Risk of Recurrence in Women With Bipolar Disorder During Pregnancy: Prospective Study of Mood Stabilizer Discontinuation

Harvard University, Cambridge, Massachusetts, United States
American Journal of Psychiatry (Impact Factor: 12.3). 01/2008; 164(12):1817-24; quiz 1923. DOI: 10.1176/appi.ajp.2007.06101639
Source: PubMed


This study estimated the risk of recurrence of mood episodes among women with a history of bipolar disorder who continued or discontinued treatment with mood stabilizers during pregnancy.
In a prospective observational clinical cohort study, the authors determined recurrence risk and survival-analysis-based time to recurrence of a new episode in 89 pregnant women with DSM-IV bipolar disorder. Eligible subjects were euthymic at conception and continued mood stabilizer treatment or discontinued treatment proximate to conception.
The overall risk of at least one recurrence in pregnancy was 71%. Among women who discontinued versus continued mood stabilizer treatment, recurrence risk was twofold greater, median time to first recurrence was more than fourfold shorter, and the proportion of weeks ill during pregnancy was five times greater. Median recurrence latency was 11 times shorter after abrupt/rapid versus gradual discontinuation of mood stabilizer. Most recurrences were depressive or mixed (74%), and 47% occurred during the first trimester. Predictors of recurrence included bipolar II disorder diagnosis, earlier onset, more recurrences/year, recent illness, use of antidepressants, and use of anticonvulsants versus lithium.
Discontinuation of mood stabilizer, particularly abruptly, during pregnancy carries a high risk for new morbidity in women with bipolar disorder, especially for early depressive and dysphoric states. However, this risk is reduced markedly by continued mood stabilizer treatment. Treatment planning for pregnant women with bipolar disorder should consider not only the relative risks of fetal exposure to mood stabilizers but also the high risk of recurrence and morbidity associated with stopping maintenance mood stabilizer treatment.

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    • "Les travaux de Viguera et al. [56] montrent que les patientes sous thymorégulateur pour des troubles bipolaires qui arrêtent leurs traitements ont deux fois plus de risques de rechute postnatale. Elles rechutent 4 fois plus vite et les épisodes durent 5 fois plus longtemps qu'en dehors de la période périnatale, d'où l'intérêt de discuter le maintien d'un thymorégulateur pendant la grossesse. "
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    ABSTRACT: Abstract in French and in English Résumé La grossesse et le postpartum sont des périodes particulières concernant l’utilisation de psychotropes chez la future mère. La prescription thérapeutique doit tenir compte du risque éventuel de malformation chez le fœtus, de syndrome de sevrage chez le nouveau-né, du type d’allaitement et du risque potentiel de la maladie mentale maternelle non traitée. Les recommandations de bonne pratique sont en perpétuel remaniement et leurs conclusions parfois contradictoires. Méthode : le but de ce travail est d’élaborer un référentiel actualisé à partir d’une revue de la littérature, facile d’utilisation pour tout professionnel concerné par le suivi ou la prescription d’un traitement psychotrope (antidépresseurs, anxiolytiques-hypnotiques, neuroleptiques, thymorégulateurs et traitements de substitution de la dépendance aux opiacés) chez une femme enceinte ou qui allaite. Résultats : ces mises au point, sous forme de tableaux, se basent également sur notre expérience clinique en tant qu’équipe spécialisée en médecine périnatale. Summary Pregnancy and the postpartum periods are particular for the mother's use of drugs. Therapeutic prescription must take into account the potential risk of fetal malformation, newborn's withdrawal syndrome, feeding type and potential risk of untreated maternal mental illness. Recommendations for good practice are constantly remodeling and their conclusions are sometimes contradictory. Method: The aim of this work is to develop an updated review, easy to use for any professional involved in the monitoring or prescription of a psychotropic medication (antidepressants, anxiolytics-hypnotics, neuroleptics, mood stabilizers and substitution treatment of opioid dependance) for pregnant or nursing women. Results: These updates in tabular form are also based on our clinical experience as a team specializing in perinatal medicine.
    La Presse Médicale 01/2015; 44(3):271-283. DOI:10.1016/j.lpm.2014.07.026 · 1.08 Impact Factor
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    • "Yet the care of pregnant and breastfeeding mothers with mental illness remains poorly researched and under resourced, sometimes with tragic consequences [10]. Many women with psychiatric illness require psychotropic medication treatment during pregnancy and postpartum because there is a 50% or more risk of relapse of bipolar and psychotic disorders during pregnancy and the immediate postpartum period [11], [12]. The appropriate use of psychotropic medication during pregnancy substantially reduces the risk of relapse in women with bipolar disorder [11], [13]. "
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    ABSTRACT: Many women diagnosed with varying psychiatric disorders take antipsychotic medications during pregnancy. The safety of antipsychotic medications in pregnancy is largely unknown. We established the National Register of Antipsychotic Medications in Pregnancy in 2005. Women who are pregnant and taking an antipsychotic medication are interviewed every 6 weeks during pregnancy and then followed until their babies are one year old. The baby's progress is closely followed for the first year of life. As of April 18 2012, 147 pregnancies had been followed through to completion. There were 142 live births and data is available for 100 one year old babies. 18% of babies were born preterm, with a higher dose of antipsychotic medication correlating to an increased likelihood of premature delivery; 43% of babies required special care nursery or intensive care after birth; 37% had any degree of respiratory distress and 15% of babies developed withdrawal symptoms. Congenital anomalies were seen in eight babies. Most pregnancies resulted in the birth of live, healthy babies. The use of mood stabilisers or higher doses of antipsychotics during pregnancy increased the likelihood of babies experiencing respiratory distress or admission to Special Care Nursery or Neonatal Intensive Care Units. There is a great need for safety and efficacy information about the use of antipsychotic medications in pregnancy. Live, healthy babies are the most common outcome following the use of antipsychotic medication in pregnancy, but clinicians should be particularly mindful of neonatal problems such as respiratory distress.
    PLoS ONE 05/2014; 9(5):e94788. DOI:10.1371/journal.pone.0094788 · 3.23 Impact Factor
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    • "However, recent studies have shown that relapse rates for bipolar disorder during pregnancy can reach 50%, casting doubt on the role of pregnancy as a protective factor.2–6 A recent prospective study found that 70.7% of patients with bipolar I or II disorder underwent at least one mood-destabilizing episode during pregnancy, and the risk of relapse was higher for those who stopped taking their medication.7 Even with a high risk of recurrence without treatment, only 5.5% of patients receive appropriate pharmacotherapy,8 which is most likely to be due to incomplete safety data for pregnant patients and the known teratogenicity of agents frequently employed to manage the illness. "
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    ABSTRACT: Women with bipolar disorder have a high risk for symptom exacerbation during pregnancy and the risk is elevated further when mood stabilizers are discontinued. This report describes a 31-year-old bipolar woman who discontinued medication before pregnancy but had to resume her pharmacotherapy due to manic episodes that recurred during the second trimester. Olanzapine, an atypical antipsychotic, was administered from week 25 of gestation and then replaced with quetiapine in week 35 of gestation. Even though a consensus on clinical interventions for pregnant patients with symptom relapse has not been reached, clinicians should still discuss pregnancy and therapeutic management with every female bipolar patient of childbearing age. This discussion is important because treatment can be managed most effectively in these individuals if pregnancy is planned. Ultimately, clinical decisions should be made on a case-by-case basis, weighing the risks to the mother and fetus between the disorder itself and the teratogenicity of pharmacotherapy.
    Neuropsychiatric Disease and Treatment 02/2014; 10:325-8. DOI:10.2147/NDT.S59481 · 1.74 Impact Factor
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