Choosing whether to maintain or discontinue mood stabilizer treatment during pregnancy requires weighing the risks of teratogenic outcomes associated with exposure to a particular drug against the risks of recurrence of untreated affective illness. However, previous studies have suggested that decisions about psychotropic treatment during pregnancy appear to be largely independent of past illness severity or clinical recommendations (Viguera et al 2002, Bonari et al 2005).
A recent study from the MGH Center for Women’s Health aimed to examine factors influencing individual decisions about continuing or discontinuing mood stabilizer treatment during pregnancy in women with bipolar disorder.
Pregnant women (N=138) diagnosed with DSM-IV bipolar disorder (type I or II) completed a treatment preference questionnaire as part of a study of recurrence risk during pregnancy. Of these 138 women, 55 decided to maintain treatment with their mood stabilizer, 35 discontinued their mood stabilizer before conception, and 48 discontinued their mood stabilizer after conception. This study questionnaire required subjects to rank a list of reasons for their decision to continue or discontinue mood stabilizing treatment.
For women who chose to maintain their mood stabilizer, the top three reason were: anxiety about relapse (69.1%), physician advice (47.3%), and failed past discontinuation (40%). The top three reasons for women to discontinue their mood stabilizer before conception were: fear of the effect on baby (60%), considering illness not severe (17.1%), and opinion of partner/husband (14.3%). The top three reasons for women to discontinue their mood stabilizer after conception were: fear of effect on the baby (56.3%), opinion of family/friends (10%), and physician advice (8.3%).
In summary, the main determinant in decisions to continue maintenance mood stabilizer treatment was patient concern about risk of recurrence during pregnancy. Among women who decided to discontinue their mood stabilizer during pregnancy, concerns over potential fetal teratogenic risks superseded other determinants. These findings clarify factors associated with decisions about treatment during pregnancy by women with bipolar disorder, and suggest that clinicians carefully consider an individual patient’s concerns when discussing treatment options.
Rachel Vanderkruik, BA
Adele C. Viguera, MD, MPH
Vanderkruik R, Viguera AC, Whitfield TH, Baldessarini, Cohen LS. Treatment Decisions by Pregnant Women with Bipolar Disorder. Presented at the 2009 Annual Meeting of the American Psychiatric Association.
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: 2102–2104.
Bonari L, Koren G, Einarson TR, Jasper JD, Taddio A, Einarson A. Use of antidepressants by pregnant women: evaluation of prediction of risk, efficacy of evidence-based counseling, and determinants of decision making. Arch Women’s Ment Health2005; 8:214–220.