Managing bipolar disorder can be difficult in the easiest of times. There are literally thousands of medication combinations available to find the right treatment. Doing so during pregnancy and postpartum can be especially complicated. Because of this it is important to find effective treatment that will have the fewest risks and side effects. Lithium has been proven effective postpartum, but can be difficult to manage. New research has found that lamotrigine (Lamictal) may be a good alternative to lithium.
Similar to postpartum depression, which affects up to 15% of women, people with bipolar disorder can suffer from symptoms shortly after giving birth and especially within the first few weeks peripartum. Approximately 35% of women with bipolar disorder relapse postpartum including outcomes like suicide and infanticide. Those who experience psychosis have an even higher relapse rate. When a mother goes untreated during pregnancy, the rate of relapsing postpartum jumps to 66%.
Preventing this trigger is of utmost importance so finding the right treatment is imperative. One barrier to managing treatment during pregnancy is that several medications used to treat bipolar disorder can cause serious birth defects like cardiovascular abnormalities, spina bifida, microcephaly and liver toxicity. There is also the risk that the baby will suffer from withdrawal symptoms.
Lithium is the highest recommended maintenance therapy treatment for bipolar disorder. It cuts the number of episodes and the amount of time spent in both depression and mania in half. It reduces the likelihood of a manic episode by 40%. Despite this, it is one of the least prescribed medications for bipolar disorder. One reason is that blood levels need to be tested regularly, both to insure that levels are at their most therapeutic but also to protect against lithium toxicity.
Despite the effectiveness of lithium, mood stabilizers like lamotrigine have become the most prescribed. Lamotrigine is possibly the most effective mood stabilizer for treating and preventing episodes of depression. It also does not require blood tests.
Using either of these medications during pregnancy carries risks. One reason lithium may be risky during pregnancy is its 2.8% risk for birth defects. These include Ebstein’s anomaly, increased birth weight, jaundice, hypothyroidism and diabetes. Lamotrigine has anywhere from a 1.9-4.6% risk of congenital malformations including cardiac and gastric malformations, neural tube defects and cleft palate. Chances for defects decrease the lower the dosage is in the first two trimesters.
The benefit of both of these drugs is that they are effective at preventing relapse during and after pregnancy. Since patients now take lamotrigine at a higher frequency than lithium, it is important to note if it is as effective at preventing relapse. Researchers, led by Richard Wesseloo of Erasmus Medical Centre in the Netherlands, conducted a study to find the answer.
They examined the records of 114 women to compare whether or not they were hospitalized due to bipolar disorder within three months postpartum. Researchers tracked relevant patient information including previous hospital admissions for bipolar disorder, age at delivery and medication use during pregnancy with average dosage rates.
Overall, 11% of women were hospitalized for bipolar disorder postpartum, with 53.8% hospitalized for mania or psychosis and 46.2% for depression. For those taking lamotrigine, the rate of hospitalization was 7.3% compared with lithium at 15.3%. However, the researchers deemed this difference statistically insignificant, putting them at roughly equal.
So, since lamotrigine is currently prescribed more than lithium in both pregnant women and those with bipolar disorder in general, it may be safe to say that there is little difference between the two medications as far as preventing relapse postpartum. However, it is important for those who are pregnant or intend to become pregnant to speak with their psychiatrists and obstetricians about treatment for bipolar disorder during pregnancy. That way, all risks and benefits can be discussed and the best, personalized treatment option can be found.
Image credit: Jake Guild