‘Mental health is maternal health’: Screen, treat pregnant patients for bipolar disorder
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Women should be screened and treated for bipolar disorder during pregnancy despite hesitations about pharmacologic treatment, according to a presentation at The Pregnancy Meeting.
“Your heartrate might go up a little bit when you think about using lithium,” Emily S. Miller, MD, MPH, assistant professor in the department of obstetrics and gynecology at Northwestern University, said during the presentation. “But your heartrate should go up when you’re thinking about somebody not being treated for 3 to 4 months with bipolar disorder.”
Common cases and screening strategies
Miller noted the publicized cases in the media of women who have harmed themselves and their children and attributed their actions to their mental illness.
“If you hear personal accounts from women who recover from postpartum psychosis, it’s like hearing the fabric of nightmares,” Miller said. “Women describe these chilling stories of feeling possessed, this overwhelming sense of danger, and trapped in these terrifying delusions.”
Half of all women with postpartum psychosis have a history of bipolar disorder, Miller said. Also, Miller cited a study that found that 1,396 — or approximately 14% — of 10,000 pregnant women were positive for depression on the Edinburgh Postnatal Depression Scale (EPDS). Research assistants then conducted structured clinical interviews for diagnosis with these women and found 70% of them had a primary diagnosis of unipolar depression with a major depressive episode.
“That’s kind of what we would have expected. But what’s fascinating about this research is that 23% of people who screened positive on the EPDS who ostensibly we would think had postpartum depression did indeed have bipolar disorder,” Miller said.
Miller added that there are tools available to OB/GYNs to screen patients for bipolar disorder. She prefers the Mood Disorder Questionnaire (MDQ), which consists of 13 questions, takes about 5 minutes to complete, and is freely available online in multiple languages.
“By routinely administering the MDQ to someone with a positive EPDS result, it’s going to open the door to some thought or conversation, and you can use your clinical judgment to assess that diagnostic dilemma,” Miller said. “The take-home message is to not stop with a screen for depression like we often do but to take it a step further to make sure you’re evaluating for bipolar disorder.”
Undertaking treatment
Once bipolar disorder has been indicated, Miller said treatment should begin immediately, even though psychiatrists with perinatal experience may be difficult to find.
“No treatment during pregnancy is a high-risk exposure. Untreated bipolar disorder carries substantial increased risks for maternal morbidity and mortality as well as increased risks for adverse pregnancy outcomes,” she said.
Providers should follow three principles during treatment, Miller said. The first, risk-risk counseling, acknowledges that treatment and lack of treatment both come with risks. Second, monotherapy is ideal, minimizing exposure to medication and dose-titrating to achieve remission of symptoms. Finally, providers should strive to employ the lowest effective dose to reach symptom remission.
Patients who already are successful with pharmacotherapy should continue to use it, Miller said. Otherwise, providers have some decisions to make. The first is determining whether the patient is expressing mania or depressive features of bipolar disorder.
Patients with manic symptoms should receive lithium, which has an absolute risk for Ebstein anomaly during organogenesis of one to two per thousand, Miller said, which is acceptable compared with the risks for adverse outcomes that untreated bipolar disorder presents.
Other treatments are available for patients with depressive symptoms. Preconception patients should use lamotrigine, while pregnant patients should use quetiapine or lurasidone, Miller said.
“Quetiapine has more metabolic risk,” she said. “Lurasidone has a little less metabolic risk, but there’s less data on pregnancy and its safety, although the data that’s there is very reassuring.”
Ongoing support
Doctors who begin this journey with their patients do not have to proceed alone, Miller said. She leads a program at Northwestern called Compass, where OB/GYNs and midwives collaborate with a psychiatrist and care manager who also is a licensed clinical social worker to provide care.
Also, multiple states support perinatal psychiatry access programs where OB/GYN providers can find education, provider-to-provider consultations and resources and referrals. Seven states receive federal funding to support these programs.
Miller further cited the Postpartum Support International (PSI) helpline at (800) 944-4773, which offers a provider directory and other assistance. The Health Resources and Services Administration has designated PSI as a perinatal access site for the entire country as well.
“The message I want you to take away here is that mental health is maternal health,” she said. “We cannot consider ourselves maternal-fetal physicians if we neglect mental health care.”