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How to Treat Bipolar Disorder During Pregnancy

Pregnancy often marks an exciting time in a woman’s life, but for women with a serious illness it can be plagued with complicated considerations about which medications and treatments to take.

Crystal Clark, MD, shares how she has devoted both her research and her psychiatry practice to optimizing treatment for women with bipolar disorder during pregnancy and post-partum. In this episode, she walks us through her work and some of the approaches she takes with patients who have bipolar disorder and have or would like to start a family.
How to Treat Bipolar Disorder During Pregnancy
Featuring:
Crystal Clark, MD
Crystal Clark, MD, MSc, is an assistant professor of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology at Northwestern Medicine. Her research focuses on optimizing treatment for women with bipolar disorder during pregnancy. Clark received her medical degree and masters of science  degree from the University of Louisville and competed a residency at Johns Hopkins University School of Medicine in psychiatry.
Transcription:

Melanie Cole, MS (Host):    Pregnancy often marks such an exciting time in a woman’s life, but for women with a serious illness it can really be plagued with complicated considerations about which medications and treatments to take. My guest today is Dr. Crystal Clark. She’s an assistant professor of psychiatry and behavioral sciences and obstetrics and gynecology at Northwestern Medicine. Dr. Clark, what a pleasure to have you on. As I said in my intro, pregnancy is such an exciting time, but for someone with bipolar can be also quite scary. Give us a little bit of a brief history of how treatment for bipolar disorder and pregnant women with bipolar disorder has evolved and moreover, what has been the standard of care.

Crystal Clark MD (Guest): So the history of bipolar disorder and pregnancy management and postpartum management for that matter is definitely evolving, but we have a long way to go. So years ago—not too far ago, maybe four decades, maybe three—there was this thought that pregnancy was a time of wellbeing. So the thought was that bipolar disorder just went away during pregnancy and women were well and fulfilled and happy. There was no treatments considered for women with bipolar disorder or other mental illnesses for that matter. Thankfully today we are seeing more interest around mental illness and pregnancy in general. Most of the focus, however, has been on depression and anxiety. Depression is really—We hear a lot about postpartum depression, pregnancy and depression, anxiety is slowly on the rise.

Bipolar disorder, however, continues to be somewhat in the shadows and understudied. So we have a long way to go. Because mental illness and pregnancy is getting more attention, providers, particularly specialists, in perinatal psychiatry are definitely taking more efforts in their clinics through collaborative care models and just thinking more about how do we monitor, how do we treat—whether that’s through therapy and medication or one of the other these women.

Host:  Really good information Dr. Clark. So if treating bipolar disorder during pregnancy is difficult—and that would be due to many factors. One primary one being an absence of risk free options? What are some of the most important considerations when you're making treatment decisions based on a bipolar disorder? What should other providers consider first? Are we looking at the patient’s preferences? Are you looking at medication side effects? What are you looking at? What do you consider first?

Dr. Clark:  Great question. So I first want to just home in on that idea of risk free options. Often when we’re thinking about mental illness treatment, particularly treatment for bipolar disorder, there’s this idea that something’s different about this illness. So risk free options given that there aren’t any physicians or prescribers geared to treat this patient or patient population will this illness. Really when we think about pregnancy and illness in generally—whether it’s seizure disorder or diabetes or high blood pressure—there are no risk free options for any illness in pregnancy and bipolar disorder isn’t any different.

So I want to start there by helping people to think about the fact that this is not unlike any illness we would treat in pregnancy regardless for a woman. When I'm thinking about a patient who is coming in and needs to be treated for this illness, I talk to them about—of course their patient preferences. I bring in their mate when possible and we all discuss it. What are they concerned about? What are their worries? What are their fears? But we also talk about well what’s been the course of your illness? How many times have you had an episode? How difficult has it been to treat episodes in the past? How quick are they to relapse if they are not on medication? Have they been hospitalized? Have their episodes ever led to suicidal thoughts? Have they ever attempted suicide? All of those are major considerations. Also thinking about have they had a history of having an episode in pregnancy in the past? Or a postpartum episode. What's their family history? So there's so many factors to consider. Most important we’re thinking about treatment. We’re thinking about well how many of those boxes does the patient check yes to? How many risk factors do they have and how severe has the illness course been? Particularly without medication. For some even with medication management they can still have a pretty rocky road. So those are a lot of the things that we have to consider when we are talking about whether or not to treat the patient but also preparing the patient for okay. These are the risk factors. This might be the course if you're not taking medications, and then talking about their preferences given those risk considerations.

Host:  So your research, Dr. Clark, focuses on optimizing treatment for women with bipolar disorder during pregnancy. Is this a relatively new area of research? Tell us a little bit about it.

Dr. Clark:  Yes. I'm very passionate about the research I'm doing because I meet so many women who come to me because someone—a previous psychiatrist or other provider—has decided to stop their medication or has advised them to stop it and told them, “Come back to me when you're not pregnant and you're not breastfeeding.” Unfortunately, that is not a good strategy for most of the women that I see, and their illness will recur and does recur. They're usually coming to me out of desperation. So I started this research thinking about how do we better prevent these outcomes. I don’t want to see a woman come to me after she’s already in a full blown episode and now we’re trying to get her well again. So my research is really looking at not only how are we proactive instead of reactive. How can we understand the pharmacokinetics of medications during pregnancy so that we can optimize dosing and prevent recurrent episodes.

Host:  What a great point. This is such an interesting topic Dr. Clark. So tell other providers some of the common misconceptions about treating pregnant women with bipolar. What do you find are some of the biggest challenges that you’ve seen in other practices or with patients? Then while you're telling us about that, tell us about your approach to treating women who are pregnant or trying to get pregnant who have bipolar.

Dr. Clark:  Yeah. So some of my approaches are that I am monitoring women more frequently. Commonly in psychiatry we will monitor a patient who is stable, for instance, every three months. So have them come in every three months. That’s an average approach. Some people may space the appointments out a little bit further or see people a little bit more frequently. Three months is average. Someone who’s not doing well, we might be seeing them anywhere from weekly to monthly. For patients who are pregnant, although nine months may be a long time for the woman, nine months is not a long time for monitoring and treatment. I increase the frequency of patient visits during that time to monitor them more closely. So instead of an average of three months, I'm seeing patients every four to six weeks.

Some people will say oh my gosh. That’s a lot of appointments. That’s pretty frequent. What I've learned through my research is that medication concentrations are changing so rapidly due to the profound physiological changes in pregnancy. So the metabolism of drugs is going up pretty significantly depending on that particular patient and drug concentrations are dropping making that drug less effective. In which case, they will start to have a recurrence of symptoms. So depending on the drug and what labs we have available for that drug, I will check labs monthly if the lab is dropping. So say the patient comes in with a lab of—They get their labs checked for lithium. When they're doing well, they're at 1.0. Well in pregnancy that might drop down to .5. What I'm doing is checking monthly to see whether that concentration drops and adjusting the dose by increasing it so that we can get back to where they normally live and where the drug is effective for them. For drugs where we don’t have a concentration to check, I'm just monitoring symptoms. Trying to get a sense of any little sign that things are heading in the wrong direction. So let’s adjust your dose and make sure we’re keeping you well. Let’s add therapy if needed and any other intervention we might need to include, more supports, what have you. So those are some of the things I'm doing and encouraging my colleagues to do.

Host:  Certainly is a challenging time for the woman. As we wrap up, Dr. Clark, what would you like other providers to know about optimizing effective treatment for these women and how to weigh the risks versus the benefit for the women and the baby when dealing with pregnancy and bipolar disorder?

Dr. Clark:  I would wrap up by saying that this is a severe mental illness. It’s a diagnosis that requires treatment, and it’s usually medication that must be continued to manage this illness well. So I recommend, first of all, my OB colleagues and other primary care providers who are front in line to screen for it. Does the patient have bipolar disorder because often because of the stigma patients may not share. I encourage them to increase monitoring for symptom worsening during pregnancy for patients who have this illness, and to adjust the dose for drugs such as lithium, lamotrigine where we have established lab values to monitor every four to six weeks. Regardless, monitor symptoms closely and again adjust the doses as needed to keep these women well. We’ve got to be more proactive instead of reactive so that these women are not going into post-partum already on the edge and then post-partum they are at much more risk of an episode. That is exactly what we are trying to avoid. We’re trying to avoid poor outcomes. These women who are untreated or not treated effectively are at much higher risk of poor outcomes, whether that’s preterm birth or low for gestational age babies. Those are the things went want to prevent.

Finally, I would say I had many great situations, actually, in which patients have come to me and they’ve been told that not only should they not take medication, but they shouldn’t have children. That’s awful to hear, but I have had the fortune of being the physician for many patients who have had great outcomes and have then shown that yes. They can have children. They can start families. That bipolar disorder’s not an illness that should prevent anyone from childbearing. So that’s what I would leave people with. I love this work. I love this research. I'm hoping that in the next decade we make some major advances in globalizing some standard protocols on guidelines for managing bipolar disorder and pregnancy and post-partum.

Host:  Wow. That was an excellent summary. I can hear the passion in your voice, Dr. Clark. What good points all. It’s such an important and interesting topic. Thank you so much for joining us and sharing your expertise. That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. For more information on the latest advances in medicine, please visit nm.org to get connected with one of our providers. If you found this podcast as informative as I did, please share with other providers. Share on your social media. Share with other women that you know that might be suffering from bipolar and wanting to get pregnant. Be sure to check out all the other fascinating podcasts in the Northwestern Medicine library. Until next time, I'm Melanie Cole.