There are strong parallels between the clinical management of bipolar disorder and epilepsy, and women with these disorders face significant challenges while pregnant or planning to conceive. In this setting, treatment decisions must balance the risks of recurrence of severe illness with the risks of potential harm to the fetus when certain medicines are taken during pregnancy.
Neurologists have led the way in developing and disseminating information related to the use of anticonvulsants in women of childbearing age, and much of what is known about anticonvulsants in pregnancy derives from studies of women with epilepsy. Indeed, many aspects of the pharmacology of anticonvulsants are similar among women with epilepsy and bipolar disorder, including the effects of pregnancy on drug metabolism, potential endocrine consequences of anticonvulsant use, and reproductive safety.
Despite these similarities in treatment issues facing pregnant women with epilepsy or with bipolar disorder, there appear to be great differences in clinical practices and attitudes involving anticonvulsants between the two specialties. Accordingly, we conducted a study to survey the opinions and recommendations regarding the use of anticonvulsants among 166 neurologists (n=88) and psychiatrists (n=78) practicing in Massachusetts.
We found that the two specialties were similar in terms of routinely informing patients of the potential teratogenic risks of anticonvulsants and the recommendation to avoid valproate use during pregnancy. Neurologists, however, were more likely than psychiatrists to encourage pregnancy, as well as breastfeeding, in women receiving anticonvulsant therapy. Psychiatrists were more cautious regarding the perinatal safety of anticonvulsants, citing the potential for long-term neurobehavioral risks and possible complications of breastfeeding.
These findings indicate that psychiatrists and neurologists differed substantially regarding the recommendations made related to the use of anticonvulsants for women patients during pregnancy and lactation. Neurologists generally were more tolerant than psychiatrists of anticonvulsant treatment during pregnancy and lactation and appeared to be less concerned about potential adverse effects of anticonvulsant treatment on pre- and postnatal fetal development.
These observed differences may reflect the relatively limited range of anticonvulsants that are FDA-approved for psychiatric conditions, as well as the availability of several non-anticonvulsant alternative treatments for mood disorders that may be less risky during pregnancy and the postpartum period. There may also be differences in benefit/risk ratios for anticonvulsants as applied to mood versus epileptic disorders: some neurologists may perceive the risk associated with untreated seizures during pregnancy outweigh the potential adverse effects of most anticonvulsants. This view is consistent with guidelines provided by the American Epilepsy Foundation (www.epilepsyfoundation.org), as well as by the American Academy of Neurology and the American Epilepsy Society.
In contrast, some psychiatrists may perceive the risks associated with anticonvulsant treatment as outweighing the risks of untreated affective illness in the mother. This position is strikingly at variance with growing evidence that indicates that untreated maternal mood disorders and emotional distress may be associated with adverse fetal and neonatal outcomes, in addition to their potentially severe impact on pregnant women and their families.
There also may be some professional and popular bias against pregnancy and motherhood for women with major, recurrent mood disorders. In a previous study, we found that approximately half of pregnant women diagnosed with bipolar disorder had been advised against pregnancy by a healthcare professional, 69% of who were psychiatrists (Viguera et al, 2002). Finally, in contrast to expert guidelines for the clinical care of pregnant women with epilepsy cited above, guidelines for the clinical care of women with major affective disorders are far less well developed (Yonkers et al, 2004). Our impression is that much more investigation, and inter-specialty collaboration, are required to develop such guidelines for the rational and safe use of anticonvulsants during pregnancy for women with mood disorders.
Adele C. Viguera, MD
Viguera AC, Cohen LS, Whitfield T, Reminick AM, Bromfield E, Baldessarini RJ.
Perinatal use of anticonvulsants: differences in attitudes and recommendations among neurologists and psychiatrists. Arch Womens Ment Health. 2010 Jan 5.
Viguera AC, Cohen LS, Bouffard S, Whitfield TH, Baldessarini RJ. Reproductive decisions by women with bipolar disorder after pre-pregnancy psychiatric consultation. Am J Psychiatry 2002; 159(12):2102-2104.
Yonkers KA, Wisner KL, Stowe Z, Leibenluft E, Cohen L, Miller L, Manber R, Viguera A, Suppes T, Altshuler L. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004; 161(4):608-620.