Bipolar Disorder in the Peripartum Period Discussion Response 

Bipolar Disorder in the Peripartum Period

Isobel Nimtz(Bipolar Disorder in the Peripartum Period Discussion Response Essay)

College of Nursing-PMHNP, Walden University

NRNP 6675-10: PMHNP Care Across the Lifespan II

Dr. Fletcher

April 30, 2023

Treatment for bipolar disorder often involves mood stabilizers and antipsychotic medications. Studies show that among peripartum women who screened positive for depression, as many as one in five were also positive for bipolar disorder (Bhat et al., 2018). As appropriate, when a woman conceives, sometimes medications can be withheld, but generally, this leaves the woman in jeopardy of episodes or exacerbations of psychiatric illness. Bipolar disorder can involve suicidal ideation and attempts, risky and impulsive behavior, or psychosis. Often the medication can be titrated in accordance with what we know about fetal susceptibility and teratogenic vulnerability during each trimester. All psychotropic medications cross into breast milk and across the placenta to some degree. The task is to weigh the risks of severe psychiatric illness and sequelae versus potential harm to the fetus or breastfeeding newborn. (Bipolar Disorder in the Peripartum Period Discussion Response Essay)

Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your chosen disorder in older adults or pregnant women.

One FDA-approved drug for bipolar disorder that I could prescribe to a pregnant or breastfeeding woman, given a circumstance that necessitates a mood stabilizer, would be lamotrigine. An off-label medication for bipolar depression during pregnancy would be aripiprazole. A non-pharmacological treatment for a pregnant patient with bipolar disorder would be cognitive behavioral therapy. Because bipolar disorder has its roots in heredity and neurobiology, we theorize, medications are the gold standards, but CBT can help diminish cognitive distortions, help patients stay compliant with their meds, explore their feelings, and helps providers stay in touch with them to monitor their psychological state (Chiang et al., 2017). (Bipolar Disorder in the Peripartum Period Discussion Response Essay)

Explain the risk assessment you would use to inform your treatment decision-making.  

The risk assessment I would recommend broadly for all peripartum women is the PHQ-9 depression questionnaire. Women who screen positive for depression could then be screened for bipolar depression using the Mood Disorder Questionnaire. For a specific patient, given positive results on these forms, I would conduct a qualitative assessment using the DSM-5 criteria to establish a diagnosis (Hendrik, 2023)(Bipolar Disorder in the Peripartum Period Discussion Response Essay).  

What are the risks and benefits of the FDA-approved medicine?

Lamotrigine is the safest anticonvulsant for use in pregnancy, although more data would be welcome. The benefit is that it is efficacious in treating mania, hypomania, and depression seen in bipolar disorder. The risk is a reported 1% to 5.6% rate of fetal malformation, including cleft pallet. In investigating pharmacotherapy for bipolar disorder during pregnancy I discovered that over the last twenty years, outpatient psychiatry has been moving toward prescribing atypical antipsychotics more frequently than mood stabilizers though there really isn’t any research to support the switch (Rhee, 2020). A 2018 meta-analysis conducted to refine what we know about the congenital risks of lamotrigine in utero showed that of 81 pregnant women, none of them gave birth to babies with malformations or neurological problems (Cohen-Israel, 2018). Adverse effects of mood stabilizers are well known, including increased SI, dizziness, headache, nausea, and serious but rare skin reactions.(Bipolar Disorder in the Peripartum Period Discussion Response Essay) 

What are the risks and benefits of the off-label drug? 

When working with a pregnant patient a PMHNP would consider an SGA, especially if the symptoms are new and they are initiating monotherapy. SGAs are actually first-line medications for peripartum bipolar disorder, including mania and hypomania, and have a low incidence of fetal malformations (Hendrick, 2023). Even so, it might not be the right medication for that patient if they have failed trials of SGAs in the past and/or been on maintenance therapy with mood stabilizers. SGAs seem to have fewer fetal effects, but the pharmacodynamic effect has unique mechanisms which may not, in certain cases, stave off severe episodes of dysfunctional behaviors as a part of bipolar disorder. SGAs can cause weight gain, sedation, orthostatic hypotension, and akathisia. In pregnant women, gestational diabetes can be problematic for mother and child. (Bipolar Disorder in the Peripartum Period Discussion Response Essay)

Clinical Practice Guidelines 

There are clinical practice guidelines such as Uptodate, but because of ethical considerations, randomized control trials using pregnant subjects are limited to those involving women taking either SGAs for bipolar or mood stabilizers for their anti-seizure properties. The issue is not studied enough to be anything but cautious and reasonable when making pharmacological decisions in these cases. Depakote and carbamazepine are particularly discouraged due to their teratogenic natures, while lamotrigine and SGAs are relatively benign. Relapse of bipolar disorder is dramatically reduced when patients stay on their medications. Many factors, including severity of psychiatric illness, comorbid conditions, support network, and patient preferences, are all part of making a nuanced care plan (Albertini et al., 2019). (Bipolar Disorder in the Peripartum Period Discussion Response Essay)

References

Albertini, E., Ernst, C., Tamaroff, R. (2019). Lactation: A case-by-case approach to using current evidence. Focus: The Journal of Lifelong Learning and Psychiatry, (17)3.https://doi.org/10.1176/appi.focus.20190007

Bhat, A., Cerimele, J. M., & Byatt, N. (2018). Pregnant and postpartum women with bipolar disorder: taking the care to where they are. Psychiatric Services 69(12), 1207–1209. https://doi.org/10.1176/appi.ps.201800133Links to an external site.

Chiang, K. J., Tsai, J. C., Liu, D., Lin, C. H., Chiu, H. L., & Chou, K. R. (2017). Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PloS one, 12(5), e0176849. https://doi.org/10.1371/journal.pone.0176849

Cohen-Israel, M., Berger, I., Martonovich, E. Y., Klinger, G., Stahl, B., & Linder, N. (2018). Short- and long-term complications of in utero exposure to lamotrigine. British Journal of Clinical Pharmacology, 84(1), 189-194. https://doi.org/10.1111/bcp.13437

Bipolar Disorder in the Peripartum Period Discussion Response Essay

            Excellent post! Your discussion on bipolar disorder during the peripartum period was informative and engaging. It is instrumental in weighing the risks between managing severe psychiatric conditions and potential harm to the fetus or the newborn after birth. While different pharmacological and non-pharmacological interventions are used for bipolar management in pregnant women, risk assessments are necessary to inform treatment strategies. While some medications are more advantageous, following the required clinical practice guideline is essential when selecting suitable medications for pregnant women.(Bipolar Disorder in the Peripartum Period Discussion Response Essay)

            Typically, psychotropic medications are not safe for use during pregnancy. Although all psychotropic medications cross the placenta, agents potentially pose more significant harm and risks to the fetus or newborn than others. Thus, psychotropic medication should be used by pregnant women only when the risks to the fetus and the mother only when the risks of not administering the drugs outweigh the treatment risks. Standard psychotropic medications should be used when pregnant patients portray an inability to seek perinatal care or take care of themselves when the patients are dangerous to themselves and others, from severe depression, severe mental illness, or impaired reality testing.(Bipolar Disorder in the Peripartum Period Discussion Response Essay)

Besides lamotrigine, one FDA-approved medication for bipolar disorders that can be administered to a pregnant or breastfeeding woman is valproate. Albertini et al. (2019) suggest that lamotrigine is best widely administered to treat bipolar among pregnant women as it is considered relatively safe. However, Carbamazepine can be used as an alternative. The research further claims that using Carbamazepine is associated with neural tube defects; thus, it should be avoided during pregnancy. The research states that lamotrigine is linked with low congenital malformations. One off-label medication I would use is lithium. The medication should only be used in pregnancy when there are no alternatives and the benefits outweigh the risks of obstetrical complications. Lithium is the most incompatible with breastfeeding compared to Carbamazepine, which has a relatively low level in breast milk. Subsequently, psychotherapy is the most appropriate non-pharmacological intervention for bipolar in pregnancy (Wang et al., 2020). The research asserts that interpersonal psychotherapy relieves patients’ symptoms and improves their interpersonal functioning. The intervention works best in mild to moderate depression but can be integrated with pharmacological treatment to improve the treatment outcomes.(Bipolar Disorder in the Peripartum Period Discussion Response Essay)

                                                                  References

Albertini, E., Ernst, C. L., & Tamaroff, R. S. (2019). Psychopharmacological decision making in bipolar disorder during pregnancy and lactation: a case-by-case approach to using current evidence. FOCUS, A Journal of the American Psychiatric Association, 17(3), 249-258.

Wang, Y., Li, H., Peng, W., Chen, Y., Qiu, M., Wang, J., … & Zhu, T. (2020). Non-pharmacological interventions for postpartum depression: A protocol for systematic review and network meta-analysis. Medicine, 99(31).

Frequently Asked Questions

How do you respond to bipolar disorder?

Bipolar disorder is a complex mental health condition characterized by alternating periods of elevated mood (mania) and depression. Treatment typically involves a combination of mood-stabilizing medications, psychotherapy, and lifestyle adjustments. It’s important to work closely with mental health professionals to create a personalized treatment plan that addresses the individual’s specific needs and helps manage the symptoms of bipolar disorder effectively.(Bipolar Disorder in the Peripartum Period Discussion Response Essay)

What are the negative coping strategies for bipolar disorder?

Negative coping strategies for bipolar disorder can include substance abuse as a way to self-medicate or escape mood fluctuations, social isolation which can exacerbate feelings of depression or mania, and impulsive behaviors such as overspending or risky sexual activity during manic episodes, which can lead to detrimental consequences. These strategies may provide temporary relief but can ultimately worsen the overall course of the disorder and hinder effective management.(Bipolar Disorder in the Peripartum Period Discussion Response Essay)

What is the summary of bipolar disorder?

Bipolar disorder is a mental health condition characterized by extreme mood swings, including periods of elevated, manic episodes and depressive lows. These shifts in mood can significantly impact a person’s daily life, relationships, and functioning. Treatment often involves a combination of medication, therapy, and lifestyle adjustments to help manage and stabilize mood fluctuations.(Bipolar Disorder in the Peripartum Period Discussion Response Essay)

What are 3 things people may experience when someone with bipolar goes through a depression period?

When someone with bipolar disorder enters a depressive period, people around them might notice a significant decrease in their energy levels and enthusiasm, often leading to social withdrawal. They may also observe changes in their sleep patterns, such as excessive sleeping or insomnia. Additionally, individuals experiencing bipolar depression might exhibit feelings of hopelessness, sadness, and difficulty concentrating, impacting their overall functioning and daily activities.(Bipolar Disorder in the Peripartum Period Discussion Response Essay)