CEU; Collaborative Management of Women with Bipolar Disorder During Pregnancy and Postpartum: Pharmacologic Considerations

Lithium Treatment Over the Lifespan in Bipolar Disorders

Lithium has been the treatment of choice for patients with bipolar disorder (BD) for nearly 70 years. It is recommended by all relevant guidelines as a first-line treatment for maintenance therapy. In this review, we outline the current state of evidence for lithium in the treatment of BD over the lifespan. First, we summarize the evidence on efficacy in general, from relapse prevention to acute anti-manic treatment and its role in treating mood episodes with mixed features and bipolar depression. As patients are often treated for many years and different aspects have to be considered in different phases of life, we discuss the particularities of lithium in the treatment of paediatric BD, in older aged individuals and in pregnant women. Lastly, we discuss the evidence on lithium's proposed suicide-preventive effects, the dangers of rapid discontinuation and lithium's adverse effects, particularly with regard to long-term treatment.

Lithium Use and Non-use for Pregnant and Postpartum Women with Bipolar Disorder

PURPOSE OF REVIEW

Despite being recognized as a first-line treatment for bipolar disorder, there is still inconsistent use of lithium in perinatal populations. This article will review data regarding lithium use during the peripartum and provide management recommendations for general psychiatric clinicians.

RECENT FINDINGS

In contrast to prior data, recent studies indicate that lithium use in pregnancy is associated with either no increased malformations risk or a small increase in risk for cardiac malformations including Ebstein's anomaly. Limited data also show no significant effect on obstetric or neurodevelopmental outcomes. Data regarding infant lithium exposure via breastmilk remains limited. Lithium is currently under-prescribed and is an important treatment for women with bipolar disorder in pregnancy and the postpartum. Clinicians must weigh the risk of lithium treatment versus the risk of withholding or changing lithium treatment when managing bipolar disorder in this population.

Mindfulness-Based Cognitive Therapy for Perinatal Women with Depression or Bipolar Spectrum Disorder

The perinatal period is a high-risk time for mood deterioration among women vulnerable to depression. This study examined feasibility, acceptability, and improvement associated with mindfulness-based cognitive therapy (MBCT) in perinatal women with major depressive disorder (MDD) or bipolar spectrum disorder (BSD). Following a diagnostic evaluation, 39 perinatal women with a lifetime history of MDD (n = 27) or BSD (n = 12) enrolled in an 8-week program of MBCT classes (2 h each) that incorporated meditation, yoga, and mood regulation strategies. Participants were pregnant (n = 12), planning pregnancy (n = 11), or up to 1-year postpartum (n = 16). Participants were self-referred and most had subthreshold mood symptoms. Assessments of depression, (hypo)mania, and anxiety were obtained by interview and self-report at baseline, post-treatment and at 1- and 6-month post-treatment. Women with a history of MDD were more likely to complete the classes than women with BSD. Of 32 women who completed the classes, 7 (21.9 %) had a major depressive episode during the 6-month post-treatment follow-up. On average, participants with MDD reported improvements in depression from pre- to post-treatment. Mood improvement was not observed in the BSD group. In the full sample, improvements in depression symptoms across time points were associated with increasing mindful tendency scores. This study was limited by its uncontrolled design, heterogeneous sample, and questionnaire-based assessment of mindfulness skills. MBCT may be an important component of care for perinatal women with histories of major depression. Its applicability to perinatal women with BSD is unclear.

Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring

OBJECTIVE

Pharmacotherapy for mood disorders during pregnancy is often complicated by pregnancy-related pharmacokinetic changes and the need for dose adjustments. The objectives of this review are to summarize the evidence for change in perinatal pharmacokinetics of commonly used pharmacotherapies for mood disorders, discuss the implications for clinical and therapeutic drug monitoring (TDM), and make clinical recommendations.

METHODS

The English-language literature indexed on MEDLINE/PubMed was searched for original observational studies (controlled and uncontrolled, prospective and retrospective), case reports, and case series that evaluated or described pharmacokinetic changes or TDM during pregnancy or the postpartum period.

RESULTS

Pregnancy-associated changes in absorption, distribution, metabolism, and elimination may result in lowered psychotropic drug levels and possible treatment effects, particularly in late pregnancy. Mechanisms include changes in both phase 1 hepatic cytochrome P450 and phase 2 uridine diphosphate glucuronosyltransferase enzyme activities, changes in hepatic and renal blood flow, and glomerular filtration rate. Therapeutic drug monitoring, in combination with clinical monitoring, is indicated for tricyclic antidepressants and mood stabilizers during the perinatal period.

CONCLUSIONS

Substantial pharmacokinetic changes can occur during pregnancy in a number of commonly used antidepressants and mood stabilizers. Dose increases may be indicated for antidepressants including citalopram, clomipramine, imipramine, fluoxetine, fluvoxamine, nortriptyline, paroxetine, and sertraline, especially late in pregnancy. Antenatal dose increases may also be needed for lithium, lamotrigine, and valproic acid because of perinatal changes in metabolism. Close clinical monitoring of perinatal mood disorders and TDM of tricyclic antidepressants and mood stabilizers are recommended.

[Treatment of bipolar disorder during pregnancy and in the postpartum period]

BACKGROUND

Pharmacological treatment and prophylaxis of bipolar disorders during pregnancy and in the postpartum period imply complicated clinical assessments.

MATERIAL AND METHOD

This article is based on a non-systematic search in PubMed and the authors' clinical experience.

RESULTS

If a woman is already using a prophylactic drug at the time of pregnancy, she can in general continue to do so during pregnancy, with the exception of valproate. If the disorder starts during pregnancy; lithium, lamotrigine or second generation antipsychotic drugs are suitable alternatives. In general, drugs used during pregnancy can also be used in the postpartum period, although some require special precautions if the mother wishes to breast-feed. If treatment is initiated after delivery, the mother's wish to breast-feed should be taken into consideration when choosing a drug.

INTERPRETATION

Although existing studies have weaknesses, there is sufficient evidence to give qualified advice regarding choice of medication for bipolar disorder during pregnancy and in the postpartum period.

Teratogenesis associated with antibipolar agents

OBJECTIVE

To review the teratogenic effects associated with the use of Food and Drug Administration-approved agents for bipolar disorder.

METHODS

A PubMed search of all English language articles published from January 1966 to December 2008 was conducted. The key search terms included all major bipolar agents, cross-referenced with: teratogenicity, teratogen, safety, pregnancy, fetus, bipolar disorder, and malformation. The search was augmented with manual reviews of relevant article reference lists as well as http://clinicaltrials.gov and http://www.fda.gov (both last accessed in April 2008). Several pregnancy registries were also reviewed to determine malformation rates as well as teratogenesis attributable to each agent. Articles selected for review were based on author consensus, adequacy of sample size, the use of standardized experimental procedures, validated assessment measures, and overall manuscript quality.

RESULTS

Valproate is associated with the highest rate of major congenital malformations (6.2%-16%). The relative risk of neural tube defects with valproate and carbamazepine is reported as approximately 1%-5% and 0.5%-1%, respectively. Preliminary evidence suggests that the relative risk for oral clefts (cleft lip or palate) is increased with lamotrigine relative to other antiepileptic drugs (AED) (ie, approximately 0.4%). The rate of major congenital malformations is higher in fetuses exposed to AED polytherapy (ie, >or=2 drugs) in comparison with AED monotherapy. Adverse neurobehavioral effects are insufficiently reported for most agents. In-utero exposure to valproate is associated with a greater risk of developmental difficulty requiring special education interventions as well as decreased verbal IQ scores. The risk of Ebstein's anomaly associated with lithium use is increased relative to the general population. The major congenital malformation rate with chlorpromazine and atypical antipsychotics is not established as being higher than a non-exposed group; the teratogenic risks associated with the olanzapine-fluoxetine combination are unknown.

CONCLUSIONS

Well-characterized risks are associated with valproate, carbamazepine, lamotrigine, and lithium. The risks associated with psychotropic drug use need to be understood in the context of significant rates of relapse and associated morbidity when discontinuing bipolar treatment during pregnancy.