Managing bipolar disorder during pregnancy and the postpartum period: a critical review of current practice

ABSTRACT

Introduction: Despite increased interest in the pharmacotherapy of bipolar disorder during pregnancy and the postpartum period, management of the disorder during these critical periods in a woman’s life remains challenging.

Areas covered: The authors review the effect of pregnancy and the postpartum period on the course of bipolar disorder, describe adverse pregnancy and birth outcomes, and discuss the pharmacotherapy of bipolar disorder during and after pregnancy.

Expert opinion: When treating women with bipolar disorder of childbearing age, clinicians should consider the possibility of pregnancy. Pre-conception counseling should be an integral part of the overall plan to manage bipolar disorder during and after pregnancy. Peripartum management of bipolar disorder is challenging and requires balancing of risks associated with the use of drugs and the potentially deleterious effects of untreated bipolar disorder on the fetus/child. Formulation of personalized treatment requires knowledge of both current (episode type, symptom severity, psychiatric comorbidity, and safety concerns) and historical (episode frequency, response to drugs and psychotherapy, and the effect of reproductive events including pregnancy and postpartum period) factors. Close monitoring is essential for early detection and management of mood episodes. Routine safety assessments are necessary to identify women at risk of harming themselves or the newborn.

KEYWORDS:

• Antidepressants
• antipsychotics
• bipolar disorder
• breastfeeding
• depression
• lithium
• mood stabilizers
• postpartum
• pregnancy
• safety

Article Highlights

• When prescribing for women with bipolar disorder of childbearing age, clinicians should consider the possibility of pregnancy

• Treated or untreated bipolar disorder can be associated with adverse maternal and fetal outcomes

• Maintenance treatment with mood-stabilizing medication is associated with fewer and later recurrences of mood episodes during pregnancy

• Careful balancing of risks and benefits is necessary when psychotropic drugs are used in pregnancy

• Treatment planning should be decided on a case-by-case basis, taking into account both current and historical clinical information

• Compared to pregnancy, the risk of recurrence of mood episodes is greater in the postpartum period

• Women with bipolar II disorder appear to be at a particularly high risk for recurrence of depression in the postpartum period

• Early detection and management of subthreshold symptoms may prevent a full-blown episode in the postpartum period

• Close monitoring is essential for early detection of emerging symptoms of mood episodes.

Acknowledgments

The authors thank Christine Baczynski for her help in preparing the manuscript for submission.

Declaration of Interest

V Sharma reports personal fees from the Neuroscience Education Institute and grants from Assurex, Genome Canada, Sage Therapeutics, Stanley Medical Research Institute, and Sunovion Pharmaceuticals, and participation on the advisory boards for Sunovion Pharmaceuticals and Otsuka, outside the submitted work. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer Disclosures

A reviewer on this manuscript has disclosed work on advisory boards for Sage Therapeutics or their agents, Janssen and Mathematica Policy Research. They have also acted as a consultant for Sage Therapeutics or their agents, Gerson Lehrman Group and Ovia Health. They also declare interests as an Executive Director of Lifeline4Moms, a Medical Director for MCPAP for Moms as well as being a Council member for Gerson Lehrman Group and holding a place on the steering committee for Medscape. Finally, this reviewer has been a speaker for Medscape and been a speaker receiving honoraria for Miller Medical Communications and Sage Therapeutics or their agents. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.