Considerations in the pharmacotherapy of bipolar disorder during and after pregnancy

There are conflicting data on the course of bipolar disorder during pregnancy but childbirth is generally considered a time of high risk for the onset or exacerbation of mood and psychotic episodes in women with bipolar disorder. Despite the increasing use of psychotropic drugs in women with psychiatric disorders, there is a paucity of information in the pharmacological treatment of bipolar disorder during and after pregnancy. Optimal drug treatment requires an understanding of the illness course prior to, during, and after pregnancy; bipolar disorder type and dominant polarity, psychiatric comorbidity, physical health status, prior response to psychotropic drugs, effectiveness of medications in the acute and preventative treatment of mood episodes, side effect profile including teratogenicity, and finally family history of psychiatric illness. For women who discontinue psychotropic drugs abruptly upon finding out about the pregnancy, the withdrawal symptoms of medications should be distinguished from the symptoms of the disorder. Compatibility of drugs with breastfeeding is another important consideration. Antidepressants should be avoided as much as possible due to their association with manic switches, rapid cycling, and suicidality. An important aspect of pharmacotherapy in women with a personal or family history of bipolar I disorder or postpartum psychosis should be the management of insomnia that can either be an early symptom of, or a trigger for postpartum manic/mixed or psychotic episodes. Whereas polypharmacy may be unavoidable, every effort should be made to keep the overall number of medications and dosages to a minimum.