Prescribing Patterns for the Treatment of Bipolar Disorder in Pregnancy: A Retrospective Cohort Study

Background: Untreated bipolar disorder during pregnancy is associated with poor prenatal care, decreased fetal growth, and an increased risk for postnatal complications, including postpartum psychosis. Although mood stabilizers are first-line therapy, many patients and providers discontinue them in early pregnancy. Antidepressants as monotherapy can increase the risk of mania and rapid cycling, especially in patients with bipolar I, and are not recommended. Objective: This study aims to describe prescribing patterns for the pharmacologic management of bipolar disorder in pregnancy. Methods: This retrospective cohort study included pregnant patients, ≥14 years old, with a documented diagnosis of bipolar disorder and ≥two clinic visits after 1 January 2014, who delivered by 31 October 2017, within our health system. Eligible patients were identified by the ICD-9 and ICD-10 codes for bipolar disorder and their medication profiles. The primary outcome was to describe bipolar disorder treatment regimens at first visit, during pregnancy, and at delivery. Descriptive statistics were used. Results: Of the 214 pregnancies analyzed, 134 (62.6%) used psychiatric medications during pregnancy, with 79/134 (59%) being mood stabilizers. During the initial visit, 61/214 (28.5%) pregnancies were on psychiatric medications, including 30 (49.2%) on mood stabilizers and 16 (26.2%) on antidepressants alone. At delivery, 98/214 (45.8%) pregnancies were on psychiatric medications, with 48/98 (49%) on mood stabilizers and 35/98 (35.7%) on antidepressants without mood stabilizers. Other therapies included benzodiazepines, buspirone, and amphetamines, as monotherapy or combination. Conclusions: Despite having documented bipolar disorder, only 30/214 (14%), 79/214 (36.9%), and 48/214 (22.4%) pregnancies were treated with mood stabilizers at the first visit, during pregnancy, and at delivery, respectively. Unfortunately, justification for discontinuation was not documented. The most commonly prescribed mood stabilizer was lurasidone, followed by lamotrigine. Antidepressant monotherapy persisted throughout pregnancy, demonstrating inappropriate disease management.