Cleveland_Clinic_Host: Although pregnancy has typically been considered a time of emotional well being, recent studies suggest that up to 30-50% of women with bipolar disorder suffer from a mood episode during pregnancy, and 50% or more will experience an episode post-partum. Psychiatric illness in the mother is not a benign event and may cause significant morbidity for the mother and child; thus, discontinuing or withholding medication during pregnancy is not always the safest option. It is important that these issues be discussed with the OB/GYN and a Psychiatrist.
Cleveland Clinic’s Neurological Institute Center for the Care and Study of Women’s Mental Health integrates research into clinical services. For more than a decade, this sub-specialty center has provided outpatient services including clinical assessment, consultation and treatment for women presenting with a wide range of reproductive-associated psychiatric syndromes. This includes premenstrual dysphoric disorder, antenatal mood disorders, postpartum depression, and peri– and postmenopausal disturbance.
Adele C. Viguera, MD, MPH, is Director of the Center for the Care and Study of Women’s Mental Health at Cleveland Clinic. She studied at Dartmouth Medical School, Massachusetts General Hospital, McLean Hospital and Harvard University.
Dr. Viguera completed her medical internship at the Massachusetts General Hospital before starting her psychiatry residency at McLean Hospital in Belmont, Massachusetts. She completed a clinical fellowship in Consultation-Liaison Psychiatry and a fellowship in Perinatal and Reproductive Psychiatry at MGH. She has played an important role in the program’s growth into a nationally recognized clinical and research center addressing a wide range of reproductive- associated psychiatric syndromes including premenstrual dysphoric disorder, antenatal mood disorders, postpartum depression, and peri and postmenopausal mood disturbance. Her leadership within the Program has been complemented by dedication to teaching and mentoring psychiatric residents, fellows, medical students, and junior faculty over the past ten years.
Dr. Viguera was the Associate Director of the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital since 1997, and Assistant Professor of Psychiatry at Harvard Medical School. She joined the Cleveland Clinic staff in October 2007, and continues to lead research efforts in women’s mental health.
With respect to research, Dr. Viguera has had very successful track record securing support to study important research questions in reproductive psychiatry. Early in her academic career, she was the recipient of an NIMH K23 Career Development Award (K23 MH-11609), focused on The Course of Bipolar Disorder in Pregnancy and the Postpartum Period. In 2003, she also earned a Masters degree in Public Health in Quantitative Methods at the Harvard School of Public Health as part of her K23 grant.
She has received additional awards from private foundations including two consecutive National Alliance for Research in Schizophrenia and Depression (NARSAD) Young Investigator research Awards for the study of Neonatal Outcome Following Exposure to Lithium . In 2004, she received a two-year Harvard Medical School Scholars in Medicine Fellowship Claflin Award for a project entitled, Screening for Antenatal Bipolar Disorder associated with Maternal Morbidity and Adverse Neonatal Outcome.
The body of research laid the groundwork for an R01 award in 2005 from The National Institute of Mental Health for a multi-site collaborative study with Emory School of Medicine on Bipolar Disorder in Pregnancy: Predictors of Morbidity (Collaborative Grant: R01 MH 071762 [Viguera]; R01 MH 071531[Newport]). The study is currently in progress.
Dr Viguera’s major research interests include:
- longitudinal course and treatment of psychiatric illness during pregnancy and the postpartum period
- efficacy of antidepressant therapy for premenstrual dysphoric disorder, postpartum psychiatric illness, and perimenopausal mood disturbance
- perinatal and neurobehavioral sequelae of maternal psychiatric illness on child development
- psychotropics and lactation,
- efficacy of hormone therapy for the acute and prophylactic treatment of mood disturbance in women
With her family’s recent move to Cleveland, Dr. Viguera will lead research efforts in women’s mental health at the Cleveland Clinic, as well as, continue her collaboration Massachusetts General Hospital.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Adele Viguera. We are thrilled to have Dr. Adele Viguera here today for this chat. She is considered an expert in the field women’s mental health and reproductive-associated psychiatric syndromes. Let’s begin with some general questions.
Bipolar Disorder Overview: Pregnancy and Postpartum
Reese_Sally: How can you differentiate between a depressive episode due to a bipolar disorder and postpartum depression?
Speaker_-_Dr__Adele_Viguera: There is really no significant difference between these two types of episodes. With postpartum depression, we tend to see a high rate of anxiety and not infrequently, intrusive, negative thoughts about the baby or harming the baby. These thoughts are obviously very anxiety provoking for the mother.
peterrobert: What are the tests conducted to find out if a person has Bipolar Disorder?
Speaker_-_Dr__Adele_Viguera: There is no blood test or other test for bipolar disorder. The diagnosis is made based on a comprehensive psychiatric evaluation by a trained mental health professional. It is often helpful to have other family members present to provide collateral information as well.
happy_feet: Can my bipolar disorder be passed down to my child?
Speaker_-_Dr__Adele_Viguera: Yes, there is likely a strong genetic component to this illness. In many families, a bipolar condition can be inherited. If both parents have the disorder, the risk for the child is about 50%. However, the inheritance of bipolar disorder is complex and we do not have enough data at this point to measure this risk accurately. We also know that postpartum psychosis, which is a form of bipolar disorder, has a strong genetic component.
Therefore, knowing your family history is very important to your clinical care. If you have the opportunity, take the time to ask relatives about any history of mood disorder, psychiatric hospitalizations, postpartum episodes, or completed suicides. Also find out if they received any treatment, what kind of treatment, and if they did well on that treatment. Be sure to share this information with your doctor.
copperfield: If I am bipolar, is it possible that my meds won't work after delivery, and I could have post-partum depression? Or if I continue with my meds during pregnancy, will this prevent that?
Speaker_-_Dr__Adele_Viguera: The risk for a postpartum episode whether it be mania or depression is probably close to 50% or more for women with bipolar disorder. The current standard of care is to recommend postpartum prophylaxis which means reintroducing a mood stabilizer a few weeks before delivery. The available data suggests that postpartum prophylaxis with Lithium reduces postpartum occurrence by 5 fold.
A postpartum episode can sometimes represent the first manifestation of bipolar disorder. Therefore it is very important for a postpartum mother to be monitored closely for at least one year. In addition, a family history of bipolar disorder might increase the risk.
Trouble: What medications lead to the best maternal and neonatal outcomes? What is best for maintenance?
Speaker_-_Dr__Adele_Viguera: This is a hard question to answer since for the treatment of bipolar disorder, many of the major mood stabilizers are known teratogens like lithium or depakote. In general , the ideal maintenance treatment is the one you have responded to best in the past. However, if you have never tried a medication for which there is better reproductive safety data, switching to a relatively “safer” medication preconception may be the most prudent option.
count_down: Are there alternatives to medication that I can use to manage my bipolar disorder during my pregnancy?
Speaker_-_Dr__Adele_Viguera: It is important to pay attention to sleep hygiene, sticking to a strict routine, minimizing stress, receiving support from friends and family. These components all help with keeping a person well. There is some data to suggest that omega-3 fatty acids can help with bipolar disorder. They are considered safe in pregnancy. The current recommendation for their use to treat mood disorders is about 1-2 grams a day.
mkgall: How do you help these women not destroy their personal lives? I have seen so many divorces in bi-polar patients.
Speaker_-_Dr__Adele_Viguera: Early intervention and recognition of the problem is critical. In my experience the patients that have done the best are those that have accepted their diagnosis and are committed to treatment with medication and talk therapy. It is also helpful if the patient has lots of support from friends and families as well as paying attention to having a daily structured routine. It also important to minimize stress, pay attention to sleep hygiene, exercise and have good nutrition.
funny_bones: What are the treatment options for bipolar disorder during pregnancy and the postnatal period?
Speaker_-_Dr__Adele_Viguera: For women with bipolar disorder, maintenance treatment with a mood stabilizer during pregnancy can significantly reduce the risk of relapse; however, many of the medications commonly used in this setting, including lithium and valproic acid, carry some degree of teratogenic risk. First trimester exposure to lithium has been associated with an increased risk of cardiovascular malformation estimated to be between 1 in 2000 (0.05%) and 1 in 1000 (0.1%).
The anticonvulsant valproic acid carries a much higher risk of teratogenesis, with overall rates of malformation around 10%. and these birth defects include craniofacial abnormalities, cardiovascular malformation, limb defects and genital anomalies, as well as other central nervous system structural abnormalities.
While other anticonvulsants are being used more frequently in the treatment of bipolar disorder, there is limited information on the reproductive safety of these newer anticonvulsants, specifically gabapentin (Neurontin®), oxcarbazepine (Trileptal®), topiramate (Topamax®), tiagabine (Gabitril®), levetiracetam (Keppra®), zonisamide (Zonegran®).
However, there is a growing body of information regarding the reproductive safety of lamotrigine (Lamictal®), and this may be a useful alternative for some women. The International Lamotrigine Pregnancy Registry was created by GlaxoSmithKline (GSK) in 1992 to monitor pregnancies exposed to lamotrigine for the occurrence of major birth defects. Data from the Registry did not show an elevated risk of malformations associated with lamotrigine exposure.
Other data from the North-American Anti-Epileptic Drug Registry indicates the prevalence of major malformations in a total of 564 children exposed to lamotrigine monotherapy was 2.7%; however, five infants had oral clefts, indicating a prevalence rate of 8.9 per 1000 births. In a comparison group of 221,746 unexposed births, the prevalence rate for oral clefts was 0.37/1000, indicating a 24-fold increase in risk of oral cleft in infants exposed to lamotrigine.
However, other registries have not demonstrated such a significant increase in risk for oral clefts. It is important to put this risk into perspective. If we assume that the findings from the North American registry are true, the absolute risk of having a child with cleft lip or palate is about 0.9%. Clearly more data are essential to better evaluate the reproductive safety of lamotrigine; important questions regarding the safety of lamotrigine and other anticonvulsants might be best addressed by collaboration between multiple registries, including EURAP and the North-American Anti-Epileptic Drug Registry.
Bipolar Disorder: Prenatal Considerations
hola: I was diagnosed with bipolar disorder 10 years ago. I take Lithium. My doctor said that I would have to go off Lithium if I wanted to have a baby. What is your opinion?
Speaker_-_Dr__Adele_Viguera: Lithium is not necessarily considered a contraindication in pregnancy. It is however a known teratogen. Initially the risk associated with the exposure to Lithium during pregnancy was thought to be quite high for an unusual heart defect. This defect is known as Ebstein's Anomaly. This defect occurs in about 1:20,000 in the general population, however among children exposed to Lithium during the first trimester the new revised risk estimate is about 1:1,000.
So for some women with very severe bipolar disorder, remaining on Lithium even during the first trimester might be the most prudent clinical decision. However for women with mild illness we may try a discontinuation trial during the first trimester and resume Lithium after the teratogenic window is passed.
Bipolar Disorder and Pregnancy
Plan2: If I have bipolar disorder and am pregnant, should I discontinue my meds during my pregnancy? What about if I breast feed my baby?
Speaker_-_Dr__Adele_Viguera: Not necessarily…stopping your maintenance medications can carry a high risk of recurrence, especially if you stop your medicine abruptly. The most recent data from studies of pregnant women with bipolar disorder suggest that risk for recurrence (i.e. getting ill) once you stop is high, at >70%.
Breastfeeding is an important bonding experience as well as an excellent nutritional source for the infant. About 60% of mothers decide to breastfeed these days compared to the decade of the 1960s when most mothers’ bottle-fed their children. We recommend breastfeeding for mothers with bipolar disorder in the following circumstances:
- stable maternal mood
- monotherapy or at least a simple medication regimen
- adherence to infant monitoring recommendations
- a healthy infant
- a collaborative pediatrician
Trouble: Are some anti-depressants/drugs safer than others to take while I am pregnant?
Speaker_-_Dr__Adele_Viguera: Over the past 15 years, multiple studies have addressed the reproductive safety of various antidepressants. Data on the overall teratogenicity of SSRIs has come from relatively small prospective observational studies, larger international birth registries, managed health care databases, and case series; these data have cumulatively supported the reproductive safety of fluoxetine and certain other SSRIs.
In a recent meta-analysis including 1774 antidepressant-exposed infants, first trimester exposure to SSRIs was not associated with an increased risk of major malformations above the baseline of 2%-3% seen in the general population (Einarson & Einarson, 2005). The bulk of the data thus far has suggested that SSRIs, SNRIS, and tricyclic antidepressants are not major teratogens; however, concerns about the potential teratogenicity of SSRIs were first raised in 2005 when several preliminary studies suggested that paroxetine may be associated with a small increase in risk of congenital abnormalities.
BenJ2: My wife is pregnant and although she has never had a bipolar episode, her family has a bipolar disorder history. What are the signs to look for if my wife is having a bipolar disorder?
Speaker_-_Dr__Adele_Viguera: Bipolar disorder is characterized by episodes of mania, hypomania as well as depressive episode. Mania is characterized by elevated or euphoric mood or intense irritability. In addition to other symptoms including racing thoughts, lack of need for sleep, reckless behaviors including spending sprees, sexual indiscretions, reckless driving as well as increased interest in various activities and talking fast or pressured speech where it can be difficult to interrupt the person.
Depressive episodes are characterized by low mood, loss of pleasure in hobbies or other interests, suicidal ideation, lack of energy, lack of appetite or overeating, and insomnia or oversleeping.
Trouble: Will pregnancy cause any abnormal or unexpected bipolar episodes even if I continue my medication?
Speaker_-_Dr__Adele_Viguera: No, from the limited data available, risk of recurrence among women with bipolar disorder who maintained their maintenance medications was around 30%. This is a substantially lowered risk of recurrence compared to data suggesting that stopping medications is associated with a risk> 70%. When planning pregnancy, it is important to consider the following general principles in managing bipolar disorder in pregnancy
- Planned pregnancy provides time for thoughtful treatment choices
- Streamline medication regimen
- Use minimum effective dose
- Consider patient a “high-risk” pregnancy and monitor closely
- Guidelines may vary with severity of illness
- Consider pregnancy and the postpartum period as separate “risk periods” and individualize treatment plan accordingly
- Evaluate need for postpartum prophylaxis (strongly recommended)
Masters232: I have had a bipolar episode during my pregnancy but I’m better now. What are the chances that it will happen again?
Speaker_-_Dr__Adele_Viguera: The chances are relatively high. Bipolar disorder is a chronic mood disorder characterized by episodes of mania or hypomania and depressive episodes. One is never “cured” of bipolar disorder and like other chronic conditions, it has to be managed properly (i.e. follow routines, good sleep hygiene, reduce stress, take maintenance medications if needed, tracking moods daily…etc).
It is unusual to see new onset bipolar disorder during pregnancy, but it can happen. Usually, after a careful clinical assessment, one can generally find a past history of hypomania, depression, mania, or a history of a poor response to antidepressant treatment including worsening of depressive symptoms and increased mood cycling.
Hunter: My wife is bipolar and pregnant and her doctors recommend electroconvulsive therapy to get her symptoms under control. Can electroconvulsive treatments hurt the baby?
Speaker_-_Dr__Adele_Viguera: No, the data suggest that ECT is safe during pregnancy. It is not considered a contraindication. In some severe cases, ECT can be life saving and it certainly is an important treatment option to consider if a patient presents with a severe depression, manic episode or psychotic episode.
TaylorB: Can pregnancy reduce symptoms of bipolar? My sister seems to be much better since her pregnancy began.
Speaker_-_Dr__Adele_Viguera: The data suggests that there is a subgroup of patients who may do well in pregnancy. This is the exception rather than the rule in clinical settings. In general, pregnancy is a potentially high risk time for women with bipolar disorder.
Bipolar Disorder, Pregnancy and ECT
fsilber: I came late; please forgive me if this was already asked. I understand that medicines for bi-polar are harmful to the baby during pregnancy. If our daughter were to marry and want children, would it be an option for her to first go off her medication, and then have the bi-polar treated via ECT? Or would ECT also be incompatible with pregnancy?
Speaker_-_Dr__Adele_Viguera: I just answered this a few minutes ago, but to reiterate the data suggests that ECT is safe during pregnancy and is not considered a contraindication. It can be a life-saver in severe situations.
For some women with bipolar disorder, tapering off of medications prior to conception or immediately after conception, along with close monitoring by a clinician may be a reasonable option. But it is important to keep in mind the patient's past history. If there is a history of multiple episodes, the risk for recurrence during pregnancy is quite high.
fsilber: To clarify my previous question, my daughter cycles and was cycling quite rapidly, and I am certain that she would have symptoms quite soon upon stopping her medication. I would have to ask my wife exactly what she's taking, but it's not Lithium. It's Lamictal® and a couple of others, I think. If you are pretty sure she would have episodes of the medication were stopped, would it be better to continue them during pregnancy, or to try to replace them with ECT, at least temporarily?
Speaker_-_Dr__Adele_Viguera: Some patients do elect to receive maintenance ECT throughout pregnancy as an alternative to remaining off of medications. However, there are some limitations to this treatment including negative side effects such as memory loss. In general, decisions about treatment and the treatment options available should be addressed in a formal consultation with a psychiatrist who has expertise in this area. There is not one right answers and it is important to individualize the treatment recommendations.
Bipolar Disorder and Postpartum
Reese_Sally: Why is the postpartum period a time for greatly increased risk of relapse, or for an onset of more severe bipolar episodes in women?
Speaker_-_Dr__Adele_Viguera: Yes, the postpartum period represents a time of risk for patients with bipolar disorder, probably because of the dramatic hormonal fluctuations that occur during this unique time period. The most acute risk is during the first 6-8 weeks postpartum. In the literature, there is some debate about how to define the postpartum period. In general, the risk is highest during the first 6 weeks, followed by the first 12 weeks after delivery and probably up to the first 6 months postpartum. An episode with onset after 6 months postpartum is probably not officially a “postpartum” episode.
Patients with a past history of postpartum depression or a past history of bipolar disorder are at 50% risk of experiencing a subsequent postpartum episode. Patients who have had a postpartum psychosis are at greater than 90% risk of experiencing a subsequent postpartum psychosis. Also patients who have a family history of postpartum episodes should also be considered at risk as well.
Clinical Research Study
newtonm: Dr. Viguera, can you tell us a little about the research study you are conducting in this area?
Speaker_-_Dr__Adele_Viguera: It is an observational research study to examine risk factors for relapse of bipolar disorder during pregnancy and the postpartum period. Currently, very little is known about how pregnancy and the postpartum period affect bipolar disorder. So there is little information available on how to choose the best treatments for pregnant women with bipolar disorder.
The main goal of this study is to help fill that gap by finding the risks that may make it more likely for a woman with bipolar disorder to experience a depressive, manic, or hypomanic episode during her pregnancy and the postpartum period.
We hope that information gathered from this study will lead to better outcomes for pregnant women with bipolar disorder in the future. Basically, this study will monitor the course of your bipolar disorder during pregnancy and the postpartum period.
The risk factors that we will study include: the severity of your illness in the past; the stressors in your life and any treatment that you receive during pregnancy and the postpartum period.
We are hoping to gather information regarding: the effect that bipolar disorder or medications taken during pregnancy have your baby’s well-being at delivery; how pregnancy affects the way that your body breaks down any medications you take for bipolar disorder and how much of these medicines your baby is exposed to during pregnancy or breastfeeding.
For more information or to determine if you are eligible for the study you may contact Judy Meinert LISW, CCRP Research Coordinator at 216.445.7168 or email@example.com
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Dr. Adele Viguera is now over. Thank you again Dr. Viguera for taking the time to answer our questions about Bipolar Disorder in Pregnancy and the Postpartum Period.
Speaker_-_Dr__Adele_Viguera: Thank you for your participation.
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This chat occurred on September 8, 2009.
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