman who has already experienced an episode of Bipolar Disorder has a high risk of recurrent episodes. Prevention of relapse is an important part of treatment in both prenatal and postnatal care of women with Bipolar Disorder. Relapse is common if women discontinue medication without careful planning and medical advice.
Women may be concerned that medications may have some side affects for her and her baby during pregnancy and while breastfeeding. In order to plan continued treatment, it is recommended that a woman consults with her treating physician and/or psychiatrist
- if possible, before pregnancy
- as soon as possible on discovering she is pregnant
- right through pregnancy and after the birth of the baby
Referral to a specialist Reproductive Psychiatrist is advised to establish an individual treatment plan for the woman. This treatment plan should be followed by the woman throughout pregnancy and the post partum period. The plan should involve discussion with the woman, her partner and family as well as psychiatry, maternity and primary care services.
What are the treatment options for women with Bipolar Disorder?
Bipolar Disorder can be successfully managed in pregnancy and following the birth by treating any current episode of mania or depression and preventing (or continuing to prevent) the long term recurrence of episodes. Usually, medications in addition to non-pharmacological treatments are required. Most women can be treated as out patients but hospitalization may be necessary if the woman is psychotic and if there is concern that she is at risk of harming herself or her infant.
Medications when prescribed, will be used in four main ways:
- to treat or prevent mania by stabilizing the mood
- to treat the depressive symptoms
- to treat psychotic symptoms, if present
- to treat associated anxiety symptoms.
Mood stabilizers are medications used to treat and prevent ‘highs’ (manic or hypomanic episodes) or lows (depressive episodes). They also help to minimize the negative effects of mood states on functioning in the home, social or work situations.
Lithium is the most commonly used mood stabilizing medication although other medications are also available. Valproic acid is best avoided in women of childbearing years. It is known to significantly increase the risk of birth defects, especially spina bifida. Alternative, safer medications are available.
Antipsychotics may be prescribed with mood stabilizers and are medications used to treat psychotic symptoms that the woman may experience during a manic or depressive episode. Examples of antipsychotic medications are the conventional neuroleptics (like haloperidol) or atypical neuroleptics (like risperidone)
Benzodiazepines may also be prescribed in conjunction with mood stabilizers and antipsychotics and are medications used to treat the insomnia or anxiety that a woman may experience during a manic or depressive episode.
There are a number of options to manage medications depending on the mental health status of the woman. Some of the medications or medication combinations are prescribed as a short term measure to stabilize the woman’s mood. They may also be used over the long term as maintenance treatment to prevent relapses.
Guidance on medication in the perinatal period for women with Bipolar Disorder
Women will naturally be concerned about the side effects of medications they are taking when pregnant or breastfeeding. The goal of treatment is to minimize risk of the developing baby’s exposure to medications while limiting risks of untreated mental health disorders in the mother. The lowest most effective dose to control symptoms will be sought.
Careful management is required throughout pregnancy and breastfeeding and monitoring of the baby is advised where necessary because of some risks associated with medications used to treat Bipolar Disorder. Do not stop taking medications. Consult with your treating physician or psychiatrist to work out a care plan that is best for you and your baby.
Women with less severe illness and stable for a significant time may be able to slowly wean off mood stabilizing medication prior to pregnancy.
Women with more severe illness or at high risk of relapse will need to be maintained on treatment during their pregnancy.
Moms can breastfeed their baby while taking these medications but caution is advised and the lowest effective dose should be prescribed. Extra caution is advised with the use of lithium and the baby’s lithium levels will need to be closely monitored.
Patients who relapse in pregnancy or who it is known are at high risk of relapse, may need to remain on the lowest effective antipsychotic medication that treats their symptoms during pregnancy.
These medications pass into breast milk.and are present in low concentrations. There is limited information about long term exposure effects. It is important to monitor the baby for any side effects (e.g., drowsiness).Breastfeeding should be avoided if the mom is on multiple medications.
Some women with high levels of anxiety or recurrent sleep problems during their pregnancy may require either occasional or regular treatment with benzodiazepines during pregnancy.
These medications pass into breast milk. The recommendation is to use cautiously and monitor the baby for sleepiness. Avoid using regular high doses of benzodiazepines. Breastfeeding should be avoided if the mom is on multiple medications.
Psychologically based therapies also play a role in coping with and managing Bipolar Disorder and may be combined with medication. However, they may be insufficient to treat or manage bipolar disorder without combining with medication. Adjunct therapies may be in any of the following areas:
Psycho-education aims to help the woman, her partner, friends and family to understand more about the illness, the importance of building social networks and supports and to develop general strategies for managing her illness and ensuring good care of the baby.
Family and Relationship Counselling
It is important to assist women, their partners and family to develop focused strategies to cope with the stressful times around episodes of mania or depression and to provide practical support in helping the mom care for her infant.
Psychotherapy can be either interpersonal therapy or group therapy offering support to the woman to develop insight into the illness. Learning different ways of managing thought processes and feelings is helpful. Cognitive Behavior Therapy is a helpful treatment based on the understanding that the way we think and behave influences our feelings.
A diagnosis of Bipolar Disorder always requires careful management during pregnancy, following the birth and when breastfeeding as mood symptoms may interfere with the woman’s ability to take care of herself and her baby and prescribed medications have potential side effects for the baby. However, it cannot be stressed too highly how important it is that the woman does not discontinue medication without consultation with her treating physician or psychiatrist as this will increase her risk of relapse. Untreated Bipolar Disorder has serious implications for the mother and the baby.