Bipolar I Disorder in Pregnancy

DSM 5: Bipolar I Disorder (F31.11) Mild

FDA-approved Drug, one off-Label Drug, and One Nonpharmacological Intervention for Treating your Chosen Disorder in Pregnant woman

Lamotrigine is among the safest medications for a developing fetus, both in terms of fetal malformations and postpartum cognitive development. These findings make lamotrigine probably the first choice of antiepileptic drug for women wishing to become pregnant and for whom the medication is appropriate (Kaplan & Demir, 2021).  Cognitive Behavioral Therapy (CBT). CBT is efficient in the acute treatment of bipolar disorder (BD) and may provide a viable alternative to antidepressant medications for even more severely depressed unipolar patients when implemented in a competent fashion (Henken, Kupka, Draisma, et al., 2020). CBT also may be of use as an adjunct to medication treatment for BD. CBT does appear to have an enduring effect that protects against consequent relapse and recurrence following the end of active treatment, something that cannot be said for medications. A main goal of CBT is to help patients change negative behaviors and ways of thinking that are linked to BD

 Risk assessment you would use to Inform your Treatment Decision making. What are the Risks and Benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug.

The management of bipolar disorder during pregnancy is a critical clinical situation demanding great attention to issues such as reproductive safety of psychiatric medications used by women with bipolar disorder to maintain emotional well-being, compared with the established risk of relapse if patients stopped those medications.  Some data shows that there is a 50 percent change the child may have a cleft left while taking Lamotrigine. The FDA-approved prescribing information says that lamotrigine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. The potential benefit is generally the mother’s mental health condition. Sodium valproate it is a teratogen with a very high risk for neural tube defects. In contrast, data over the 15 years have been very supportive of the reproductive safety of lamotrigine (Andrade, Nguyen, Warri, et al., 2019).

Explain whether clinical practice guidelines exist for this disorder, and if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration

There are numerous practice guidelines available for bipolar disorder which cover both bipolar I and bipolar II.  While no practice guidelines are a substitute for your clinical judgement and decision making, they can offer useful information and serve as a good reference. Many guidelines discuss use of medications like lithium and other mood stabilizers as well as antipsychotic medications during different phases of the illness including acute mania and bipolar depression (Gomes, Cerqueira, Lee, et al., 2022). They also offer input on psychosocial interventions, lifestyle interventions, and managing co-morbid conditions.  Most guidelines take up to a year to draft, and many are not updated for many years after release, so are not able to reflect the most current evidence.

References

Andrade, F. de O., Nguyen, N. M., Warri, A., & Hilakivi-Clarke, L. (2019). Valproic acid use during pregnancy. Scientific Reports, 9(1), 20271. https://doi.org/10.1038/s41598-019-56854-5

Gomes, F. A., Cerqueira, R. O., Lee, Y., Mansur, R. B., Kapczinski, F., McIntyre, R. S., Yatham, L. N., Berk, M., Milev, R., & Brietzke, E. (2022). What not to use in bipolar disorders: A systematic review of non-recommended treatments in clinical practice guidelines. Journal of Affective Disorders, 298(Part A), 565–576. https://doi.org/10.1016/j.jad.2021.11.007

Henken, H. T., Kupka, R. W., Draisma, S., Lobbestael, J., van den Berg, K., Demacker, S. M. A., & Regeer, E. J. (2020). A cognitive behavioural group therapy for bipolar disorder using daily mood monitoring. Behavioural and Cognitive Psychotherapy, 48(5), 515–529. https://doi.org/10.1017/S1352465820000259

Kaplan, Y. C., & Demir, O. (2021). Use of Phenytoin, Phenobarbital Carbamazepine, Levetiracetam Lamotrigine and Valproate in Pregnancy and Breastfeeding: Risk of Major Malformations, Dose-dependency, Monotherapy vs Polytherapy, Pharmacokinetics and Clinical Implications. Current Neuropharmacology, 19(11), 1805–1824. https://doi.org/10.2174/1570159X19666210211150856