I Have Bipolar Disorder. Can I Keep Taking My Meds While Pregnant?

Guest

[ 00:00:00 ] I want to thank both of you for listening to my questions and answering those questions because I had these questions in mind for such a long period of time.  I was diagnosed maybe like five, six years back.  And then since then, I have been having these questions in my mind.  What about pregnancy?  What about having a baby?  Will the baby have any kind of malformations because of the medication or because of the condition that I have, the bipolar disorder.  So all these things were running in my mind and I wanted answers all the time.  And finally, I got some people who can answer my questions.

Dr. Ruta

[ 00:00:34 ] Welcome to So Glad You Asked, the show where real moms bring us their toughest questions.  I'm Dr. Ruta Nonacs, a perinatal psychiatrist at Mass General Hospital with over 30 years of experience supporting the mental health of moms and helping them navigate the emotional highs and lows – and the often unexpected challenges that come with planning a family, pregnancy, and motherhood.

Allie

[ 00:00:57 ] And I'm Allie Hales, a mom of four.  I know what it's like to scour the internet, wide awake at 2 a.  m., with a million questions, wondering if what I was experiencing was normal.  That's why we created this show.  It isn't just for real moms, it's by real moms.  Every episode is a conversation led by you.  Your questions, your experiences, your mental health, front and center.

Dr. Ruta

[ 00:01:20 ] And we don't just listen.  We provide real, evidence-based answers and reliable resources from trusted experts.  Because moms don't just deserve support.  They deserve solutions.

Allie

[ 00:01:31 ] Today we're discussing a critical topic that we don't talk about enough.  Safe medication use during pregnancy.  We'll hear from a listener who's planning for pregnancy and wondering whether she can continue to take her psychiatric medication safely, without impacting her health or her babies.  Plus, author and advocate Michelle Yang will weigh in on this important topic, sharing her personal journey managing her mental illness throughout pregnancy, as well as her unique cultural experiences as an Asian mom.  We hope that you walk away from this episode equipped with practical insights and actionable tips to make the best decisions for your health and your family.

Guest

[ 00:02:16 ] Hello, I'm a homemaker navigating the journey of pregnancy and mental health and managing mental well-being while considering pregnancy comes with unique challenges, especially when it involves medication decisions.  And I'm here to share my personal experiences and thoughts in the hope that it resonates with others facing similar situations, all while maintaining my privacy.  I had a few questions like, What precautions should someone with bipolar disorder take before getting pregnant while on aripiprazole and escitalopram?  That is the question that I wanted to ask.

Dr. Ruta

[ 00:02:52 ] Where are you in the information gathering process?  Who have you talked to so far?

Guest

[ 00:02:59 ] So I have talked to a psychiatrist and I have read some articles as well.  So I'm a little confused.  Because there's so many things like my psychiatrist is telling that it's fine to take those medications while you're planning for pregnancy or during pregnancy.  And I have also read some articles which say that the benefits outweigh the risk.  So, that's what I have read.

Dr. Ruta

[ 00:03:24 ] I think a lot of people go onto the Internet, which can be a really scary and confusing place because there's a lot of conflicting information.

Guest

[ 00:03:34 ] Exactly.  I've read so many articles.  I've talked with so many people, but still, I just wanted a second opinion because this is about my baby, right?  So I don't want to take any risk.

Dr. Ruta

[ 00:03:44 ] Absolutely.  In a perfect world, this is when we like to talk about medications during pregnancy.  So we like to talk to women before they conceive so we can do some planning.  We can talk about what medications are safe and what medications we want to avoid.  And this is especially tricky with bipolar disorder because some of the medications, not any of the medications you're on, but some of them actually carry some risks.  So we want to do a lot of planning in advance.  We talk about the risks of medication, but we also talk about what are the risks of untreated illness in the mother.  So if we were to take away these medications, there's a risk of relapse during pregnancy.  That might not be a big deal for some disorders, but there are women with recurrent depression or bipolar disorder where stopping medications can have a really big impact in terms of their ability to function.  We also don't want them to have a relapse of illness during pregnancy because the stress associated with a relapse can have negative impact on the physiology of the pregnancy.  Unfortunately, there's no decision that's really risk-free.  There's risks associated with a medication, but there's also risks associated with untreated illness.  And for many women with bipolar disorder, there's a pretty high risk of relapse.  And we've seen that about half of women who stop their medications before pregnancy relapse during the course of pregnancy.  So we have a tendency to maintain women on medications during pregnancy.

Guest

[ 00:05:17 ] So I'm in a combination of medication, right?  So will that have any kind of risk of fetal anomalies while taking those two medications?

Dr. Ruta

[ 00:05:28 ] The biggest question that we answer with regard to the use of medications during pregnancy is whether or not they'll cause any birth defect or malformation.  And you are on two medications.  One is aripiprazole, which is a medication that's being used as a mood stabilizer.  And the other is escitalopram or Lexapro, which is a serotonin reuptake inhibitor.  And, in terms of the medications you're on, there is really a lot of data to support the use of serotonin reuptake inhibitors during pregnancy.  And among all classes of medications, it's actually been studied very, very well.  And there has been no consistent pattern of malformations associated with exposure to medications, including escitalopram or Lexapro.  So I feel very comfortable with that medication that you're taking.  I feel comfortable with the dose you're taking.  Usually we want to keep the dose of the medication in the recommended range during the course of pregnancy.  Aripiprazole is a little bit less well-studied than the escitalopram, so Aripiprazole or Abilify.  There have been a bunch of studies which have looked at large databases and have not seen any association between Aripiprazole and increased risk of malformations.  So there's less data, but there's enough data to feel comfortable with using it during pregnancy.

Guest

[ 00:06:58 ] You said that the dose is just fine with what I'm taking right now.  So is it just fine?  Or do I have to reduce it before getting pregnant?

Dr. Ruta

[ 00:07:07 ] No, I think we tend not to use super high doses during pregnancy because most of the information we've gathered is on standard doses of medication.  So we try to keep it in the normal range.  I think also there's a tendency to try to reduce the dose of medication during pregnancy with a thought that sort of less is better.  But what we see happening is that sometimes when women decrease their doses, it just sets them up for relapse during pregnancies.  The other thing that can happen metabolically is as you go through pregnancy, your body increases its metabolic rate and it can chew up those medications more quickly.  In some women, the levels of the medication actually fall during pregnancy.  So that would be another reason not to decrease the dose prior to pregnancy.

Guest

[ 00:08:00 ] And postpartum, I have heard that there might be some kind of neonatal abstinence syndrome or something like that in babies, something like neonatal abstinence syndrome.

Dr. Ruta

[ 00:08:10 ] While most of the data has sort of focused on looking at risks during pregnancy, there's some data looking at risk for neonatal symptoms after delivery.  And some people call it neonatal abstinence syndrome, which is a little confusing.  It's also a little bit stigmatizing because that's what babies who are exposed to opiates experience, and it's totally not the same thing.  So what we would like to call it is poor neonatal adaptation or neonatal symptoms.  I think that's a more accurate description of what happens.  And it's pretty common in women who have taken SSRIs and SNRIs during pregnancy.  It probably occurs in about a quarter to a third of women, which sounds scary, but it's important to remember that these symptoms are really benign.  And there's a lot of overlap between this neonatal symptoms associated with SSRI and just normal baby behavior.  So it's kind of hard to tell sometimes.  But the good news is that they're really time-limited and don't require any specific treatment.

Allie

[ 00:09:19 ] I just had a question while you're talking.  How long do those symptoms, if your baby has those, how long do they last?

Dr. Ruta

[ 00:09:26 ] That's a great question.  They can last a couple of hours to a couple of days.  Sometimes the baby might go to the special care nursery after delivery for monitoring, and it really seems to be very short-lived, and we don't do anything special with monitoring or treatment.

Guest

[ 00:09:44 ] And I had another question.  Are there any long-term developmental or cognitive effects associated with prenatal exposure to these medications?

Dr. Ruta

[ 00:09:54 ] We actually have a fair amount of data on both the SSRIs and the atypical antipsychotics like aripiprazole.  And in terms of the SSRIs, kids who have been exposed to SSRIs versus kids who have not been exposed have normal IQ.  They hit their normal developmental milestones at an appropriate age.  So that data is very reassuring.  I would say the data on aripiprazole, there was one study which was a little fuzzy, which showed a slight increase in neurodevelopmental disorders.  But sometimes we can see associations, but it's not necessarily a cause and effect relationship.  It doesn't mean I wouldn't use aripiprazole because it has worked for you.  And I don't see that there is necessarily a better agent given that you've been on this medication and that you've been stable.

Guest

[ 00:10:48 ] I was like, I'm really stable on those medications.  And if you ask me personally, I would not want to change those medications.  But I didn't want any like long-term developmental or cognitive effects on my baby.  So I wanted to be sure about it.

Dr. Ruta

[ 00:11:03 ] I'm glad to hear that you don't want to change your medications.  I think sometimes what happens is that women go on the Internet and they find something that says that Zoloft is better or, don't take X, Y, and Z, and they make all these changes to their regimen, and it doesn't end up serving them well.  So we really want you to stay well during pregnancy because that makes it more likely to stay well during the postpartum period.

Allie

[ 00:11:31 ] Ruta and I were talking about this earlier.  She shared something with me that I wished I had heard when I was pregnant because I also wanted to find all the information and make the right choice, and be well-informed, and understand risks and benefits.  And Ruta said something to the effect of, if there's a statistic you find online, you don't know where you fall in that.  You do need to talk to your psychiatrist, talk to your OB.  And to me, that was really reassuring.

Dr. Ruta

[ 00:11:58 ] Yeah, I think YouTube is great when you want to fix your vacuum cleaner.  It's not particularly good for figuring out about what's going on in pregnancy.  And, you know, there are reputable sites for information, but I think there's a lot of information out there and it can be really, really difficult to navigate.  And it's information that doesn't necessarily pertain to that individual woman.  So I might see two patients with the same disorder, the same medications, but they might choose to do very different things during pregnancy.  And that's dependent on their personal history, their attitudes towards medication, whether psychotherapy works for them or not.  So we really want all of those things to be considered when you're.  Talking about medications, that means having multiple discussions with your provider about what's the right choice for you.

Guest

[ 00:12:56 ] I had another question as well.  So is it safe to breastfeed while taking those two medications?

Dr. Ruta

[ 00:13:04 ] Everything you take gets into the breast milk, but to varying degrees.  And what we found out with the antidepressants were that the levels were very, very low in the infants.  And with aripiprazole, There hasn't been a lot of study of medication levels in the breast milk, but based on some scientific data and animal studies, we believe that the levels passed on to the infant are very low.  And so we don't recommend stopping the medications in order to breastfeed, nor do we recommend that you don't breastfeed.  I think there's some happy middle ground where you can take your medications and breastfeed.  So you had asked about like precautions specifically to bipolar disorders.  We've seen that women who stay well during pregnancy are less likely to have postpartum symptoms.  So it's really our goal to keep you healthy during pregnancy.  And the other thing we really want to keep track of is sleep, because we know that sleep or the interruption of sleep is really a risk factor for relapse in all patients with bipolar disorder.

Allie

[ 00:14:13 ] As I talked to more people, I realized I know hardly anyone that's had a straightforward pregnancy without having to make these decisions of picking this option or this option.  And maybe both have some risk and some benefit.  And at the end of the day, you work with your provider, your support system, yourself to figure out what that best route is forward.  But throughout my pregnancies and postpartum, I felt like I had to make a lot of those decisions and weighing those things.  And I just wasn't anticipating that.  And for a really long time, I felt guilty about not doing the best thing.  And that was really hard for me to get over.  Obviously, I'm not really even fully over it.

Dr. Ruta

[ 00:14:58 ] I think a lot of these discussions about medications take place in these very private places.  And whether women are taking antidepressants or whether they have bipolar disorder, it's a discussion with their psychiatrist.  And sometimes their partner doesn't even know that.  They have mental health history or the family doesn't know.  So it's often very secretive.  And I think that doesn't help the situation because if you're deciding on something less important, like what type of stroller to buy, you talk to everybody about it.  I think you're in a really good place and you're not pregnant yet.  You know, you have a chance to explore the various options.  We want you to feel comfortable with the pregnancy and feel that the medications aren't an issue.

Allie

[ 00:15:45 ] One resource that we had was the National Pregnancy Registry for Psychiatric Medications.  Do you mind just speaking a little bit about what that is?

Dr. Ruta

[ 00:15:53 ] So this is really one of these amazing research studies that we have at our program where we've been collecting data on pregnancy outcomes in women who have taken atypical antipsychotics as well as other medications like ADHD medications, some of the newer antidepressants.  And that data is really, really important for informing other women about the risks associated with these medications.  And the really neat thing about the study is that it includes people from all over the country because it's completely remote.  So we want patients like our guests to contact the Registry when they find out they're pregnant so that we can gather that data.  And from that resource, we've put out many publications on the safety of these medications.

Allie

[ 00:16:43 ] I just wanted to thank our guests too for being so vulnerable and willing to talk about this because, like Ruta said, I think a lot of women have these questions and these conversations, but they don't necessarily share them with others.  And I think a lot of women will be able to listen to this and resonate with the things that you're saying and have the same questions that you have.  So I think you being willing to be vulnerable and ask these questions, it really helps that conversation destigmatize these issues that are so real for so many women.

Guest

[ 00:17:14 ] I want to thank both of you for listening to my questions and answering those questions because I had these questions in mind for such a long period of time.  I was diagnosed maybe like five, six years back.  And then since then, I have been having these questions in my mind.  What about pregnancy?  What about having a baby?  Will the baby have any kind of, you know, malformations because of the medication or because of the condition that I have, the bipolar disorder?  So all these things were running in my mind and I wanted answers all the time.  And finally, I got some people who can answer my questions.  I'm actually very happy and I'm very lucky to be a part of this podcast.

Dr. Ruta

[ 00:17:57 ] Joining us now is Michelle Yang, a mom, advocate, and author who shares her story of managing a mood disorder during pregnancy and the postpartum period.  What we would like you to talk about, if you're comfortable, is your experiences with planning for pregnancy and having to make some really difficult decisions about what to do because you were taking medications.

Michelle

[ 00:18:26 ] At the time, my husband and I wanted to start a family.  My bipolar disorder had been well managed for; well over a decade.  But because I had moved across the country for graduate school and then starting a job after, I didn't have the continuity of having the same psychiatrist over a long period of time.  So when I started the pregnancy journey, I needed to find a new doctor.  As a new patient, it was really difficult to find a psychiatrist who was open to working with someone who lives with a bipolar disorder and who wanted to start a family.  As somebody who lives with bipolar, I know that it's going to be a difficult pregnancy.  But then to have the doctors sort of shut the door on my face was really heartbreaking.  And it felt really judgmental because they didn't know me.  And so that but that was the problem.  I didn't have a trusting relationship with the doctor established.  I was on Depakote at the time, which is unsafe to take while pregnant for the child.  And so she advised I taper off the medication, which I did.  And I actually had a beautiful pregnancy.  I was so happy.  Didn't have any issues or complications.  Bipolar symptoms, mood symptoms, that I was just happy.  It wasn't until very late pregnancy that I became very uncomfortable.  I had a really hard time sleeping most nights because I was uncomfortable in my body and it was getting to a point where it was causing a problem.  So yeah, I had started out assembling a team.

Allie

[ 00:20:05 ] Michelle, you're incredible. You’re so strong. How did you feel advocating for yourself in those situations? I mean, if you were talking to someone who's experiencing something similar to what you were experiencing pregnant, what would you tell yourself in 2013?  I think about this all the time.

Michelle

[ 00:20:18 ] I am a good advocate for myself.  I have a lot of privilege.  I have a master's degree.  I have a stable job.  I have all of these things that make me empowered to advocate for myself.  Yet, it is still so challenging.  And I can't imagine for other people with less privilege, like how just how difficult it is.

Allie

[ 00:20:46 ] So, I was wondering if you could talk a little bit about, you know, what what type of team did you have?  Was it effective for you?  Would you have done anything differently in that?

Michelle

[ 00:20:57 ] Yeah, I had some struggles.  I had to switch psychiatrists because she seemed not very supportive, even though she did sign on to be my psychiatrist.  But I ended up switching to a psychiatrist at the hospital.  She was much better, much more supportive and understanding.  You need someone that you feel like they're in your corner and advocating for you.  And I did not feel that with the first psychiatrist.

Allie

[ 00:21:20 ] I know people have felt that way.  Like, I don't feel like this physician is listening to me.  How did you manage that transition?  At what point did you feel like this isn't working for me?  Can I actually switch?  What do I say?  How do I do that?  So just curious how you did that.  It's tremendously difficult.

Michelle

[ 00:21:38 ] Change is difficult.  Every time you switch, you have to kind of retell your story and that is draining.  and triggering in itself, you have to just really reach a point of like, this person is really not here to look out for me.  And I did reach that point with this doctor and she was tremendously well, had wonderful accolades and, you know, came to me recommended.  And so I didn't want to leave her, right?  Because I was like, well, if she's the best out there, shouldn't I just stick with her?  She would just always stare at me with this like stern face and she never smiled.  And I didn't want that negativity, especially during pregnancy.  And so I started to look around to see what other options were there.  And of course, I ended up at my hospital, and I had a great experience there.  I had this therapist that I loved, but turns out was not so well prepared to handle someone who lived bipolar because I don't know that if she ever had a patient, a client who lives with bipolar one.  If I had to do it over again, I would love to have my OBGYN and my psychiatrist and my therapist all be part of the same organization so that they can share notes and they can communicate with each other and have a better, more comprehensive care so that they're not each telling me different things.

Allie

[ 00:22:58 ] You're such a powerful advocate and just your willingness to de-stigmatize this is so powerful too.  And I know that there are going to be people listening to this who live with the same health conditions and wonder if there's hope for them.  And I think even just hearing your story brings hope.  It's just so wonderful listening to you talk and hearing your strength despite, you know, all that you went through to get to this point.  Thank you, Allie.

Michelle

[ 00:23:26 ] I mean, that's actually why I wrote my memoir.  It's called Phoenix Girl, How a Fat Asian with Bipolar Found Love.  And I wrote that book because when I was first diagnosed at age 20, I had no hope.  I had a lot of struggles, though academically and on paper, I was such a high achiever, but a lot of mental health struggles.  And when I was diagnosed and I was hospitalized at that time, I was terrified.  Went to the library to look for a book because that's what I did.  And I couldn't find anyone.  You know, there's very few books written back then about somebody living with a bipolar disorder, let alone somebody who was an immigrant, who's BIPOC, let alone somebody who was Asian American.  I just had to keep the faith and put one foot in front of the other.  By the time I was in my late 30s, that's when I decided to write my book.  I had achieved everything that my 20-year-old self feared that I would never have.  Being a writer, it's just one way that I'm advocating.  And it has, you know, everything I went through in it.  But ultimately, I wanted it to be a positive story.  I thought that as somebody who wanted to read stories like this, I wanted it to be.  A story of how I survived and how I have hope and how I found happiness and how there was joy throughout my life, even when there were challenges, because I know that that can be true for everyone, no matter what condition that they live with.

Dr. Ruta

[ 00:24:54 ] That's a good way to sum up.  And I think the importance of hope is especially important for pregnancy because there's so many things we can't control and we're not expecting, but you have to have some hope to move from one step to another.

Allie

[ 00:25:13 ] I just am so inspired by your courage, both in living through what you've lived through, but also coming out and advocating and just providing such a message of hope for so many people.  Thank you so much.  It was my pleasure.  And that wraps up today's show.  We hope it gives you the clarity, reassurance, and tools you need to take care of your mental health.  Dr. Ruta, what's something you hope our listeners take away from today?

Dr. Ruta

[ 00:25:38 ] I'm so glad you asked.  As we wrap up this episode, remember that mood and anxiety disorders are common during pregnancy, and many women will have to make difficult decisions regarding the use of medications while pregnant.  This choice requires balancing the potential risks of the medication with the risks associated with untreated illness in the mom.  However, with so much information out there, it can be overwhelming.  Rather than navigating this journey alone, we recommend working closely with a healthcare provider who can help interpret the data, consider your personal preferences and experiences, and help you to make informed decisions that are right for you.  Thanks for tuning in.  As a reminder, please note that this podcast is not intended to be a substitute for professional medical care.  The views, thoughts, and opinions shared today are the speaker's own.  Your feedback and questions drive this show, so feel free to send us an email at podcast@womensmentalhealth.org or leave a voicemail at 617-643-9232.

Allie

[ 00:26:45 ] This is So Glad You Asked with Dr. Ruta Nonacs and Allie Hales, brought to you by the MGH Center for Women's Mental Health and the J.  Willard and Alice S.  Marriott Foundation.  Additional resources are available at Dr. Ruta's resource hub at womensmentalhealth.org.  Listen and subscribe wherever you get your podcasts.