Stopping Mood Stabilizers During Pregnancy Doubles Relapse Risk in Bipolar Disorder

Marlene Busko

January 3, 2008 — In a prospective observational study of 89 pregnant women with bipolar disorder, 71% had at least 1 mood episode recurrence during pregnancy. Compared with the women who continued taking mood stabilizers, those who stopped this treatment had a 2-fold higher risk for mood relapse, a 4-fold shorter time to relapse, and a 5-fold greater amount of time spent ill during pregnancy.

These findings by Adele C. Viguera, MD, from the Cleveland Clinic Neurological Institute, in Ohio, and colleagues are published in the December issue of the American Journal of Psychiatry.

“The present findings challenge the evidently common practice of abruptly stopping maintenance treatment for psychiatric disorders during pregnancy,” the group writes, adding that given the high morbidity associated with discontinuation of mood stabilizing treatment and its uncertain impact on fetal development, they recommend a more balanced consideration of risks and benefits in the clinical management of pregnant women with bipolar disorder.

Knowledge Gaps

Women with bipolar disorder who become pregnant encounter several obstacles to care, including “extraordinary knowledge gaps” about the course of the illness during pregnancy, predictors of recurrence, and reproductive safety data for mood stabilizers, the group writes.

They aimed to examine the risk for recurrence of mood episodes among women with a history of bipolar disorder who continued or discontinued taking mood stabilizers when they became pregnant.

They prospectively enrolled 89 pregnant women diagnosed with bipolar disorder (69% bipolar 1 disorder and 31% bipolar 2 disorder) who were seeking psychiatric consultation in a specialized center. The women had a mean age of 32.7 years, and most were white, well educated, married, and working outside the home. Most women (n=55) were taking lithium and 32 were taking an anticonvulsant as their primary mood stabilizer; 46 women were also taking an antidepressant and 24 women were also taking an antipsychotic agent.

A total of 62 of the 89 women discontinued treatment with a mood stabilizer.

High Risk for Maternal Morbidity

During pregnancy, 70.8% of the women experienced at least 1 episode of bipolar disorder. Compared with the women who continued taking a mood stabilizer, those who discontinued this treatment had a 2-fold greater risk for recurrence and a more than 4-fold shorter time to a new episode of bipolar disorder.

Morbidity During Pregnancy: Continuing vs Stopping Mood Stabilizers

Morbidity    Continued Treatment, n=27    Discontinued Treatment, n=62    All Subjects, n=89
At least 1 recurrence of bipolar episode, %    37.0    85.5    70.8
% of pregnancy weeks spent ill with a mood disorder    8.8    43.3    32.8
Median time to first recurrence, weeks    9.0    >40    —
Most new mood episodes emerged early in pregnancy; risk in the first, second, and third trimester was 47.2%, 31.9%, and 18.8%, respectively. Most episodes (74%) were depression or a mixed state rather than hypomania or mania.

Women who discontinued their mood stabilizers abruptly (1–14 days, n=35) had a 50% risk for recurrence of mood episodes within 2 weeks; among women who discontinued more gradually, it took 22 weeks to attain this risk level. Rapid discontinua