Mood stabilizers during breastfeeding: a review

A New Safety Scoring System for the Use of Psychotropic Drugs During Lactation

BACKGROUND

Psychotropic drugs are frequently used to treat postpartum women with psychiatric diagnoses, especially psychotic disorder, major depression, and bipolar mood episodes. Pharmacotherapy in breastfeeding mothers is a major challenge.

STUDY QUESTION

This article presents a new safety scoring system for the use of psychotropic drugs during lactation.

STUDY DESIGN

The scoring system is based on the following 6 safety parameters: reported total sample, reported maximum relative infant dose, reported sample size for relative infant dose, infant plasma drug levels, prevalence of reported any adverse effect, and reported serious adverse effects. The total score ranges from 0 to 10. Higher scores represent a higher safety profile.

RESULTS

According to this scoring system, sertraline and paroxetine, respectively, had the highest scores representing "very good safety profile." Citalopram, olanzapine, and midazolam were assigned to "good safety profile." Among drugs evaluated in this article, trifluoperazine, aripiprazole, amisulpride, clozapine, doxepin, zaleplon, and zolpidem are not recommended owing to safety scores ≤3.

CONCLUSIONS

Most psychotropic drugs examined in this article have "moderate" or "low" safety profile.

Maternal Carbamazepine Therapy and Unusual Adverse Effects in a Breastfed Infant

BACKGROUND

Usually, no adverse effects are observed in breastfed infants whose mothers are treated with the anti-epileptic carbamazepine. In this article, we described unusual short-term adverse effects observed in a young infant after exposure to carbamazepine during pregnancy and lactation.

CASE REPORT

A 40-day-old female infant, born at term, was admitted to the Pediatric Clinic at University of Sassari, Italy, for recurrent regurgitations and vomiting. She was breastfed since birth and her mother was under chronic carbamazepine therapy. Gastroesophageal reflux was initially suspected; therefore, thickening of feeds and postural therapy were applied without any benefit. Subsequently, high levels of carbamazepine were detected in infant serum and in maternal breast milk. After an unsuccessful attempt to combine breastfeeding with formula feeding, the switch to exclusive formula feeding was made, with subsequent rapid resolution of symptoms and body weight increase.

DISCUSSION AND CONCLUSIONS

The use of carbamazepine is considered compatible with breastfeeding, even if the potential risk of adverse reactions in breastfed infants exists. In this case, the discontinuation of breastfeeding resulted in the complete resolution of symptoms, suggesting a correlation between the observed manifestations in the infant and her exposure to maternal therapy.

Psychotropic medication and breast-feeding

Adverse effects of psychotropic medication on breast-fed infants have not been studied in controlled and systematic research. Existing information comes from small case series and single case reports. These limited data confirm that psychotropics are excreted into breast milk and that the infant is exposed to them. In recent decades sufficient data have accumulated to allow psychiatrists to prescribe tricyclic antidepressants, selective serotonin reuptake inhibitors, conventional antipsychotics, carbamazepine and sodium valproate to breast-feeding mothers with safety. There are not sufficient data on atypical antipsychotics to allow women to breast-feed safely. Mothers on clozapine or lithium should not breast-feed. It is good practice to recommend that breast-feeding mothers requiring psychotropic medication be on a low dose of one single drug. Future research taking account of maternal mental health, psychopharmacological factors, infant physiological environment and individualised risk/benefit assessment will yield clearer responses to this complex issue.

Short-Term Safety of Paroxetine and Sertraline in Breastfed Infants: A Retrospective Cohort Study from a University Hospital

OBJECTIVE

Primary pharmacological agents for depression and anxiety disorders are antidepressants, especially selective serotonine reuptake inhibitors. The aim of this study was to examine the features and prevalence of adverse effects of paroxetine and sertraline in breastfed infants.

METHODS

The study had a retrospective cohort design. Five-year clinical data of 72 patients were included in the study. Psychiatric diagnoses were ascertained by means of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

RESULTS

The prevalence rate of adverse events in the infants was 12.5%. Insomnia (88.9%), restlessness (55.6%), and constant crying (22.2%) were the most frequent adverse events. A switch between paroxetine and sertraline performed in five patients, who reported an adverse event in their breastfed infants, resulted in cessation of the adverse events.

CONCLUSION

The results suggest that the prevalence rate of adverse events in the infants exposed to sertraline or paroxetine is relatively low and mostly mild.

Adverse Effects in the Pharmacologic Management of Bipolar Disorder During Pregnancy

Management of bipolar disorder during pregnancy often involves medications with potential adverse effects, including risks to the mother and fetus. Although some specifics are known, many medications continue to have incompletely characterized reproductive safety profiles. Women with bipolar disorder who are planning pregnancy face challenging decisions about their treatment; careful risk-benefit discussions are necessary. With the goal of further informing these discussions, this article reviews the data currently available regarding medication safety in the management of bipolar disorder during pregnancy, with specific attention to lithium, valproic acid, lamotrigine, carbamazepine, and antipsychotic medications.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Mood stabilizers during breastfeeding: a systematic review of the recent literature

OBJECTIVE

This review examined the safety of mood stabilizers in exposed breastfed infants.

METHODS

PubMed was searched for English language reports between 1 January 1995 and 30 August 2015 by using combinations of key words breastfeeding, lactation, postpartum period, puerperium, mood stabilizers, lithium, lamotrigine, valproate, carbamazepine, and oxcarbazepine. Case reports, case series, and prospective or cross-sectional studies including relevant data such as relative infant dose, milk-to-plasma ratio, infant drug plasma levels, and adverse events were identified.

RESULTS

A total of 26 of 604 relevant reports in PubMed were included in the study. These reports included lamotrigine (122 cases in 12 reports), lithium (26 cases in five reports), carbamazepine (64 cases in five reports), valproate (nine cases in three reports), and oxcarbazepine (two cases in two reports). Of 26 reports, one report included both carbamazepine and valproate. The reports suggest that a considerable amount of lithium and lamotrigine are excreted into breast milk. There is a paucity of data on valproate and oxcarbazepine; however, the infant/maternal ratio of serum drug concentration seems to be lower in valproate exposure compared to other mood stabilizers. The incidence of adverse events in infants exposed to mood stabilizers is reported to be very low.

CONCLUSIONS

The current data suggest that mood stabilizers can be prescribed without any adverse events in most infants in lactating women. The available reports also suggest a low prevalence rate of laboratory abnormalities including hepatic, kidney, and thyroid functions in the infants. Additional studies examining short-term and especially long-term effects of mood stabilizers on breastfed infants are required.

Use of psychotropic drugs during pregnancy and breast-feeding

OBJECTIVE

To write clinical guidelines for the use of psychotropic drugs during pregnancy and breast-feeding for daily practice in psychiatry, obstetrics and paediatrics.

METHOD

As we wanted a guideline with a high degree of consensus among health professionals treating pregnant women with a psychiatric disease, we asked the Danish Psychiatric Society, the Danish Society of Obstetrics and Gynecology, the Danish Paediatric Society and the Danish Society of Clinical Pharmacology to appoint members for the working group. A comprehensive review of the literature was hereafter conducted.

RESULTS

Sertraline and citalopram are first-line treatment among selective serotonin reuptake inhibitor for depression. It is recommended to use lithium for bipolar disorders if an overall assessment finds an indication for mood-stabilizing treatment during pregnancy. Lamotrigine can be used. Valproate and carbamazepin are contraindicated. Olanzapine, risperidone, quetiapine and clozapine can be used for bipolar disorders and schizophrenia.

CONCLUSION

It is important that health professionals treating fertile women with a psychiatric disease discuss whether psychotropic drugs are needed during pregnancy and how it has to be administered.

Postpartum psychiatric disorders: Early diagnosis and management

Postpartum period is demanding period characterized by overwhelming biological, physical, social, and emotional changes. It requires significant personal and interpersonal adaptation, especially in case of primigravida. Pregnant women and their families have lots of aspirations from the postpartum period, which is colored by the joyful arrival of a new baby. Unfortunately, women in the postpartum period can be vulnerable to a range of psychiatric disorders like postpartum blues, depression, and psychosis. Perinatal mental illness is largely under-diagnosed and can have far reaching ramifications for both the mother and the infant. Early screening, diagnosis, and management are very important and must be considered as mandatory part of postpartum care.

Mood stabilizers in pregnancy and lactation

Management of bipolar during pregnancy and postpartum is very challenging. The treating clinicians have to take into account various factors like current mental state, longitudinal history of the patient, past history of relapse while off medication, response to medication, time of pregnancy at which patient presents to the clinician, etc. The choice of drug should depend on the balance between safety and efficacy profile. Whenever patient is on psychotropic medication, close and intensive monitoring should be done. Among the various mood stabilizers, use of lithium during the second and third trimester appears to be safe. Use of valproate during first trimester is associated with major malformation and long-term sequalae in the form of developmental delay, lower intelligence quotient, and higher risk of development of autism spectrum disorder. Similarly use of carbamazepine in first trimester is associated with higher risk of major congenital malformation and its use in first trimester is contraindicated. Data for lamotrigine (LTG) appears to be more favorable than other antiepileptics. During lactation, use of valproate and LTG is reported to be safe. Use of typical and/atypical antipsychotic is a good option during pregnancy in women with bipolar disorder.

Breastfeeding and migraine drugs

PURPOSE

Breastfeeding women may suffer from migraine. While we have many drugs for its treatment and prophylaxis, the majority are poorly studied in breastfeeding women. We conducted a review of the most common anti-migraine drugs (AMDs) and we determined their lactation risk.

METHODS

For each AMD, we collected all retrievable data from Hale's Medications and Mother Milk (2012), from the LactMed database (2014) of the National Library of Medicine, and from a MedLine Search of relevant studies published in the last 10 years.

RESULTS

According to our review, AMDs safe during breastfeeding are as follows: low-dose acetylsalicylic acid (ASA), ibuprofen, sumatriptan, metoprolol, propranolol, verapamil, amitriptyline, escitalopram, paroxetine, sertraline, acetaminophen, caffeine, and metoclopramide. AMDs compatible with breastfeeding but warranting caution are as follows: diclofenac, ketoprofen, naproxen, most new triptans, topiramate, valproate, venlafaxine, and cyproheptadine. Finally, high-dose ASA, atenolol, nadolol, cinnarizine, flunarizine, ergotamine, methysergide, and pizotifen are contraindicated.

CONCLUSIONS

According to our review, the majority of the revised AMDs were assessed to be compatible with breastfeeding.

Effect of Anaesthesia Methods for Regaining Daily Life Activities in Cesarean Patients

OBJECTIVE

Postpartum period is physically, socially and emotionally a difficult time for the parents and the baby to become a family. We tried to investigate how the anaesthesia method affects patients who underwent cesarean delivery, as a factor which also affects this period.

METHODS

Two hundred and six parturients, who underwent elective cesarean delivery in Celal Bayar University Hafsa Sultan Hospital were recruited for our study. After demographic data and anaesthesia methods were noted, an EQ-5D health survey and Katz ADL scale were evaluated face to face 24 hours postoperatively, and by telephone on the 5th postoperative day.

RESULTS

The percentage of patients who had general anaesthesia was 35.2% (n=71), while 19.8% (n=40) had epidural anaesthesia and 45% (n=91) had spinal anaesthesia. Among -these three methods, the EQ-5D health survey revealed that the outcome at postoperative 24 hours was best in epidural anaesthesia and that general anaesthesia outcome was the worst (p=0.007). The Katz ADL scale at postoperative 24. hours showed that epidural anaesthesia was better than the other methods for regaining daily life activities (p<0.05).

CONCLUSION

Our study showed that epidural anaesthesia had the most effective role among the methods in regaining daily life activities after elective cesarean delivery, which was demonstrated using the EQ-5D health survey and Katz ADL scale.

Antiepileptic drugs and breastfeeding

INTRODUCTION

This review provides a synopsis for clinicians on the use of antiepileptic drugs (AEDs) in the breastfeeding mother.

METHODS

For each AED, we collected all retrievable data from Hale's "Medications and Mother Milk" (2012), from the LactMed database (2013) of the National Library of Medicine, and from a MedLine Search of relevant studies in the past 10 years.

RESULTS

Older AEDs, such as carbamazepine, valproic acid, phenytoin, phenobarbital, primidone are considered to have a good level of safety during lactation, due to the long term clinical experience and the consequent amount of available data from the scientific literature. On the contrary, fewer data are available on the use of new AEDs. Therefore, gabapentin, lamotrigine, oxcarbazepine, vigabatrin, tiagabine, pregabalin, leviracetam and topiramate are compatible with breastfeeding with a less documented safety profile. Ethosuximide, zonisamide and the continue use of clonazepam and diazepam are contraindicated during breastfeeding.

CONCLUSIONS

Although the current available advice on the use of AEDs during breastfeeding, given by different accredited sources, present some contradictions, most AEDs can be considered safe according to our review.

Effect of home-based peer support on maternal-infant interactions among women with postpartum depression: a randomized, controlled trial

Approximately 15% of new mothers experience postpartum depression, representing the most common source of maternal morbidity post-delivery. Postpartum depression may impair maternal-infant interactions, contributing to poor developmental outcomes in the offspring of mothers with depression. The purpose of this study was to test the effectiveness of home-based peer support that included maternal-infant interaction teaching for mothers with symptoms of postpartum depression and their infants. Mothers with postpartum depression were randomly assigned to control (n = 33) or intervention groups (n = 27). Intervention group mothers received 12 weeks of home-based peer support that included maternal-infant interaction teaching; peers were mothers who had recovered from postpartum depression and were trained to provide support. Data were collected from all mothers at baseline, as well as 6 and 12 weeks' post-randomization. Contrary to the hypothesized direction of relationships, results favoured the control group. A significant difference between the groups was observed for one of the two measures of maternal-infant interactions. Several other measures favoured the control group, including mothers' depressive symptoms and social support scores. No significant treatment effects were observed in infant IQ scores or diurnal salivary cortisol levels in mothers or infants. The findings suggest that maternal-infant interaction teaching by peers is not well received by mothers with postpartum depression and might be more optimally delivered by professional nurses.

The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments

OBJECTIVES

Safety monitoring is an important aspect of bipolar disorder treatment, as mood-stabilising medications have potentially serious side effects, some of which may also aggravate existing medical comorbidities. This paper sets out the International Society for Bipolar Disorders (ISBD) guidelines for the safety monitoring of widely used agents in the treatment of bipolar disorder. These guidelines aim to provide recommendations that take into consideration the balance between safety and cost-effectiveness, to highlight iatrogenic and preventive clinical issues, and to facilitate the broad implementation of therapeutic safety monitoring as a standard component of treatment for bipolar disorder.

METHODS

These guidelines were developed by an ISBD workgroup, headed by the senior author (MB), through an iterative process of serial consensus-based revisions. After this, feedback from a multidisciplinary group of health professionals on the applicability of these guidelines was sought to develop the final recommendations.

RESULTS

General safety monitoring recommendations for all bipolar disorder patients receiving treatment and specific monitoring recommendations for individual agents are outlined.

CONCLUSIONS

These guidelines are derived from evolving and often indirect data, with minimal empirical cost-effectiveness data available to provide guidance. These guidelines will therefore need to be modified to adapt to different clinical settings and health resources. Clinical acumen and vigilance remain critical ingredients for safe treatment practice.

Evidence-based guidelines for treating bipolar disorder: revised second edition--recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. The second version, like the first, is based explicitly on the available evidence and presented, like previous Clinical Practice guidelines, as recommendations to aid clinical decision making for practitioners: they may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed but selective qualitative review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in treatment of episodes, relapse prevention and stopping treatment.

Lithium toxicity and the parturient: case report and literature review

A 39-year-old gravida 8, para 6 woman at 34 weeks of a twin gestation was admitted to the antenatal ward with severe agitation and restlessness. She had a history of unstable bipolar disorder for which she was treated with lithium. Before admission she had been under close supervision by psychiatric and obstetric teams and lithium levels had been stable. However, an acute deterioration in renal function secondary to ureteric obstruction resulted in toxic plasma lithium levels and associated clinical features. An emergency caesarean section was carried out under general anaesthesia. We provide a review of the current literature including: the pharmacology of lithium, the effects of lithium on fetus and mother, and the current guidelines for management of lithium treatment during pregnancy. Lithium is prescribed relatively rarely during pregnancy. We aim to increase awareness about the issues involved in the management of women receiving lithium during pregnancy.

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.

The use of electroconvulsive therapy in postpartum affective disorders

Postpartum affective disorders continue to be a major health issue for women. There is a general belief that electroconvulsive therapy (ECT) is effective in treating severe or treatment-refractory postpartum affective illnesses, but evidence to support this assertion is lacking. In this case series, we present 5 cases of women with postpartum depression and psychosis, all of whom had failed prior pharmacological therapy. All 5 women had a significant response within 3 to 6 treatments with ECT. Our findings suggest that ECT is overall an effective treatment of postpartum illnesses. In addition to being an excellent choice for women who have failed prior medication trials, ECT may also be considered for women whose severity of illness necessitates rapid symptom resolution.

Psychotropic medication during pregnancy and lactation

Despite the traditional notion that pregnancy is a time of joy and emotional well being, evidence suggests that it does not protect women against mental illness. Untreated mental illness carries wide-ranging repercussions for mother, child and family that often outweigh those associated with treatment. Clinical management is complex, involving competing risks to mother and offspring; the challenge lies in effectively treating mental illness, whilst minimising exposure of the child to harmful medication. The paucity of robust published evidence on which to base the principles of psychiatric care further compounds the issue. Pregnancy significantly affects plasma drug levels and immature foetal/neonatal physiology renders the child prone to damage from pharmacological agents, all of which cross the placenta/enter breast-milk to varying degrees. Risks include teratogenicity, obstetrical complications, perinatal syndromes, and long-term behavioural problems. Despite evidence that some psychotropic drugs may be safe during pregnancy, knowledge regarding the risks of antenatal exposure to medications remains far from complete. The pregnant or breastfeeding woman requires an individualised risk-benefit analysis with regard to the commencement or continuance of psychotropic medication. If treatment is deemed necessary, monotherapy at the lowest possible dose should be prescribed. More robust safety data is available for older psychotropic drugs, which should be employed in preference to newer agents with unestablished safety profiles. Pregnant/breastfeeding women should also be educated with regard to early detection of signs of drug toxicity in both themselves and their babies. Despite shared responsibility, the ultimate decision with regard to reasonable risk, and what constitutes it, rests with the informed patient. Close psychiatric monitoring and coordinated multidisciplinary care with the obstetrician and paediatrician combine with such informed patient choices to comprise the components of a holistic model of care, targeted at optimizing the complex management of women with psychiatric illness during pregnancy.

Using pharmacokinetics to predict the effects of pregnancy and maternal-infant transfer of drugs during lactation

Knowledge of pharmacokinetics and the use of a mechanistic-based approach can improve our ability to predict the effects of pregnancy for medications when data are limited. Despite the many physiological changes that occur during pregnancy that could theoretically affect absorption, bioavailability does not appear to be altered. Decreased albumin and alpha(1)-acid glycoprotein concentrations during pregnancy will result in decreased protein binding for highly bound drugs. For drugs metabolised by the liver, this can result in misinterpretation of total plasma concentrations of low extraction ratio drugs and overdosing of high extraction ratio drugs administered by non-oral routes. Renal clearance and the activity of the CYP isozymes, CYP3A4, 2D6 and 2C9, and uridine 5'-diphosphate glucuronosyltransferase are increased during pregnancy. In contrast, CYP1A2 and 2C19 activity is decreased. The dose of a drug an infant receives during breastfeeding is dependent on the amount excreted into the breast milk, the daily volume of milk ingested and the average plasma concentration of the mother. The lipophilicity, protein binding and ionisation properties of a drug will determine how much is excreted into the breast milk. The milk to plasma concentration ratio has large inter- and intrasubject variability and is often not known. In contrast, protein binding is usually known. An extensive literature review was done to identify case reports including infant concentrations from breast-fed infants exposed to maternal drugs. For drugs that were at least 85% protein bound, measurable concentrations of drug in the infant did not occur if there was no placental exposure immediately prior to or during delivery. Knowledge of the protein binding properties of a drug can provide a quick and easy tool to estimate exposure of an infant to medication from breastfeeding.

[Pregnancy, breast feeding and mood stabilisers: review and recommendations for practice]

INTRODUCTION

The high prevalence of bipolar affective disorder, the early age of onset and the even sex ratio imply that numerous women of childbearing age raise the question of mood stabilisers during pregnancy and breast feeding.

LITERATURE FINDINGS

Some data suggest that giving appropriate answers to bipolar women who want to have children is an unmet need. We reviewed the risks and therapeutic options of this period of life in women with bipolar disorder. The generally accepted idea that pregnancy protects from relapses in bipolar disorders may be untrue and even deceitful. Lithium is the only mood stabiliser that can be prescribed in some cases during the first three months of pregnancy. DISCUSSION AND GUIDE LINES: We give explicit criteria that allow to consider this option: a severe illness prior to lithium prescription, a highly favourable outcome since initiation of lithium, no relapse during the last 18 months. When such conditions are satisfied, a reflection of the patient and at best of the couple must be proposed and associated with very complete information, both oral and written when possible, on the risks and benefits of the interruption and/or continuation of lithium. The teratogenic risks with anticonvulsants have been demonstrated and their prescription during the first three months of pregnancy should be avoided. Besides, there is some concern about the psycho-motor development of children born from women who were under anticonvulsants during pregnancy. The more recent mood stabilisers are not recommended either due to insufficient data. Breast feeding is not recommended under lithium, but seems safe under carbamazepine or valproate and its derivatives.

Long-term prophylaxis in bipolar disorder

Bipolar disorder is a major cause of disability, and the prevention of relapse is a key management goal. Pharmacological interventions, effectively delivered through enhanced clinical care, are central to long-term management. This article summarises the available evidence for a range of pharmacological options, and provides guidance on common issues in clinical management in line with current practice guidelines. The use of medications for long-term prophylaxis should be considered in all patients meeting criteria for bipolar I disorder. Increasing high-quality evidence from randomised trials informs management decisions relating to both novel agents, such as lamotrigine and olanzapine, and longer-established therapies, such as lithium and valproate, in monotherapy. Medications taken long-term in bipolar disorder differ in the extent to which they protect against manic and depressive relapse. Consequently, the emerging challenge is to understand how combination treatments can enhance efficacy and effectiveness based on data from controlled trials rather than random polypharmacy. Clinical care can be enhanced with effective education about the illness, and the use of strategies to improve treatment adherence and the recognition and management of stressors or prodromal symptoms. Where available, a range of specific psychological interventions can be effective as an adjunct to medication. When discontinuation of prophylaxis is necessary, gradual tapering of dose over weeks or months is recommended.

Use of psychotropic medications in treating mood disorders during lactation : practical recommendations

Many new mothers who need antidepressant or mood-stabilising drug treatment may wish to breastfeed their infants, but are hesitant to do so because of possible harmful effects of the medication on the infant. This article reviews current data on drug excretion into breast milk and the effects on the breast-fed child, and provides recommendations for the use of the different psychotropic drugs in lactating women. Relevant literature was identified through systematic searches of MEDLINE, EMBASE and the Science Citation Index Expanded (ISI) from 1966 to February 2005. The present knowledge is based on the accumulation of case studies. No randomised controlled trials in breast-fed infants have been performed and there is a lack of long-term follow-up studies. Use of SSRIs and TCAs (except doxepin) is compatible with breastfeeding. However, if treatment with an SSRI is started in the postpartum period, fluoxetine and citalopram may not be drugs of first choice. With regard to other antidepressants, such as venlafaxine, trazodone, mirtazapine, reboxetine, moclobemide and other MAOIs, very little knowledge exists. Breastfeeding should be avoided while using lithium. Carbamazepine and sodium valproate (valproic acid) are generally better tolerated by the breast-fed infant than lithium. Data on lamotrigine are still sparse. Knowledge is also scarce on the novel antipsychotics and thus recommendations in lactating women cannot be made for these agents. It is unwise to expose infants unnecessarily to drugs that may have severe adverse effects. As such, clozapine should probably be avoided because of the risk of agranulocytosis. Our knowledge of the impact of drug exposure through breast milk is still limited. Infant drug exposure is, however, generally higher during pregnancy through placental passage than through breast milk. Despite the low dosage transferred to the infant through breast milk, premature infants and infants with neonatal diseases or inherited disturbances in metabolism may be vulnerable to such exposure.

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

OBJECTIVES

Bipolar disorders are reported to have a high incidence during childbearing years and the need may arise to start or continue a pharmacological treatment during pregnancy and the postpartum period. In the last few years several investigations have evaluated the efficacy of emerging mood-stabilizing agents in the treatment of bipolar disorders, such as lamotrigine, olanzapine, risperidone, quetiapine, aripiprazole and ziprasidone. A number of studies, which examined the use of oxcarbazepine, point to its potential usefulness in prophylactic treatment. The aim of this review is to compare information from the literature on the safety of lamotrigine, oxcarbazepine, risperidone, olanzapine, and quetiapine to the safety data on classic mood stabilizers during pregnancy and the postpartum period.

METHODS

A computerized search carried out from 1980 to April 5, 2006 led to the summarization of the results. (References were updated after acceptance and prior to publication.)

RESULTS

Emerging mood stabilizers show uncertain safety parameters in pregnancy and lactation. Limited information on lamotrigine and oxcarbazepine does not suggest a clear increase in teratogenicity, while olanzapine appears to be associated with a higher risk of metabolic complications in pregnant women. Data about risperidone and quetiapine are still inconclusive. Finally, the literature on the safety of these compounds in breastfeeding is anecdotal.

CONCLUSIONS

Untreated pregnant bipolar women are at an increased risk of poor obstetrical outcomes and relapse of affective symptoms. On the other hand, classic antiepileptic drugs are well-known human teratogens, whereas data on lithium are partially ambiguous. The safety of emerging mood stabilizers in pregnancy and breastfeeding has not been examined extensively. Therefore, when approaching bipolar disorder, if possible, each episode must be considered separately.

Lithium: clinical considerations in internal medicine

Bipolar Disorders affect up to 5% of the population. While the pharmacological options for the treatment of bipolar disorder have expanded over the past several years, lithium remains an inexpensive and efficacious treatment for bipolar disorder. Lithium has been demonstrated to be an effective treatment for acute mania, bipolar depression, the prophylactic treatment of bipolar disorder, and as an augmentation agent in the treatment of unipolar major depression. Lithium also is the only mood stabilizer that has been demonstrated to lower the suicide rate in patients with bipolar disorder. Use in special populations, side effects and toxicity, and drug interactions are discussed. Important laboratory monitoring guidelines are included in this review. Lithium remains an important intervention for the treatment of mood disorders.

A review of postpartum psychosis

OBJECTIVE

The objective is to provide an overview of the clinical features, prognosis, differential diagnosis, evaluation, and treatment of postpartum psychosis.

METHODS

The authors searched Medline (1966-2005), PsycInfo (1974-2005), Toxnet, and PubMed databases using the key words postpartum psychosis, depression, bipolar disorder, schizophrenia, organic psychosis, pharmacotherapy, psychotherapy, and electroconvulsive therapy. A clinical case is used to facilitate the discussion.

RESULTS

The onset of puerperal psychosis occurs in the first 1-4 weeks after childbirth. The data suggest that postpartum psychosis is an overt presentation of bipolar disorder that is timed to coincide with tremendous hormonal shifts after delivery. The patient develops frank psychosis, cognitive impairment, and grossly disorganized behavior that represent a complete change from previous functioning. These perturbations, in combination with lapsed insight into her illness and symptoms, can lead to devastating consequences in which the safety and well-being of the affected mother and her offspring are jeopardized. Therefore, careful and repeated assessment of the mothers' symptoms, safety, and functional capacity is imperative. Treatment is dictated by the underlying diagnosis, bipolar disorder, and guided by the symptom acuity, patient's response to past treatments, drug tolerability, and breastfeeding preference. The somatic therapies include antimanic agents, atypical antipsychotic medications, and ECT. Estrogen prophylaxis remains purely investigational.

CONCLUSIONS

The rapid and accurate diagnosis of postpartum psychosis is essential to expedite appropriate treatment and to allow for quick, full recovery, prevention of future episodes, and reduction of risk to the mother and her children and family.

Bipolar affective disorder: advances in genetics and mood-stabilising medication

The lifetime prevalence of bipolar affective disorder is between 1 % and 2%. This educational review paper focuses on two areas of interest and relevance to trainees preparing for the membership examination of the Royal College of Psychiatrists: (a) advances in the genetics of bipolar affective disorder; and (b) mood-stabilising medication in bipolar affective disorder.

Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies

Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar II disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring.

The AGNP-TDM Expert Group Consensus Guidelines: focus on therapeutic monitoring of antidepressants

Therapeutic drug monitoring (TDM) of psychotropic drugs such as antidepressants has been widely introduced for optimization of pharmacotherapy in psychiatric patients. The interdisciplinary TDM group of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) has worked out consensus guidelines with the aim of providing psychiatrists and TDM laboratories with a tool to optimize the use of TDM. Five research-based levels of recommendation were defined with regard to routine monitoring of drug plasma concentrations: (i) strongly recommended; (ii) recommended; (iii) useful; (iv) probably useful; and (v) not recommended. In addition, a list of indications that justify the use of TDM is presented, eg, control of compliance, lack of clinical response or adverse effects at recommended doses, drug interactions, pharmacovigilance programs, presence of a genetic particularity concerning drug metabolism, and children, adolescents, and elderly patients. For some drugs, studies on therapeutic ranges are lacking, but target ranges for clinically relevant plasma concentrations are presented for most drugs, based on pharmacokinetic studies reported in the literature. For many antidepressants, a thorough analysis of the literature on studies dealing with the plasma concentration-clinical effectiveness relationship allowed inclusion of therapeutic ranges of plasma concentrations. In addition, recommendations are made with regard to the combination of pharmacogenetic (phenotyping or genotyping) tests with TDM. Finally, practical instructions are given for the laboratory practitioners and the treating physicians how to use TDM: preparation of TDM, drug analysis, reporting and interpretation of results, and adequate use of information for patient treatment TDM is a complex process that needs optimal interdisciplinary coordination of a procedure implicating patients, treating physicians, clinical pharmacologists, and clinical laboratory specialists. These consensus guidelines should be helpful for optimizing TDM of antidepressants.

Bipolar disorder in women: reproductive events and treatment considerations

OBJECTIVE

Bipolar disorders are prevalent in women. Women with bipolar disorder often present with different clinical features than men. Reproductive events and hormonal treatments may impact the course of bipolar disorder. Our main objectives are to i) assess the impact of reproductive events on the course of the disorder, and ii) to discuss the relationships between reproductive events and psychiatric treatments.

METHOD

A literature search was conducted of MEDLINE journals from 1965 to present. Manual literature searches were also conducted. We review the presentation, clinical course, and treatment considerations of bipolar disorder in women, with emphasis on treatment considerations in the context of reproductive events. Treatment-related issues such as teratogenicity, breastfeeding, polycystic ovarian syndrome, weight gain and obesity, and medication interactions with oral contraceptives are reviewed.

RESULTS

Women with bipolar disorder may be more vulnerable to mood episodes in the context of reproductive events, particularly postpartum. In women of reproductive age, mood stabilizers must be selected with teratogenic risks in mind, with the highest reported risks in pregnancy with valproate, and the greatest concern during breastfeeding with lithium use. In the areas of the perimenopause and polycycstic ovarian syndrome, more data are needed to advise treatment decisions.

CONCLUSION

We urgently need further study in these areas to deliver care that is appropriate to women with bipolar disorder.

Considerations in the management of bipolar disorder in women

OBJECTIVE

Recent research has emphasized important gender differences in the epidemiology, course, comorbidity and treatment of bipolar disorder. This article aims to provide an overview of these important findings in order to assist the clinician in treating women with bipolar disorder. Complex issues regarding the treatment of bipolar disorder during pregnancy and the post-partum period are discussed.

METHOD

A literature review was undertaken using Medline (1966-current), PsychInfo and PubMed databases. Search terms used were gender, sex, women, bipolar disorder, suicide, epidemiology, rapid cycling, mixed episode, treatment, mood stabilizers, antidepressants, antipsychotics, pregnancy, post-partum, menopause, lactation and breast-feeding.

RESULTS

The lifetime prevalence of bipolar I disorder is equal in men and women; however, bipolar II appears to be more common in women. Gender differences have been reported in the phenomenology, course and outcome of this condition. Some comorbid disorders, such as thyroid disease and anxiety disorders have more relevance to women. Increasingly, sex differences in the pharmacokinetics and pharmacodynamics of medications used in bipolar disorder are being reported.

CONCLUSIONS

There is increasing evidence for gender differences in a number of clinical features of bipolar disorder that have relevance to management. Although more studies are needed, it is important for clinicians to be aware of these issues to optimize treatment of women with this condition.

Drug use and breastfeeding

Section 1 describes the benefits of breastfeeding to both mother and infant as well as the potential risks to the infant from maternal drug use. The extent of adverse drug-related events and the need for quality information on drug transfer is stated. Section 2 describes the physiology of lactation and the effects of drugs that stimulate or decrease milk production. Section 3 deals with transport mechanisms for drug passage into milk and factors that may modify the infant's exposure to drugs. The critical descriptors of 'absolute' and 'relative' infant dose are defined to give an objective measure of infant exposure to drugs in milk. Section 4 reviews new or commonly used drugs under the headings of analgesics and anti-inflammatory agents, neurological, endocrine, psychotropic and antihypertensive drugs. Section 5 concludes with an expert opinion of the drug industry and drug use in lactation, herbal preparations, the process of 'risk-benefit' analysis, minimising infant exposure, understanding drug-related adverse events and fostering good experimental design for drugs in lactation studies.

Psychotropic drugs in pregnancy and lactation

The management of psychotropic medications during pregnancy and lactation involves a difficult and complex decision for both patient and provider, particularly due to the many unknown effects medication may have on the infant. Available studies concerning use of psychotropic medications in pregnant and lactating women are limited and there are no universal guidelines. This article reviews the literature on the use of psychotropic drugs, including antidepressants, mood stabilizers, antipsychotics, and benzodiazepines, in pregnant and breast-feeding women and presents relevant data on teratogenic effects, neonatal toxicity, perinatal syndromes, and neurobehavioral sequelae.

Lamotrigine in psychiatry: pharmacology and therapeutics

Following the introduction of lamotrigine in 1994 as a treatment for epilepsy in the United States, the drug has seen progressively greater application in psychiatry, particularly as a treatment for bipolar disorder. This review critically evaluates the support for lamotrigine use across a broad range of psychiatric disorders as well as discuss its pharmacology, side-effect profile, and interactions with other medications.

Anticonvulsivantes e antipsicóticos no tratamento do transtorno bipolar

O transtorno bipolar é uma condição médica complexa e até o momento não há um tratamento único comprovadamente eficaz no controle de todos aspectos da doença. Foram revisadas a literatura disponível sobre o uso de anticonvulsivantes (valproato, carbamazepina, oxcarbazepina, lamotrigina, gabapentina, topiramato, clonazepam) e antipsicóticos atípicos (clozapina, risperidona, olanzapina, quetiapina, ziprasidona e aripiprazole) no tratamento agudo e profilático do transtorno bipolar. Existe um acúmulo de evidências acerca da eficácia do lítio na profilaxia e de ser melhor no tratamento da mania aguda do que nos episódios depressivos. Outros dados indicam que a carbamazepina e o valproato são eficazes na mania aguda. A lamotrigina parece reduzir ciclagem e ser eficaz em episódios depressivos. Baseado nas informações disponíveis, as evidências apontam a olanzapina como o antipsicótico atípico mais apropriado no tratamento de pacientes bipolares em mania, embora existam estudos sugerindo a eficácia da risperidona, aripiprazol e da clozapina. Resultados preliminares avaliando a eficácia de ziprasidona e quetiapina no transtorno bipolar ainda são bastante limitadas. Não há dados consistentes apoiando o uso profilático dos novos antipsicóticos.

Clinical utilization of atypical antipsychotics in pregnancy and lactation

OBJECTIVE

To analyze the available literature regarding the safety of atypical antipsychotics in pregnancy and lactation in order to recommend evidence-based strategies for pharmacologic management of psychosis in these conditions.

DATA SOURCES

We summarized the results from articles identified via MEDLINE/PubMed/TOXNET (1993-January 31, 2004), using the key terms pregnancy, lactation, breast-feeding, human milk, psychotropic drugs, atypical antipsychotics, olanzapine, quetiapine, risperidone, clozapine, ziprasidone, and aripiprazole.

STUDY SELECTION AND DATA EXTRACTION

Retrospective studies, clinical observations, and case reports regarding the 6 atypical antipsychotics mentioned above were selected and analyzed. Extensive manual review of pertinent journals and textbooks was also performed.

DATA SYNTHESIS

Reviewed studies show that olanzapine and clozapine apparently do not increase the teratogenic risk if administered to pregnant women, while evidence on quetiapine, risperidone, aripiprazole, and ziprasidone is still limited. In contrast, available information is not able to exclude unwanted serious effects associated with the use of all atypical antipsychotics on mother-infant dyads. Furthermore, more than a few studies suggest increased hyperglycemic risk for pregnant women related to atypical antipsychotic therapy during gestation. Finally, published evidence about the effects on long-term infant neurodevelopment of drug exposure through both placenta and breast milk is represented only by sporadic case reports.

CONCLUSIONS

It is well known that potential consequences of an untreated psychotic episode may be severe and may lead to the mother attempting suicide and/or infanticide. For these reasons, clinicians need to help mothers weigh both fetal and neonatal risks of exposure to drugs against the potential risk they and their infant may incur if the psychiatric illness is not treated. On the other hand, atypical antipsychotics in pregnancy and breast-feeding do not show evident advantages in safety when compared with typical neuroleptic agents. Therefore, we suggest that the most relevant parameters for selecting the best clinical option for pregnant and breast-feeding women with schizophrenia and related disorders remain strongly related to 3 main points: (1). cautious evaluation of the risk/benefit ratio of fetal and neonatal drug exposure, (2). degree of severity of maternal psychiatric illness, and (3). careful preliminary choice of drugs characterized by a balanced safety/efficacy profile.

Psychopharmacological treatment with lithium and antiepileptic drugs: suggested guidelines from the Danish Psychiatric Association and the Child and Adolescent Psychiatric Association in Denmark

A subcommittee under the Danish Psychiatric Association and the Child and Adolescent Psychiatric Association in Denmark have recently developed national guidelines for the psychopharmacological treatment with lithium and antiepileptic drugs, and the present translation aims at contributing to the international discussion on the development of proper guidelines for the treatment of bipolar disorder. Among the antiepileptic drugs, the report deals with valproate, carbamazepine and lamotrigine and to a lesser extent with oxcarbazepine, gabapentin and topiramate. The various drugs will be reviewed, outlining the scientific evidence for mood-stabilizing properties and discussing major side effects, the most important interactions with other drugs and practical use. Special considerations during pregnancy and lactation, during treatment of children and adolescents and during treatment of the elderly will also be presented. Antidepressants and antipsychotics are beyond the scope of the report, but due to the mood-stabilizing properties of at least some of the atypical antipsychotics, these agents will be brought into some focus in connection with the overall treatment guidelines for the different phases of bipolar disorder given at the end of this report.

Special considerations in treating bipolar disorder in women

There are obvious gaps in research surrounding issues specific to women who suffer from bipolar disorder, including gender differences and their implications for management, the impact of the reproductive cycle, and evidence based treatment guidelines for pregnancy and the postpartum period. Gender differences have not been reported for the prevalence of bipolar disorder; however, women are more likely to experience rapid cycling, mixed mania, and antidepressant-induced manias. This may affect response to treatment, which has been found, in some cases, to differ in men and women. In addition, side effects in response to treatments may well differ in men and women, especially with regard to lithium and valproate prescription. The course of bipolar disorder in women may be influenced by the menstrual cycle, pregnancy, the postpartum period, and menopause, although many issues require further clarification. Treatment of bipolar disorder during pregnancy and the postmenopausal period requires careful consideration, as does treatment during the childbearing years, as some mood stabilizers influence the metabolism of oral contraceptives. This review article has attempted to evaluate existing literature regarding women with bipolar disorder in a comprehensive and critical way, and to consolidate into a single source the gender-specific aspects of the disorder that may have treatment implications for women.

Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. They are based explicitly on the available evidence and presented, similar to previous Clinical Practice guidelines, as recommendations to aid clinical decision-making for practitioners. They may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment.

Lamotrigine in mood disorders

Lamotrigine is an anticonvulsant drug with good efficacy and safety in the treatment of epilepsy. There is now substantial evidence that lamotrigine is also useful in treating resistant depression, rapid cycling bipolar affective disorder, depressive episodes in bipolar affective disorder and in the maintenance phase or prophylaxis of bipolar affective disorder. There are possible roles in managing mood changes in borderline personality disorder, reducing chronic pain and treating schizoaffective disorder. The general range of doses found effective in affective disorders is from 50 to 300 mg daily. Clinical use seems to involve a titration of dose upwards over several weeks until the desired effect is obtained. However, further definitive double-blind, randomised controlled trials against gold standard treatments are required. Lamotrigine has a preferable side-effect profile compared to standard agents for bipolar affective disorder such as lithium or carbamazepine. Further research is certainly warranted and, given its tolerability, could point to lamotrigine as the treatment of choice for some affective disorders.

Managing bipolar disorder during pregnancy: weighing the risks and benefits

BACKGROUND

Challenges for the clinical management of bipolar disorder (BD) during pregnancy are multiple and complex and include competing risks to mother and offspring.

METHOD

We reviewed recent research findings on the course of BD during pregnancy and postpartum, as well as reproductive safety data on the major mood stabilizers.

RESULTS

Pregnancy, and especially the postpartum period, are associated with a high risk for recurrence of BD. This risk appears to be limited by mood-stabilizing treatments and markedly increased by the abrupt discontinuation of such treatments. However, drugs used to treat or protect against recurrences of BD vary markedly in teratogenic potential: there are low risks with typical neuroleptics, moderate risks with lithium, higher risks with older anticonvulsants such as valproic acid and carbamazepine, and virtually unknown risks with other newer-generation anticonvulsants and atypical antipsychotics (ATPs).

CONCLUSIONS

Clinical management of BD through pregnancy and postpartum calls for balanced assessments of maternal and fetal risks and benefits.