COMMENTARY

The Management of Bipolar Disorder During Pregnancy

Zachary N. Stowe, MD; D. Jeffrey Newport, MD, MS, MDiv

Disclosures

December 14, 2007

In This Article

Course of Bipolar Disorder During Pregnancy and the Postpartum Period

The natural course of illness for women with BPD over the course of pregnancy is obscure. Kraepelin observed that attacks of mania and melancholia were more common after childbirth than during pregnancy.[7] Similarly, several early case reports suggested that some women with BPD maintain euthymia during pregnancy even after discontinuation of medication.[8,9,10,11] Lier and colleagues[10] found that pregnancy was not associated with significantly altered risk for BPD recurrence. Furthermore, a retrospective study by Grof and colleagues[11] suggested an apparent protective effect of pregnancy on the course of lithium-responsive type I BPD.

In contrast, 3 retrospective studies and some case reports suggest that pregnancy is not protective and may instead represent a time of substantial risk for relapse.[12,13,14] In one large, well-characterized clinical sample, Blehar[12] found that 45% of women with BPD experienced an exacerbation of their illness during pregnancy. More recently, Freeman and colleagues[13] found that at least 50% of a sample of women with BPD became symptomatic during pregnancy. A retrospective study of women with BPD who discontinued lithium proximate to conception found nearly identical high rates of recurrence within 40 weeks in 42 pregnant (52%) and 59 nonpregnant (58%) women.[14] Recurrence rates were similar for BPD I and II subtypes, higher in those with more than 4 prior episodes or who discontinued lithium therapy, especially rapidly or abruptly. Prospective investigations supported by the National Institute of Health (NIH) have demonstrated significant risk for relapse (greater than 70%) in women discontinuing mood-stabilizing medications compared with those who continued medications (approximately 25% relapsed).[15,16]

The postpartum period is a particularly high-risk period for women with BPD. Recurrence rates in women with BPD during the first 3-6 months postpartum are at least 20% to 50%, and recent observations suggest that the postpartum relapse risk without mood-stabilizer therapy may be as high as 70%.[17,18,19,20,21,22,23,24,25,26,27,28] Symptom emergence is often rapid and may occur in late pregnancy or within the first few days to weeks after delivery. Women with BPD are at very high risk for postpartum psychosis (10% to 20%), at least 200-fold higher than the background rate of 0.05%.[25,26,27]

In summary, women with BPD have a variable course during pregnancy that is significantly influenced by decisions regarding pharmacotherapy. In contrast, the postpartum period is a time of increased risk, and the prophylactic benefit of continued pharmacotherapy warrants further investigation.

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