Managing Bipolar Disorder during Pregnancy: Weighing the Risks and Benefits

Background: Challenges for the clinical management of bipolar disorder (BD) during pregnancy are multiple and complex and include competing risks to mother and offspring. Method: We reviewed recent research findings on the course of BD during pregnancy and postpartum, as well as reproductive safety data on the major mood stabilizers. Results: Pregnancy, and especially the postpartum period, are associated with a high risk for recurrence of BD. This risk appears to be limited by mood-stabilizing treatments and markedly increased by the abrupt discontinuation of such treatments. However, drugs used to treat or protect against recurrences of BD vary markedly in teratogenic potential: there are low risks with typical neuroleptics, moderate risks with lithium, higher risks with older anticonvulsants such as valproic acid and carbamazepine, and virtually unknown risks with other newer-generation anticonvulsants and atypical antipsychotics (ATPs). Conclusions: Clinical management of BD through pregnancy and postpartum calls for balanced assessments of maternal and fetal risks and benefits. Contexte: Les problèmes liés au traitement clinique du trouble bipolaire (TB) durant la grossesse sont profonds et peuvent entraîner des risques concurrents pour la mère et l'enfant. Méthode: Nous avons examiné les résultats récents de la recherche sur le cours du TB durant la grossesse et le post-partum, de même que les données d'innocuité reproductrice des principaux régulateurs de l'humeur. Résultats: La grossesse et surtout la période du post-partum comportent des risques élevés de récurrence du TB. Les risques semblent être limités par les traitements aux régulateurs de l'humeur et notablement accrus par la cessation abrupte de ces traitements. Toutefois, les médicaments utilisés pour traiter ou prévenir les récurrences du TB varient beaucoup en ce qui concerne les risques tératogènes: les risques sont faibles pour les neuroleptiques typiques, modérés pour le lithium, élevés pour les anciens anticonvulsivants comme l'acide valproïque et la carbamazépine, et presque inconnus pour les autres anticonvulsivants de la nouvelle génération et les antipsychotiques atypiques (APA). Conclusions: Le traitement clinique des femmes souffrant du TB durant la grossesse et le post-partum demande des évaluations équilibrées des risques et des avantages pour la mère et le foetus.

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Considerations in the Management of Bipolar Disorder in Women

Australian & New Zealand Journal of Psychiatry ◽

10.1080/j.1440-1614.2005.01650.x ◽

2005 ◽

Vol 39 (8) ◽

pp. 662-673 ◽

Cited By ~ 22

Author(s):

Caryl Barnes ◽

Philip Mitchell

Keyword(s):

Gender Differences ◽

Bipolar Disorder ◽

Post Partum ◽

Mood Stabilizers ◽

Rapid Cycling ◽

Pharmacokinetics And Pharmacodynamics ◽

Men And Women ◽

Mixed Episode ◽

Search Terms ◽

Bipolar Ii

Objective: Recent research has emphasized important gender differences in the epidemiology, course, comorbidity and treatment of bipolar disorder. This article aims to provide an overview of these important findings in order to assist the clinician in treating women with bipolar disorder. Complex issues regarding the treatment of bipolar disorder during pregnancy and the post-partum period are discussed. Method: A literature review was undertaken using Medline (1966–current), PsychInfo and PubMed databases. Search terms used were gender, sex, women, bipolar disorder, suicide, epidemiology, rapid cycling, mixed episode, treatment, mood stabilizers, antidepressants, antipsychotics, pregnancy, post-partum, menopause, lactation and breast-feeding. Results: The lifetime prevalence of bipolar I disorder is equal in men and women; however, bipolar II appears to be more common in women. Gender differences have been reported in the phenomenology, course and outcome of this condition. Some comorbid disorders, such as thyroid disease and anxiety disorders have more relevance to women. Increasingly, sex differences in the pharmacokinetics and pharmacodynamics of medications used in bipolar disorder are being reported. Conclusions: There is increasing evidence for gender differences in a number of clinical features of bipolar disorder that have relevance to management. Although more studies are needed, it is important for clinicians to be aware of these issues to optimize treatment of women with this condition.

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P01-204-Predictors of recurrence of bipolar disorder during pregnancy and postpartum period in a sample of egyptian women

European Psychiatry ◽

10.1016/s0924-9338(11)71915-0 ◽

2011 ◽

Vol 26 (S2) ◽

pp. 205-205 ◽

Cited By ~ 1

Author(s):

M.A. Abd El-Hay ◽

H.F. El Sawy ◽

A.A. Badawy

Keyword(s):

Bipolar Disorder ◽

Age Of Onset ◽

Unplanned Pregnancy ◽

Post Partum ◽

Bipolar I Disorder ◽

Duration Of Illness ◽

Increased Risk ◽

Pregnancy And Postpartum ◽

History Of ◽

In Pregnancy

IntroductionPregnancy and the postpartum are times of increased risk for women with bipolar disorder to develop new episodes.ObjectiveTo evaluate factors that are supposed to be associated with recurrence of bipolar I disorder among euthymic women with a history of bipolar I disorder, which could be used as a predictors of bipolar I disorder in that period.MethodEighty-three pregnant women with history of bipolar I disorder were followed through pregnancy and post-partum periods for possible recurrence of a new episode. All women were assessed using the MINI International Neuropsychiatric Interview. Factors that may contribute to recurrence were assessed prospectively; these included age of patients, age of onset of bipolar disorder, duration of illness, number of previous attacks, number of previous pregnancies, prior episodes in pregnancy or postpartum, complications during pregnancy and labor, pregnancy type, prior hospitalization, prior suicidal attempts, time since last episode in months, and continuation of medications.ResultsSixty five % of euthymic bipolar females had recurrence of a new episode, either during pregnancy (33.73%) or 4 weeks postpartum (31.32%). Discontinuation of medications, longer duration of illness, more number of previous attacks, more number of previous pregnancies, more prior episodes in pregnancy, more complication during pregnancy, more complication during labor, unplanned pregnancy type, prior hospitalization, were associated with recurrence of bipolar disorder during pregnancy and postpartum.ConclusionsMultiple factors were associated with risk of recurrence of bipolar I disorder during pregnancy and postpartum, which should be while planning treatment for such women.

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Mood Stabilizers, Oxidative Stress and Antioxidative Defense in Euthymia of Bipolar Disorder

CNS & Neurological Disorders - Drug Targets ◽

10.2174/1871527315666160321104059 ◽

2016 ◽

Vol 15 (4) ◽

pp. 381-389 ◽

Cited By ~ 12

Author(s):

Susanne A. Bengesser ◽

Nina Lackner ◽

Armin Birner ◽

Martina Platzer ◽

Frederike T. Fellendorf ◽

...

Keyword(s):

Oxidative Stress ◽

Bipolar Disorder ◽

Mood Stabilizers ◽

Antioxidative Defense

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The Safety of COVID-19 Vaccinations—We Should Rethink the Policy

Vaccines ◽

10.3390/vaccines9070693 ◽

2021 ◽

Vol 9 (7) ◽

pp. 693

Author(s):

Harald Walach ◽

Rainer J. Klement ◽

Wouter Aukema

Keyword(s):

Side Effects ◽

Confidence Interval ◽

Field Study ◽

Adverse Reactions ◽

Safety Data ◽

European Medicines Agency ◽

Point Estimate ◽

Drug Reactions ◽

Vaccination Policy ◽

Risks And Benefits

Background: COVID-19 vaccines have had expedited reviews without sufficient safety data. We wanted to compare risks and benefits. Method: We calculated the number needed to vaccinate (NNTV) from a large Israeli field study to prevent one death. We accessed the Adverse Drug Reactions (ADR) database of the European Medicines Agency and of the Dutch National Register (lareb.nl) to extract the number of cases reporting severe side effects and the number of cases with fatal side effects. Result: The NNTV is between 200–700 to prevent one case of COVID-19 for the mRNA vaccine marketed by Pfizer, while the NNTV to prevent one death is between 9000 and 50,000 (95% confidence interval), with 16,000 as a point estimate. The number of cases experiencing adverse reactions has been reported to be 700 per 100,000 vaccinations. Currently, we see 16 serious side effects per 100,000 vaccinations, and the number of fatal side effects is at 4.11/100,000 vaccinations. For three deaths prevented by vaccination we have to accept two inflicted by vaccination. Conclusions: This lack of clear benefit should cause governments to rethink their vaccination policy.

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Real-world effectiveness of mood stabilizers on self-harm and suicide attempts in patients with bipolar disorder: a 2-year mirror-image study

Journal of Affective Disorders Reports ◽

10.1016/j.jadr.2020.100064 ◽

2020 ◽

pp. 100064

Author(s):

Oskar Hougaard Jefsen ◽

Søren Dinesen Østergaard ◽

Jimmi Nielsen ◽

Christopher Rohde

Keyword(s):

Bipolar Disorder ◽

Real World ◽

Suicide Attempts ◽

Mirror Image ◽

Mood Stabilizers ◽

Image Study ◽

Self Harm

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Prescribing practices of Indian psychiatrists in the treatment of bipolar disorder

Australian & New Zealand Journal of Psychiatry ◽

10.1177/0004867419826718 ◽

2019 ◽

Vol 53 (5) ◽

pp. 458-469 ◽

Cited By ~ 2

Author(s):

YC Janardhan Reddy ◽

Venugopal Jhanwar ◽

Rajesh Nagpal ◽

MS Reddy ◽

Nilesh Shah ◽

...

Keyword(s):

Bipolar Disorder ◽

Maintenance Treatment ◽

Bipolar Depression ◽

Mood Stabilizer ◽

Self Report ◽

Mood Stabilizers ◽

Prescribing Practices ◽

Term Outcome ◽

Cross Sectional ◽

Long Term Outcome

Objective: The treatment of bipolar disorder is challenging because of its clinical complexity and availability of multiple treatment options, none of which are ideal mood stabilizers. This survey studies prescription practices of psychiatrists in India and their adherence to guidelines. Method: In total, 500 psychiatrists randomly selected from the Indian Psychiatric Society membership directory were administered a face-to-face 22-item questionnaire pertaining to the management of bipolar disorder. Results: For acute mania, most practitioners preferred a combination of a mood stabilizer and an atypical antipsychotic to monotherapy. For acute depression, there was a preference for a combination of an antidepressant and a mood stabilizer over other alternatives. Electroconvulsive therapy was preferred in the treatment of severe episodes and to hasten the process of recovery. Approximately, 50% of psychiatrists prescribe maintenance treatment after the first bipolar episode, but maintenance therapy was rarely offered lifelong. While the majority (85%) of psychiatrists acknowledged referring to various clinical guidelines, their ultimate choice of treatment was also significantly determined by personal experience and reference to textbooks. Limitations: The study did not study actual prescriptions. Hence, the responses to queries in the survey are indirect measures from which we have tried to understand the actual practices, and of course, these are susceptible to self-report and social-desirability biases. This was a cross-sectional study; therefore, temporal changes in responses could not be considered. Conclusion: Overall, Indian psychiatrists seemed to broadly adhere to recommendations of clinical practice guidelines, but with some notable exceptions. The preference for antidepressants in treating depression is contrary to general restraint recommended by most guidelines. Therefore, the efficacy of antidepressants in treating bipolar depression in the context of Indian psychiatrists’ practice needs to be studied systematically. Not initiating maintenance treatment early in the course of illness may have serious implications on the long-term outcome of bipolar disorder.

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9.3 LITHIUM VS OTHER MOOD STABILIZERS IN YOUTH WITH BIPOLAR DISORDER: CLINICAL FINDINGS AND POTENTIAL MECHANISMS

Journal of the American Academy of Child & Adolescent Psychiatry ◽

10.1016/j.jaac.2020.07.601 ◽

2020 ◽

Vol 59 (10) ◽

pp. S279-S280

Author(s):

Danella Hafeman

Keyword(s):

Bipolar Disorder ◽

Clinical Findings ◽

Mood Stabilizers

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Treatment of Bipolar Disorder During the Postpartum Period

CNS Spectrums ◽

10.1017/s1092852900025724 ◽

2006 ◽

Vol 11 (S5) ◽

pp. 13-14

Author(s):

Adele C. Viguera

Keyword(s):

Bipolar Disorder ◽

Postpartum Period ◽

Clinical Information ◽

Mood Stabilizer ◽

Mood Stabilizers ◽

Antipsychotic Treatment ◽

Close Monitoring ◽

Major Congenital Malformations ◽

Major Depressive Episodes ◽

Depressive Episodes

AbstractThe presentations and clinical courses of patients with bipolar disorder differ greatly by gender. In addition, medical therapy must be tailored differently for men and women because of emerging safety concerns unique to the female reproductive system. In November 2005, these topics were explored by a panel of experts in psychiatry, neurology, and reproductive health at a closed roundtable meeting in Dallas, Texas. This clinical information monograph summarizes the highlights of that meeting.Compared to men with bipolar disorder, women have more pervasive depressive symptoms and experience more major depressive episodes. They are also at higher risk for obesity and certain other medical and psychiatric comorbidities. Mood changes across the menstrual cycle are common, although the severity, timing, and type of changes are variable. Bipolar disorder is frequently associated with menstrual abnormalities and ovarian dysfunction, including polycystic ovarian syndrome. Although some cases of menstrual disturbance precede the treatment of bipolar disorder, it is possible that valproate and/or antipsychotic treatment may play a contributory role in young women.Pregnancy does not protect against mood episodes in untreated women. Maintenance of euthymia during pregnancy is critical because relapse during this period strongly predicts a difficult postpartum course. Suspending therapy in the first months of pregnancy may be an option for some women with mild-to-moderate illness, or those with a long history of euthymia during pre-pregnancy treatment. However, a mood stabilizer should be reintroduced either in the later stages of pregnancy or in the immediate postpartum period. Preliminary data suggest that fetal exposure to some mood stabilizers may raise the risk of major congenital malformations and neurodevelopmental delays. For women planning to become pregnant, clinicians may consider switching to other drugs before conception. The value and drawbacks of breastfeeding during treatment must be considered in partnership with the patient, with close monitoring of nursing infants thereafter. The risks and benefits of medical treatment for women with bipolar disorder should be carefully reconsidered at each stage of their reproductive lives, with a flexible approach that is responsive to the changing needs of patients and their families.

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