Prophylactic treatment of bipolar disorder in pregnancy and breastfeeding: focus on emerging mood stabilizers

Facts and myths about the use of lithium for bipolar disorder in routine clinical practice: an expert consensus paper

BACKGROUND

Bipolar disorder is one of the most burdensome severe mental disorders, characterized by high levels of personal and social disability. Patients often need an integrated pharmacological and non-pharmacological approach. Lithium is one of the most effective treatments available not only in psychiatry, but in the whole medicine, and its clinical efficacy is superior to that of other mood stabilizers. However, a declining trend on lithium prescriptions has been observed worldwide in the last 20 years, supporting the notion that lithium is a 'forgotten drug' and highlighting that the majority of patients with bipolar disorder are missing out the best available pharmacological option. Based on such premises, a narrative review has been carried out on the most common "misconceptions" and "stereotypes" associated with lithium treatment; we also provide a list of "good reasons" for using lithium in ordinary clinical practice to overcome those false myths.

MAIN TEXT

A narrative search of the available literature has been performed entering the following keywords: "bipolar disorder", "lithium", "myth", "mythology", "pharmacological treatment", and "misunderstanding". The most common false myths have been critically revised and the following statements have been proposed: (1) Lithium should represent the first choice for the treatment of patients with bipolar disorder; (2) lithium treatment is effective in different patients' groups suffering from bipolar disorder; (3) Drug-drug interaction risk can be easily managed during lithium treatment; (4) The optimal management of lithium treatment includes periodical laboratory tests; (5) Slow-release lithium formulation has advantages compared to immediate release formulation; (6) Lithium treatment has antisuicidal properties; (7) Lithium can be carefully managed during pregnancy.

CONCLUSIONS

In recent years, a discrepancy between evidence-based recommendations and clinical practice in using lithium treatment for patients with bipolar disorder has been highlighted. It is time to disseminate clear and unbiased information on the clinical efficacy, effectiveness, tolerability and easiness to use of lithium treatment in patients with bipolar disorder. It is necessary to reinvigorate the clinical and academic discussion about the efficacy of lithium, to counteract the decreasing prescription trend of one of the most effective drugs available in the whole medicine.

Evaluating the Efficacy of ChatGPT in Navigating the Spanish Medical Residency Entrance Examination (MIR): Promising Horizons for AI in Clinical Medicine

The rapid progress in artificial intelligence, machine learning, and natural language processing has led to increasingly sophisticated large language models (LLMs) for use in healthcare. This study assesses the performance of two LLMs, the GPT-3.5 and GPT-4 models, in passing the MIR medical examination for access to medical specialist training in Spain. Our objectives included gauging the model's overall performance, analyzing discrepancies across different medical specialties, discerning between theoretical and practical questions, estimating error proportions, and assessing the hypothetical severity of errors committed by a physician.

MATERIAL AND METHODS

We studied the 2022 Spanish MIR examination results after excluding those questions requiring image evaluations or having acknowledged errors. The remaining 182 questions were presented to the LLM GPT-4 and GPT-3.5 in Spanish and English. Logistic regression models analyzed the relationships between question length, sequence, and performance. We also analyzed the 23 questions with images, using GPT-4's new image analysis capability.

RESULTS

GPT-4 outperformed GPT-3.5, scoring 86.81% in Spanish (p < 0.001). English translations had a slightly enhanced performance. GPT-4 scored 26.1% of the questions with images in English. The results were worse when the questions were in Spanish, 13.0%, although the differences were not statistically significant (p = 0.250). Among medical specialties, GPT-4 achieved a 100% correct response rate in several areas, and the Pharmacology, Critical Care, and Infectious Diseases specialties showed lower performance. The error analysis revealed that while a 13.2% error rate existed, the gravest categories, such as "error requiring intervention to sustain life" and "error resulting in death", had a 0% rate.

CONCLUSIONS

GPT-4 performs robustly on the Spanish MIR examination, with varying capabilities to discriminate knowledge across specialties. While the model's high success rate is commendable, understanding the error severity is critical, especially when considering AI's potential role in real-world medical practice and its implications for patient safety.

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.

Schizophrenia and motherhood

The primary aim of this study was to analyze the impact of schizophrenic disorders on pregnancy outcomes. The secondary aim was to briefly analyze the potential role of antipsychotic treatment on influencing pregnancy outcomes in expectant mothers with schizophrenia. We searched the MEDLINE, PsycINFO, and Science.gov databases for articles published in English from January 1980 to January 2019. We used the following search terms: 'schizophrenia', 'motherhood', 'pregnancy/foetal/neonatal outcomes', and 'birth defects'. The reference lists of retrieved articles were also consulted to find additional pertinent studies missed in the electronic search and/or those published before 1980. Data were extracted from articles that provided primary data on the impact of maternal schizophrenia spectrum disorders on obstetrical and perinatal outcomes. After excluding duplicates, 35 articles were identified. Systematic reviews were searched on the same databases to briefly assess the effects of antipsychotics on pregnancy outcomes. The reviewed studies showed several limitations. They were published during a time range from the early 1970s to 2019. During this period, there were significant changes in the diagnostic criteria for schizophrenia. Moreover, such studies showed no homogeneity in the investigation of potential confounders. Most importantly, no research has differentiated the effects of maternal illness on pregnancy, fetal, and neonatal outcomes from those associated with antipsychotic treatments. Thus, it is not surprising that such studies show conflicting results. Despite such limitations, in managing pregnant women with schizophrenia clinicians should consider an integrated approach that includes: antipsychotic treatment, psychological treatment, optimal dietary approaches for prevention of excessive weight gain and gestational diabetes, meticulous gynecologic and obstetric surveillance, and social and occupational support.

Outcomes of pregnancies in women taking antiepileptic drugs for non-epilepsy indications

PURPOSE

Antiepileptic drugs (AEDs), particularly valproate (VPA), are known to be teratogens when taken by women with epilepsy (WWE), but the risk in women who take these drugs for indications other than epilepsy have been little studied. This study aims to investigate the incidence of birth defects in children born to mothers taking AEDs for non-epilepsy indications.

METHODS

The Australian Pregnancy Register (APR), established in 1998, is a prospective observational study operating with ethical approval and informed written consent for participation. Of the 2066 pregnancies enrolled in the Register, 98% are WWE and the remainder received AEDs for other indications. Data from this Register was analysed to study the rates of congenital malformations (CM) in infants exposed to AEDs in utero in WWE compared to those women taking AEDs for other indications.

RESULTS

The malformation rates in pregnancies of WWE taking AEDs (5%), is higher than the rates of infants born to untreated WWE (2%). There were 32 pregnancies enrolled from 29 mothers taking AEDs for indications other than epilepsy (2 women/2 pregnancies were lost to follow up). Out of 30 pregnancies, 9 of which were exposed to VPA, 1 resulted in a child with a malformation (3%) (cleft palate) on 1700 mg/day of valproate.

CONCLUSIONS

This is the first attempt to assess the use of AEDs in a prospective study of women who are pregnant but do not have active epilepsy. Although underpowered, this study suggests that women taking AEDs for non-epilepsy indications have a similar risk of having a child with a CM as compared with women taking AEDs for epilepsy. Larger numbers are required to investigate the risk of AED-associated malformations in this important group.

Fetal exposure to lamotrigine and quetiapine in two consecutive pregnancies

We present the case of two healthy infants born to a bipolar female maintained on low-dose lamotrigine and quetiapine.

Bipolar disorder in pregnancy and childbirth: a systematic review of outcomes

Background

Bipolar Disorder (BD) is a mental disorder usually diagnosed between 18 and 30 years of age; this coincides with the period when many women experience pregnancy and childbirth. As specific problems have been reported in pregnancy and childbirth when the mother has BD, a systematic review was carried out to summarise the outcomes of pregnancy and childbirth, in mother and child, when the mother has BD diagnosed before pregnancy.

Methods

An a priori protocol was designed and a systematic search conducted in PubMed, CINAHL, Scopus, PsycINFO and Cochrane databases in March 2015. Studies of all designs were included if they involved women with a diagnosis of bipolar disorder prior to pregnancy, who were pregnant and/or followed up to one year postpartum. All stages of inclusion, quality assessment and data extraction were done by two people. All maternal or infant outcomes were examined, and narrative synthesis was used for most outcomes. Meta-analysis was used to achieve a combined prevalence for some outcomes and, where possible, case and control groups were combined and compared.

Results

The search identified 2809 papers. After screening and quality assessement (using the EPHPP and AMSTAR tools), nine papers were included. Adverse pregnancy outcomes such as gestational hypertension and antepartum haemorrhage occur more frequently in women with BD. They also have increased rates of induction of labour and caesarean section, and have an increased risk of mood disorders in the postnatal period. Women with BD are more likely to have babies that are severely small for gestational age (<2nd-3rd percentile), and it appears that those women not being treated with mood stabilisers in pregnancy might not have an increased risk of having a baby with congenital abnormalities.

Discussion

Due to heterogeneity of data, particularly the use of differing definitions of bipolar disorder, narrative synthesis was used for most outcomes, rather than a meta-analysis.

Conclusions

It is evident that adverse outcomes are more common in women with BD and their babies. Large cohort studies examining fetal abnormality outcomes for women with BD who are not on mood stabilisers in pregnancy are required, as are studies on maternal-infant interaction.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1127-1) contains supplementary material, which is available to authorized users.

Bipolar Depression: Pregnancy, Postpartum, and Lactation

Medication management of bipolar depression in pregnancy and lactation is best done by assessing each patient's and family's needs in detail. Keeping pregnant patients as psychiatrically stable as possible is the most important principle for clinicians. Unfortunately, there is no risk-free situation for patients with psychiatric illness. This is often the most difficult and hard to accept reality for these patients, families, and clinicians. Clinicians serve these patients best by being as transparent as possible about the risk/benefit analysis of each patient's situation with the realization that ultimately the decisions are made by the patient and family.

Bipolar disorder in women

Bipolar affective disorder in women is a challenging disorder to treat. It is unique in its presentation in women and characterized by later age of onset, seasonality, atypical presentation, and a higher degree of mixed episodes. Medical and psychiatric co-morbidity adversely affects recovery from the bipolar disorder (BD) more often in women. Co-morbidity, particularly thyroid disease, migraine, obesity, and anxiety disorders occur more frequently in women while substance use disorders are more common in men. Treatment of women during pregnancy and lactation is challenging. Pregnancy neither protects nor exacerbates BD, and many women require continuation of medication during the pregnancy. The postpartum period is a time of high risk for onset and recurrence of BD in women. Prophylaxis with mood stabilizers might be needed. Individualized risk/benefits assessments of pregnant and postpartum women with BD are required to promote the health of the women and to avoid or limit exposure of the fetus or infant to potential adverse effects of medication.

Risks of neurobehavioral teratogenicity associated with prenatal exposure to valproate monotherapy: a systematic review with regulatory repercussions

Beyond its formal indications (epilepsy, bipolar disorder, and migraine), valproate sodium (VPA) is widely used in a number of other clinical conditions. Recently, however, the U.S. Food and Drug Administration (FDA) issued a warning regarding a decrease in IQ scores in children prenatally exposed to the drug. For patients with migraine, the pregnancy labeling of VPA will be changed from Category "D" to "X." VPA products will remain in pregnancy category "D" for treating epilepsy and manic episodes associated with bipolar disorder. Thus, this article aims to assess (through a computerized Medline/PubMed search) the neurobehavioral teratogenicity of valproate monotherapy, in order to evaluate alternative regulatory decisions. Reviewed information suggests a detrimental impact of antenatal valproate exposure on the global child neurodevelopment. Affected areas include not just reduced IQ scores, but also behavioral problems and a potential increase in the risk for a future diagnosis of attention-deficit/hyperactivity disorder. An increased risk of developing autism-spectrum disorders has also been reported. Thus, in my opinion, VPA should be assigned definitively to the Category "X," independent of any considerations about its clinical indications, and should be strictly avoided during pregnancy, due to the demonstrated risk of both neurobehavioral and neurocognitive teratogenicity.

Lithium protects against glucocorticoid induced neural progenitor cell apoptosis in the developing cerebellum

Respiratory dysfunction is one of the most common causes of death associated with premature birth (Barton et al., 1999). In the United States, 7-10% of pregnant women receive antenatal glucocorticoid (GC) therapy (Matthews et al., 2004), while approximately 19% of very low birth weight infants receive postnatal GC therapy (Jobe, 2009). Clinical research suggests that GC treatment causes permanent neuromotor and cognitive deficits (Yeh et al., 2004) and stunts cerebellar growth (Parikh et al., 2007; Tam et al., 2011). We previously reported that GC-mediated neural progenitor cell (NPC) apoptosis may be responsible for cerebellar neuropathology (Maloney et al., 2011; Noguchi et al., 2008, 2011). The goal of the current study was to determine whether lithium protects NPCs from GC neuroapoptosis in vivo and in vitro. Given that it protects against a range of brain insults, we hypothesized that lithium would significantly attenuate GC induced NPC toxicity. We report that acute lithium pretreatment provides potent, cell-intrinsic neuroprotection against GC induced NPC toxicity in vivo and in vitro.

Lamotrigine dosing for pregnant patients with bipolar disorder

OBJECTIVE

Little information is available on the need for dosage changes for lamotrigine in pregnant women with bipolar disorder. The authors present new data on serial serum levels of lamotrigine in pregnant patients on lamotrigine monotherapy. They also review the epilepsy literature on use of lamotrigine during pregnancy.

METHOD

Lamotrigine serum samples were obtained from eight mother-infant pairs at different time points during pregnancy and the postpartum period.

RESULTS

All of the women were taking lamotrigine throughout pregnancy. Serum-level-to-dose ratios were lower during pregnancy than the postpartum period. Lamotrigine was taken once daily in doses ranging from 100 mg to 300 mg. Three patients had an increase of 50 mg to their daily dose across pregnancy. The change in serum lamotrigine levels in the postpartum period ranged from a 30% decrease to a 640% increase compared with the first level obtained during pregnancy. Level-to-dose ratios obtained within 4 weeks after delivery reflected a mean level 402% greater than the baseline level during gestation. Compared with the third trimester, lamotrigine serum concentration increased an average of 154% within 5 weeks after delivery. The most dramatic increase in lamotrigine serum level early after delivery occurred at 1.5 weeks. The mean infant cord level was 66% of the maternal serum level at delivery. The mean breast-fed infant serum level was 32.5% of the maternal serum levels.

CONCLUSIONS

The pattern of lamotrigine changes during pregnancy in these women with bipolar disorder was consistent with that described in the epilepsy literature.

Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study

OBJECTIVE

To investigate the risks of adverse pregnancy and birth outcomes for treated and untreated bipolar disorder during pregnancy.

DESIGN

Population based cohort study using data from national health registers.

SETTING

Sweden.

PARTICIPANTS

332,137 women with a last menstrual period anytime after 1 July 2005 and giving birth anytime before the end of 31 December 2009. Women with a record of at least two bipolar diagnoses were identified and grouped as treated (n = 320)-those who had filled a prescription for mood stabilisers (lithium, antipsychotics, or anticonvulsants) during pregnancy-or untreated (n = 554). Both groups were compared with all other women giving birth (n = 331,263).

MAIN OUTCOME MEASURES

Preterm birth, mode of labour initiation, gestational diabetes, infants born small or large for gestational age, neonatal morbidity, and congenital malformations.

RESULTS

Of the untreated women, 30.9% (n = 171) were induced or had a planned caesarean delivery compared with 20.7% (n = 68,533) without bipolar disorder (odds ratio 1.57, 95% confidence interval 1.30 to 1.90). The corresponding values for the treated women were 37.5% (n = 120) (2.12, 1.68 to 2.67). The risks of preterm birth in both treated and untreated women were increased by 50%. Of the untreated women, 3.9% (n = 542) had a microcephalic infant compared with 2.3% (324,844) of the women without bipolar disorder (1.68, 1.07 to 2.62). The corresponding values for the treated women were 3.3% (n = 311) (1.26, 0.67 to 2.37). Similar trends were observed for risks of infants being small for gestational age infants for weight and length. Among infants of untreated women, 4.3% (n = 24) had neonatal hypoglycaemia compared with 2.5% (n=8302) among infants of women without bipolar disorder (1.51, 1.04 to 2.43), and 3.4% (n = 11) of the treated women (1.18, 0.64 to 2.16). The analyses of variation in outcomes did not support any significant differences between treated and untreated women.

CONCLUSIONS

Bipolar disorder in women during pregnancy, whether treated or not, was associated with increased risks of adverse pregnancy outcomes.

Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women

Mood disorders disproportionately affect women across the lifespan. Mood disorders in pregnancy and the postpartum period are common and have profound implications for women and their children. These include obstetric and neonatal complications, impaired mother-infant interactions, and, at the extreme, maternal suicide and infanticide. Because obstetrician-gynecologists are often the first (and sometimes the only) point of contact for young women in the health care system, familiarity with the presentation and treatment of depressive illness in the perinatal period is imperative. The goal of this review is to synthesize essential information on depressive illness in the perinatal period with a focus on its most common and severe presentations, major depressive disorder and bipolar disorder. Accurate diagnosis of unipolar major depressive disorder from bipolar disorder can facilitate the selection of the best possible treatment alternatives. Counseling may be sufficient for perinatal women who have mild to moderate depression, but women who are severely depressed are likely to require antidepressant treatment. Women with bipolar disorder are at high risk for relapse if mood stabilizer medication is discontinued, and they are vulnerable to relapse near the time of delivery. Comanagement of their care with psychiatrists will increase their chances of avoiding a recurrence of illness.

The clinical management of bipolar disorder complexity using a stratified model

OBJECTIVE

To provide practical and clinically meaningful treatment recommendations that amalgamate clinical and research considerations for several common, and as yet understudied, bipolar disorder complex presentations, within the framework of a proposed stratified model.

METHODS

A comprehensive search of the literature was undertaken using electronic database search engines (Medline, PubMed, Web of Science) using key words (e.g., bipolar disorder, anxiety, rapid cycling, and subsyndromal). All relevant randomised controlled trials were examined, in addition to review papers, meta-analyses, and book chapters known to the authors. The findings formed the basis of the treatment recommendations within this paper.

RESULTS

In light of the many broad presentations of bipolar disorder, a stratified model of bipolar disorder complexity was developed to facilitate consideration of the myriad of complexities that can occur during the longitudinal course of illness and the appropriate selection of treatment. Evidence-based treatment recommendations are provided for the following bipolar disorder presentations: bipolar II disorder, subsyndromal symptoms, mixed states, rapid cycling, comorbid anxiety, comorbid substance abuse, and for the following special populations: young, elderly, and bipolar disorder around the time of pregnancy and birth. In addition, some key strategies for countering treatment non-response and alternative medication recommendations are provided.

CONCLUSIONS

Treatment recommendations for the more challenging presentations of bipolar disorder have historically received less attention, despite their prevalence. This review acknowledges the weaknesses in the current evidence base on which treatment recommendations are generally formulated, and additionally emphasises the need for high-quality research in this area. The stratified model provides a means for conceptualizing the complexity of many bipolar disorder presentations and considering their management.

Lithium in pregnancy: the need to treat, the duty to ensure safety

INTRODUCTION

Untreated bipolar disorder during pregnancy leads to detrimental repercussions on the mother-infant pair's health. Despite different drugs having been proposed as mood stabilizers, lithium remains the first-choice agent for preventing mood changes.

AREAS COVERED

Analyzing up-to-date information on the reproductive safety of lithium and providing practice guidelines to optimize its use during pregnancy.

EXPERT OPINION

Findings from prospective and case-control studies confirm an increased, specific risk of Ebstein's anomaly (4.45-7.6/1000 live births), although lower than that previously reported. A potential increase in the risk of neural tube defects should also be taken into consideration. Moreover, several perinatal complications may occur, and even in the presence of relatively low infant serum levels, in the case of drug exposure during late pregnancy. Despite such concerns, lithium should still be considered the first-choice agent for treating bipolar disorder in pregnancy. Indeed, the U.S. FDA recently issued a new warning regarding the reproductive safety of antipsychotics. Moreover, the risk of fetal valproate/carbamazepine syndrome (and the confirmed neurodevelopmental teratogenicity of valproate) contraindicates the use of both medications, whereas the use of lamotrigine is limited by efficacy concerns. However, women who need lithium treatment during pregnancy should be carefully monitored: a strict gynecologic and psychiatric surveillance and, probably, preconception folate supplementation is highly advisable. Moreover, delivery should be programmed in Neonatal Intensive Care Units to ensure optimal management of potential iatrogenic perinatal complications.

Bipolar Disorder Differences between Genders: Special Considerations for Women

The objective of this article is to review clinical differences between men and women with bipolar disorder. The secondary objective is to analyze the differences in adherence to medication between genders. Men usually present with manic episodes and have comorbid drug abuse, while women usually present with major depressive episode, the onset is often later, comorbidity of physical pathology is common and adherence to medication is greater than in men. In women who have an earlier onset of the illness and are single, the risk of nonadherence is higher than in other groups of women. There are two time periods that are very important in women: pregnancy and postpartum. Both are critical periods and a relapse or recurrence of symptoms at either stage can have serious consequences for the woman and/or her baby. In addition, the effect of medication on the fetus is unclear. In conclusion, there is a clear need for more studies on gender differences in bipolar disorder and how to improve adherence to treatment. Moreover, a better understanding of how to treat women with bipolar disorder during pregnancy and lactation will undoubtedly lead to improved outcomes for both the mother and her child.

Suicidal mothers

Background:

Epidemiological research has demonstrated that suicidal ideation is a relatively frequent complication of pregnancy in both developed and developing countries. Hence, the aims of this study are: to assess whether or not pregnancy may be considered a period highly susceptible to suicidal acts; to recognize potential contributing factors to suicidal behaviors; to describe the repercussions of suicide attempts on maternal, fetal, and neonatal outcome; to identify a typical profile of women at high risk of suicide during pregnancy.

Methods:

Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, Scopus, and Google Scholar databases. Search terms were: "pregnancy", (antenatal) "depression", "suicide". Searches were last updated on 28 September 2010. Forty-six articles assessing the suicidal risk during pregnancy and obstetrical outcome of pregnancies complicated by suicide attempts were analyzed, without methodological limitations.

Results:

Worldwide, frequency of suicidal attempts and the rate of death by suicidal acts are low. Although this clinical event is rare, the consequences of a suicidal attempt are medically and psychologically devastating for the mother-infant pair. We also found that common behaviors exist in women at high risk for suicide during pregnancy. Review data indeed suggest that a characteristic profile can prenatally identify those at highest risk for gestational suicide attempts.

Conclusions:

Social and health organizations should make all possible efforts to identify women at high suicidal risk, in order to establish specific programs to prevent this tragic event. The available data informs health policy makers with a typical profile to screen women at high risk of suicide during pregnancy. Those women who have a current or past history of psychiatric disorders, are young, unmarried, unemployed, have incurred an unplanned pregnancy (eventually terminated with an induced abortion), are addicted to illicit drugs and/or alcohol, lack effective psychosocial support, have suffered from episodes of sexual or physical violence are particularly vulnerable.

[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.

Drug treatment for mood disorders in pregnancy

PURPOSE OF REVIEW

During the last few years, several researches, often showing contradictory findings, have investigated the safety of psychotropic medications used for treating mood disorders in pregnancy. Hence, the necessity exists to update this information constantly in order to ensure the safest option for the mother-infant pair.

RECENT FINDINGS

The risk of fetal anomalies associated with early in-utero exposure to antidepressants seems to be increased after paroxetine and clorimipramine exposure, whereas prenatal exposure to nearly all antidepressants is linked to the potential onset of the Prenatal Antidepressant Exposure Syndrome. As regards classic mood stabilizers, the teratogenic risk historically reported with lithium should probably be softened, whereas valproate is the medication which shows the strongest association with fetal anomalies. An increased risk of autism-spectrum disorders and infant neurodevelopmental delay is also associated with valproate exposure through the placenta. No significant reproductive safety data are available on atypical antipsychotics, although such medications may indirectly increase the rate of fetal malformation by inducing gestational diabetes.

SUMMARY

Avoiding the use of clorimipramine, paroxetine, valproate, and atypical antipsychotics during pregnancy is advisable. However, when starting or continuing pharmacological treatment during pregnancy, clinicians should consider not only the intrinsic iatrogenic risk of birth defects or perinatal complications, but also the general safety profile for the expectant mother. Indeed, specific adverse reactions (such as nausea, vomiting, constipation, and excessive weight gain) may aggravate the classic clinical findings of pregnancy, thus indirectly facilitating the occurrence of pregnancy complications and fetal and neonatal problems.

A case of delayed onset of threatened premature labor in association with electroconvulsive therapy in the third trimester of pregnancy

Electroconvulsive therapy (ECT) is recommended by the American Psychiatric Association Task Force on ECT as a safe and effective treatment of depression throughout pregnancy. We report here administration of ECT in the third trimester of pregnancy in a 33-year-old patient with severe bipolar depression. The patient had a good antidepressant response to ECT. She experienced, however, delayed onset premature uterine contractions at home after her sixth session of ECT (10 hours post-ECT administration). After receiving tocolytics, the patient's contractions did not progress to premature labor. In consultation with the obstetrics team, it was decided to terminate the ECT course earlier than planned. The patient is delivered of a healthy female newborn infant spontaneously at 37 weeks' gestational age. Four months after delivery, the baby's development is progressing normally. This case illustrates that premature contractions in association with ECT during the third trimester of pregnancy may be delayed in onset. Patients and treatment team need to be aware of this possibility, particularly when ECT is conducted on an outpatient basis.

Neurodevelopmental effects of prenatal exposure to psychotropic medications

Until now, studies on the reproductive safety of psychotropics have typically assessed the risk of congenital malformations and perinatal complications associated with in utero exposure to such medications. However, little is known of their inherent potential neurobehavioral teratogenicity. The objective is to analyze available data from studies investigating developmental outcome of children exposed prenatally to psychotropics. A computerized Medline/PubMed/TOXNET/ENBASE search (1960-2010) was conducted using the following keywords: pregnancy, child/infant development/neurodevelopment, antidepressants, benzodiazepines, mood stabilizers, and antipsychotics. A separate search was also run to complete the safety profile of single specific medications. Resultant articles were cross-referenced for other relevant articles not identified in the initial search. A noncomputerized review of pertinent journals and textbooks was also performed. All studies published in English and reporting primary data on the developmental outcome of infants exposed in utero to psychotropics and born without malformations were collected. As regards antiepileptic drugs, only studies that provided data on specific medications approved for psychiatric practice use (carbamazepine, lamotrigine, and valproate) were considered. Data were extracted from 41 articles (38 identified electronically and 3 nonelectronically), which met the inclusion criteria. Despite reviewed studies showing relevant methodological limitations, concordant, albeit preliminary, information seems to exclude that prenatal exposure to both selective serotonin reuptake inhibitors and tricyclic antidepressants may interfere with the infants' psychological and cognitive development. Conversely, information on valproate strongly discourages its use in pregnant women. Moreover, although data on carbamazepine remain controversial, information on whole classes of drugs and single medications is either absent (second-generation antipsychotics) or too limited (first-generation antipsychotics, benzodiazepines, lithium, and lamotrigine) to inform the decision-making process. For all classes of psychotropics, new and/or further studies are warranted to answer definitively the urgent question about the impact of prenatal exposure to such medications on infant development.

Screening for bipolar disorder during pregnancy and the postpartum period

Bipolar disorder is a significant mental health problem among perinatal women; however, little attention has been devoted to methods of screening for bipolar disorder during this phase of women's life cycle. There is a need for reliable and valid screening instruments for perinatal women. This paper presents a review of 11 self-report measures used to screen bipolar disorder in the general population and discusses their applicability to screening among perinatal women. Published psychometric data, including reliability, sensitivity, specificity, and positive predictive value of each self-report instrument, is presented and critiqued. We make recommendations for screening in clinical practice and highlights priorities for future research. The need for more research in this area is emphasized.

Antipsychotics in pregnancy

Women who are pregnant and who have a history of psychosis are commonly managed with antipsychotic medications. The evidence regarding the use of antipsychotics in pregnancy has been insufficient to provide adequate support for this practice and is a concern for clinicians and women alike. This review presents literature surrounding the use of antipsychotic medications in pregnancy, providing an overview of the historical and contemporary perspectives which influence clinicians prescribing practices. Data were sourced from Medline, CINAHL, PsycINFo, using the terms antipsychotics with pregnancy and psychosis or schizophrenia. This was expanded to include the most common atypical antipsychotics: olanzapine, risperidone, clozapine, quetiapine, ziprasidone and aripiprazole. Literature was found reporting the use of antipsychotic medications in pregnancy since the introduction of antipsychotics in the 1950s, comprising mainly of authors' reviews of the literature, case studies, retrospective reports, drug company registries and more recently a prospective comparative study. This review identifies that the literature provides no clear answer for clinicians as to the risk associated with the use of antipsychotics in pregnancy. To this effect, recently in Australia, the National Register of Antipsychotic Medications in Pregnancy was established to prospectively collect information regarding outcomes for mother and baby, when antipsychotic medications have been used during pregnancy.

Management of antipsychotic and mood stabilizer medication in pregnancy: recommendations for antenatal care

The aim of the present study was to develop recommendations for antenatal care and monitoring for women with bipolar disorder and schizophrenia who are on lithium carbonate, antipsychotic or anti-epileptic medication during pregnancy. A literature search and review of original research, published reviews and guidelines was undertaken for mood stabilizers and antipsychotics in pregnancy and for the management of bipolar disorder and schizophrenia in pregnancy. This information was summarized, condensed and then reviewed by representatives of psychiatry, pharmacy, paediatrics and obstetrics to produce an information booklet and subsequently monitoring recommendations and tables. A model of antenatal monitoring and care for women with schizophrenia, bipolar disorder and related disorders who are maintained on psychotropic medication was developed. This included an online and published booklet for clinicians summarizing psychotropic medication in pregnancy, and lactation and monitoring tables that could be part of patient case files. These were to assist in reminding and educating staff on the need for additional monitoring and assessment above standard antenatal care for women on mood stabilizers and antipsychotic medication. Women with bipolar disorder and schizophrenia have an increased risk of complications in pregnancy from their illness and from the medications they are prescribed. A summary of the risks and a model of suggested additional monitoring during pregnancy have been developed in consultation across a number of clinical disciplines.

Severe apnea in an infant exposed to lamotrigine in breast milk

OBJECTIVE

To report a case of severe apnea in an infant exposed to lamotrigine through breast-feeding.

CASE SUMMARY

A 16-day-old infant developed several mild episodes of apnea that culminated in a severe cyanotic episode requiring resuscitation. A thorough examination at the hospital gave no evidence of underlying diseases that could explain the reaction. The mother had used lamotrigine in increasing doses throughout pregnancy, and at the time of the apneic episodes, she used 850 mg/day. The infant was fully breast-fed, and the neonatal lamotrigine serum concentration was 4.87 microg/mL at the time of admission. Breast-feeding was terminated, and the infant fully recovered.

DISCUSSION

Although there are several reports on extensive passage of lamotrigine into breast milk, this is the first published report of a serious adverse reaction in a breast-fed infant. Lamotrigine clearance increases throughout pregnancy, and maternal dose increases are often necessary to maintain therapeutic effect. After delivery, clearance rapidly returns to preconception levels, enhancing the risk of adverse reactions in both mothers and breast-fed infants if the dose is not sufficiently reduced. In this case, the dose was slowly reduced after delivery, and the maternal lamotrigine serum concentration more than doubled in the week before the neonatal apneic episodes. A high lamotrigine concentration was detected in the breast milk, and the neonatal lamotrigine serum concentration was in the upper therapeutic range. The neonatal lamotrigine elimination half-life was approximately twice that seen in adults. The Naranjo probability scale indicated a probable relationship between apnea and exposure to lamotrigine through breast-feeding in this infant.

CONCLUSIONS

Infants can be exposed to clinically relevant doses of lamotrigine through breast-feeding. Individual risk/benefit assessment is important, and close monitoring of both mother and child is advisable, especially during the first 3 weeks postpartum.

Psychotropic drug use during breastfeeding: a review of the evidence

OBJECTIVE

The objective of this study was to review the existing literature on the use of various classes of psychotropic medications during breastfeeding to provide information about infant exposure levels and reported adverse events in breastfed infants.

METHODS

A bibliographic search in the Medline (1967 through July 2008), Embase (1975 through July 2008), and PsycINFO (1967 through July 2008) databases was conducted for studies on breastfeeding and psychotropic medications for a total of 96 drugs. References of retrieved articles, reference books, and dedicated Web sites were also checked. The manufacturers were contacted for drugs without published information. Original articles and review articles that provide pharmacokinetic data on drug excretion in breast milk and infant safety data were considered, to estimate the "compatibility level" of each drug with breastfeeding.

RESULTS

A total of 183 original articles were eligible for analysis. Documentation was retrieved for 62 (65%) drugs. In all, 19 (31%) psychotropic drugs can be used during lactation according to an evidence-based approach. For 28 drugs, the available data do not permit an evaluation of the drug's safety profile during breastfeeding and, for an additional 15 drugs, the exposure dose or observed adverse effects make their use unsafe.

CONCLUSIONS

Although most drugs are considered safe during breastfeeding, compatibility with breastfeeding has not been established for all psychotropic drugs. There is a need for additional research and accumulation of experience to guarantee a more rational use of psychotropic drugs during breastfeeding.

Postpartum depression

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.

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.

The clinical content of preconception care: women with psychiatric conditions

For a substantial proportion of women, pregnancy can be complicated by the occurrence or reoccurrence of a psychiatric condition. Psychiatric disorders during pregnancy are associated with poor obstetric outcomes, higher risk of postpartum psychiatric illness, increased rates of substance abuse, lower participation in prenatal care, and adverse infant and family outcomes. As part of preconception care, providers should be vigilant and screen for psychiatric disorders among women of reproductive age, as the detection and appropriate management of these conditions can reduce the occurrence of adverse pregnancy and family outcomes. This manuscript reviews the treatment options and the risks and benefits of discontinuing, changing, or continuing psychotropic medications for women of reproductive age with common psychiatric disorders (depression and anxiety disorders, bipolar disorder, and schizophrenia) and offers recommendations for preconception care.

Current issues: women and bipolar disorder

While the treatment of bipolar disorder (BD) is typically complex, the treatment of women with bipolar disorder is even more challenging because clinicians must also individualize treatment based on the potential for pregnancy, drug interactions with oral contraceptives, and an increased risk of endocrine diseases that can either impact the course of illness or become manifest with some treatments. Women with BD should be checked for hypothyroidism, and if prescribed antidepressants, carefully watched for rapid cycling or a mood switch to mania, hypomania, or a mixed state. Several medications interact with oral contraceptives or increase the risk of developing polycystic ovary syndrome. Consideration of possible pregnancy is essential, and should be planned in advance whenever possible. Rates of recurrence have been shown to be equal in pregnant and nonpregnant women with BD. Risks of medication to the fetus at various points of development must be balanced against the risks of not treating, which is also detrimental to both fetus and mother. The postpartum period is a time of especially high risk; as many as 40% to 67% of women with BD report experiencing a postpartum mania or depression. The decision to breastfeed must also take into account the adverse impact of sleep deprivation in triggering mood episodes. In order to best address these issues, clinicians must be familiar with the data and collaborate with the patient to assess risks and benefits for the individual women and her family.

Maternal use of antipsychotics in early pregnancy and delivery outcome

The effect of various antipsychotics during pregnancy has repeatedly been studied, but for most atypical antipsychotics, only little information is available. We identified from the Swedish Medical Birth Register 2908 women who had reported the use of any antipsychotic or lithium in early pregnancy and studied malformation rates with data also from the Register of Congenital Malformations and the Hospital Discharge Register. Comparisons were made with all births (n = 958,729) after adjustment for some confounders. Risks were expressed as odds ratios (ORs). Most women had used dixyrazine or prochlorperazine mainly because of nausea and vomiting in early pregnancy. Seventy-nine women had used lithium, and these outcomes are reported separately. Hence, the main analysis was restricted to 570 women (576 infants) using other antipsychotics. There was a statistically significant increase in the risk for a congenital malformation-after exclusion of some common and minor conditions, the OR was 1.52 (95% confidence interval, 1.05-2.19). Exclusion of infants exposed to anticonvulsants reduced the OR only slightly. Most of the increased risk was caused by cardiovascular defects, mainly atrium or ventricular septum defect. No certain drug specificity was found. Except for an increased risk for congenital malformations, a nearly doubling of the risk for gestational diabetes and a 40% increased risk for cesarean delivery was noted. Because there seems to be little drug specificity, it is possible that underlying pathology or unidentified confounding explains the excess risk.

Consecutive exposure to lamotrigine and citalopram during pregnancy

We describe the case of a pregnancy healthy outcome after in utero consecutive exposure to lamotrigine and citalopram.

Prise en charge des femmes souffrant d'un trouble bipolaire de la conception au post-partum

Any plans for pregnancy must be discussed in detail with women with bipolar disorders. They must be informed about the risks related to it and the need for some precautions. Because of the risk of relapse during pregnancy, the risk/benefit ratio of maintaining or starting prophylactic treatment should be assessed, taking into account family history and frequency of recurrences. Lithium may be used during pregnancy under close monitoring. Most anticonvulsants are contraindicated because of their teratogenicity. During the post-partum period, prophylaxis is required in most cases because of the high risk of relapse. If no prophylaxis was given during pregnancy, it must be started quickly after delivery to be effective when the risk is at its highest, i.e., during the first two weeks after delivery. Women with bipolar disorders should be advised against breast-feeding to avoid exposure of the infant to psychotropic medication. Because breast-feeding can be stressful and causes sleep deprivation, it may increase the risk of relapse. Second-generation antipsychotic agents should not be used during pregnancy or breast-feeding because inadequate information is currently available about their safety.

Atypical antipsychotics for the treatment of bipolar disorder: more shadows than lights

Atypical antipsychotics are utilised more frequently for the treatment of bipolar disorder than first-generation antipsychotics because of their improved neurological tolerability. Furthermore, recent studies suggest that psychiatric outcomes are improved in patients treated with atypical agents. The aim of this article is to review the studies evaluating the effectiveness of atypical antipsychotics in treating acute bipolar episodes (bipolar mania, bipolar depression and mixed episodes), as well as those investigating the effectiveness of atypical antipsychotics as maintenance treatment for the disorder. Because of several relevant methodological limitations affecting the vast majority of clinical trials, evidence-based information about the effectiveness of atypical antipsychotics in treating bipolar disorder is somewhat discouraging. Moreover, data indicating effectiveness in managing the acute manic phase and in long-term maintenance treatment are quantitatively robust only for olanzapine. However, olanzapine seems to have no advantages in terms of tolerability and therapy compliance when compared with classical mood stabilisers or first-generation antipsychotics. In addition, only a few studies have investigated the efficacy of atypical antipsychotics for treating bipolar depression. Hence, information regarding the effectiveness of such medications in treating this specific phase of bipolar disorder should be considered as still preliminary. Given this situation, further independent and well-designed studies are urgently needed before definitive conclusions on the effectiveness of most atypical antipsychotics in the different clinical situations characterising the natural course of bipolar disorder can be drawn.

Serotonin reuptake inhibitor-induced perinatal complications

There are a growing number of concerns about the utilization of serotonin reuptake inhibitors (SRIs) in late pregnancy and the onset of perinatal complications. This review aimed to analyze and summarize the studies evaluating the risk of perinatal complications (such as low birth weight, preterm delivery, withdrawal or toxic phenomena, and other detrimental events/poor neonatal outcomes) related to maternal SRI use in late pregnancy. A computerized search of MEDLINE (1966-January 2007) and PsycINFO (1974-January 2007) databases was performed. Articles describing perinatal complications after late in utero exposure to SRIs were selected and also reviewed for additional references. Fifty studies met the inclusion criteria. Exposure to SRIs late in pregnancy is clearly associated with an increased risk of infants developing a constellation of symptoms, including CNS and respiratory effects, often requiring close infant observation and supportive or specific treatment in intensive care units. Such symptoms are not always due to toxic or withdrawal reactions. Indeed, some evidence suggests that SRIs may interfere with the physiology of the respiratory system and parasympathetic activity in neonates. Of the most methodologically relevant studies reviewed, 50% have been published in the last 3 years. Hence, it is possible that further concerning data will become available in the future. For these reasons, the opportunity of tapering and discontinuing SRIs in late pregnancy should be taken into consideration, although to date the evidence to support such a clinical decision is preliminary.