2102 Am J Psychiatry 159:12, December 2002

Brief Report

Reproductive Decisions by Women With Bipolar DisorderAfter Prepregnancy Psychiatric Consultation

Adele C. Viguera, M.D.

Lee S. Cohen, M.D.

Suzanne Bouffard, B.A.

T. Hatch Whitfield, M.S.

Ross J. Baldessarini, M.D.

Objective: This study ascertained family planning decisions bywomen with bipolar disorder after psychiatric consultation.

Method: The authors surveyed 116 women with DSM-IV bipo-lar disorder after specialized consultation about treatment op-tions and risks regarding pregnancy.

Results: Of 70 respondents, 45% had been advised to avoidpregnancy by a health care professional before consultation. Af-ter consultation, 63% decided to pursue pregnancy.

Conclusions: Women with bipolar disorder often encounterobstacles from health care professionals regarding pregnancy.Individualized comprehensive review of risks and benefits oftreatment options during specialized preconception consulta-tion can support thoughtful clinical planning.

(Am J Psychiatry 2002; 159:21022104)

Bipolar disorder presents special challenges to womenof childbearing age as well as to their families and clini-cians. Problems include lower fertility rates, strong geneticloading, and potential fetal teratogenic risks as well ashigh risks of illness recurrence if treatment is discontinuedabruptly (110). It is noteworthy, however, that familyplanning issues for women with bipolar disorder have re-ceived scant research consideration (1, 4). Pregnancyposes several clinical dilemmas, and evidence-basedguidelines for the clinical care of this population remainvery sparse. Extensive clinical experience suggests thatwomen with bipolar disorder are often counseled to avoidor terminate pregnancy in order to avoid risks of potentialfetal exposure to psychiatric medications or risk of recur-rent illness.

Mood stabilizers, including valproate, carbamazepine,and lithium, are associated with teratogenic risks (2, 7).First-trimester exposure to lithium probably increases therisk of cardiac malformations, notably Ebsteins anomaly,by several-fold, from a baseline risk of 0.005% (1 in 20,000live births) to a risk ranging from 0.05% to 0.1% (1 in 2,000to 1 in 1,000 live births) (2). Compared with lithium, anti-convulsants such as carbamazepine and valproic acidmay pose even greater risks, including high rates (1%5%)of neural-tube defects such as spina bifida as well ascraniofacial anomalies, cardiac anomalies, microcephaly,and growth retardation (3, 10). Reproductive safety infor-mation about other, newer agents used to treat bipolardisorder remains very limited, leaving lithium as a plausi-ble first-line option, especially during mid-to-late preg-nancy (3, 10). Concern about teratogenic risks associatedwith the standard mood stabilizers can lead to incompleteconsideration of the major risks associated with recur-rences of bipolar disorder illness during pregnancy. Theserisks include not only the particularly high risk of early re-

lapse after interruption of ongoing treatment but also thehigher risk for postpartum recurrence as well as the im-pact of untreated psychiatric illness on the developmentof the fetus (1, 3, 6, 7, 10).

Although there are no empirically based treatmentguidelines for the management of bipolar disorder duringpregnancy, substantial progress has been made with im-proved information on the reproductive safety of psycho-tropic drugs used to treat bipolar disorder and a better un-derstanding of the course of the disorder and the risks ofrecurrence during pregnancy and the postpartum period.Increasingly, women with bipolar disorder who wish toconceive seek preconception consultation to better un-derstand the risks and benefits of treatment options (10).This report describes the family planning decisions madeby patients with bipolar disorder after preconception con-sultation by a reproductive psychiatry subspecialty servicein a major medical center.

Method

A questionnaire was sent to women who sought outpatientconsultation at the Perinatal and Reproductive Psychiatry Pro-gram at Massachusetts General Hospital during 19972000. Thesurvey was designed to ascertain information regarding repro-ductive decisions that followed consultation designed to providereliable information about the spectrum of risks associated withthe maintenance or discontinuation of pharmacologic treatment,thus facilitating informed reproductive decisions.

The Perinatal and Reproductive Psychiatry Program was estab-lished in 1987 as a consultation service that provides specializedcare to women suffering from reproductive-associated mood dis-orders, including affective disorders in pregnancy and the post-partum period.

The goal of the preconception consultation is to provide up-to-date information regarding the spectrum of risks associated witheither maintenance or discontinuation of treatment with psychi-atric medications. The main objective of the consultation is not to

Am J Psychiatry 159:12, December 2002 2103

BRIEF REPORTS

dictate treatment but to provide accurate information that pa-tients may use to make personal decisions regarding treatmentduring pregnancy. In our clinical experience, patients with similarillness histories who are presented with the same risk-benefit in-formation may make different decisions about maintenance ordiscontinuation of treatment in pregnancy. Although patientssurveyed in this study were seen by at least four different clini-cians in our program, the variability in treatment practices isminimal since there is general consensus among those who prac-tice within the program regarding the management of bipolar dis-order in pregnancy. A review of our programs proposed tentativeguidelines for the clinical management of bipolar disorderthroughout pregnancy has been published recently (10).

A 13-question instrument addressed 1) demographic informa-tion, 2) reproductive history, 3) family planning practices, 4) rea-sons for seeking the original consultation, and 5) clinical outcomeafter consultation. Questions 35 were multiple choice, and mul-tiple answers were encouraged. Patients were given a nominalpayment to encourage cooperation. Massachusetts General Hos-pitals institutional review board approved all study procedures,and subjects provided informed consent for use of questionnairedata for reporting in anonymous aggregate analyses.

Results

Of 116 questionnaires sent, 13 were undeliverable, and70 of 103 (68%) were completed and analyzed. The meancurrent age of the 70 respondents was 35.4 years (SD=5.7,range=2049). Most were Caucasian (97%), were married(87%), and had a college degree (69%). The mean age atmenarche was 13.2 years (SD=1.8, range=1020). Irregularmenstrual cycles were reported by half of the group, 11%(N=8) had undertaken infertility treatment, 19% (N=13)had at least one miscarriage, and 20% (N=14) had at leastone therapeutic abortion. Before consultation, pregnan-cies per subject averaged 1.6 (SD=1.3, range=05), with amedian of one live birth per subject.

Before consultation, 45% of the respondents (29 of 65)had been advised not to become pregnant by a health pro-fessional: 69% (20 of 29) by psychiatrists or other mentalhealth professionals and 14% (four of 29) by primary carephysicians or obstetricians. A spouse had urged 21% of thepatients (six of 29) to avoid pregnancy, and 45% (13 of 29)reported that a parent or sibling had advised againstpregnancy.

Respondents cited several reasons for seeking special-ized consultation regarding management of their illnessduring a potential pregnancy. A majority, 52% (36 of 69),had been encouraged by a medical professional to seeksuch consultation, and 42% (29 of 69) reported seeking asecond opinion on their own. Of those in our group, 55%(38 of 69) had been considering becoming pregnant andhad sought information about the likely course of their ill-ness and about the relative risks of the various treatmentoptions, and 22% (15 of 69) had been pregnant at the timeof consultation. About 25% of the group (17 of 69) soughtconsultation because they had previously experienced re-currences of bipolar disorder during pregnancy or thepostpartum period.

Most respondents, 85% (55 of 65), reported that theyhad followed the treatment options outlined in their con-sultation. After consultation, 63% of the group (29 of 46)attempted to conceive on the basis of their personal as-sessment of the risks and benefits provided at the con-sultation and after review of these with their treating psy-chiatrist. Of those who tried to conceive, 69% (20 of 29)became pregnant within 12 months. The other 37% (17 of46) chose to avoid pregnancy, including one who sought toadopt a child. The most commonly reported reasons toavoid pregnancy were fear of adverse effects of medicineson fetal development (56%, 10 of 18) and fear of illness re-currence if maintenance treatment were discontinued(50%, nine of 18). Fewer women expressed concerns aboutpotential genetic transmission of bipolar disorder to off-spring (22%, four of 18), reluctance to repeat previouspregnancy-associated illness (17%, three of 18), and fearthat recurring mania or depression would adversely affecta fetus or existing children (17%, three of 18).

Similar proportions of women perceived that pregnancyhad a positive influence on their illness course and overallwell-being (47%, 16 of 34) as those who reported negativeeffects (53%, 18 of 34). In addition, one-half reported thatbecoming a mother had bolstered their self-esteem.

Discussion

This follow-up survey of women with bipolar disorderwho had been evaluated in consultation within our pro-gram has clear limitations, including incomplete survey-ing and bias toward women who were well educated, eco-nomically advantaged, and highly motivated to seekexpert advice. Nevertheless, it yielded interesting prelimi-nary insights into the concerns of women of childbearingpotential who suffer from bipolar disorder. Approximatelyone-half of the 70 respondents had been advised againstpregnancy by a psychiatrist, primary care physician, ob-stetrician, or family members, suggesting widespread biasagainst pregnancy for such women.

Our experience indicates that many women with bipo-lar disorder, regardless of educational and socioeconomicbackground, as well as physicians who care for them, areill-informed about the relative risks of perinatal exposureto psychotropics and the high rates of relapse during preg-nancy and the postpartum period without treatment (3, 9,10). An important finding was that 37% of the patientschose not to pursue pregnancy when presented with verysimilar risk-benefit information on 1) the course and riskof recurrence of illness during pregnancy and the postpar-tum period and 2) the reproductive safety data of the vari-ous mood stabilizers, as compared to the 63% who at-tempted to conceive. This finding underscores the role ofpatient autonomy in clinical decision making and the im-portance of providing information about competing risksand potential benefits involved so that patients can makeinformed decisions about pregnancy.

2104 Am J Psychiatry 159:12, December 2002

BRIEF REPORTS

A majority of respondents cited concerns about terato-genic risks as well as risk of recurrence after discontinuingmaintenance medication as reasons for deciding againstpregnancy. For this study group, both types of risk weregiven similar weight, but this outcome may reflect the im-pact of the consultation process itself and recent empha-sis on maternal risk of treatment discontinuation in ourcenter (10). On the basis of our clinical experience, fearsabout potential teratogenic risks of drug treatment duringpregnancy appear still to have a strong restraining effecton both patients and physicians, despite the serious risksof treatment discontinuation in bipolar disorder, whichhave been appreciated more recently (6, 7, 10).

The study findings support our impression that provid-ing accurate and balanced information about treatmentoptions and relative risks, including the limits of currentknowledge, can contribute importantly to informed fam-ily planning by women with bipolar disorder. We propose,specifically, that judgments concerning reasonable risksduring pregnancy require shared responsibility but ulti-mately rest with the patient herself. Moreover, cliniciansshould resist automatic discontinuation of ongoing psy-chotropic medication in pregnancy without informing thepatient of the considerable clinical risks involved (6, 7, 10)and taking her wishes about treatment and pregnancyinto account. Studies in broader samples of women ofchildbearing age with bipolar disorder are required to clar-ify the unique reproductive health needs of this specialand understudied population and to develop sound poli-cies for their care.

Presented in part at the 154th annual meeting of the AmericanPsychiatric Association, New Orleans, May 510, 2001. Received Jan.25, 2002; revision received June 12, 2002; accepted June 26, 2002.From the Department of Psychiatry, Harvard Medical School, Boston;the Perinatal and Reproductive Psychiatry Program, MassachusettsGeneral Hospital; the Department of Biostatistics, Harvard School ofPublic Health, Boston; and the International Consortium for BipolarDisorder Research, McLean Hospital, Belmont, Mass. Address reprint

requests to Dr. Viguera, Perinatal and Reproductive Psychiatry Pro-gram, WACC 812, Massachusetts General Hospital, 15 Parkman St.,Boston, MA 02114; aviguera@partners.org (e-mail).

Supported in part by NIMH grant MH-01609 and a Young Investiga-tors Award from the National Alliance for Research on Schizophreniaand Depression (to Dr. Viguera), a grant from the Stanley Foundation(to Dr. Cohen), and an award from the Bruce J. Anderson Foundationand the McLean Hospital Psychopharmacology Research Fund (to Dr.Baldessarini).

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