Great Expectations: Considering Motherhood When You Have Bipolar Disorder

The risk of developing bipolar disorder amongst children with a bipolar parent is relatively low; in fact, their chances of not developing a bipolar spectrum disorder are far greater. Children born to a parent with bipolar disorder have a 4-15% chance of developing a bipolar spectrum disorder compared to a 0-2% chance for children of parents without the illness. Furthermore, some scientists believe that even genetic predisposition does not necessarily lead to bipolar presentation; rather, genetic predisposition must be unlocked by environmental factors for the disorder to articulate itself. Dr. Alexander B. Niculescu III of the Indiana University School of Medicine, explains it like this: “Your genes are not necessarily your destiny. For the illness to manifest itself, you have to have environmental effects—stress, exposure to infections, neurotoxins, drugs. In the end, prevention and early intervention in at-risk individuals can make a big difference.”

At the same time, the focus on preventing bipolar disorder didn’t sit 100% well with me. While bipolar disorder has certainly disrupted many aspects of my life and I have devoted considerable time and resources to finding effective treatment, it has also brought me tremendous joy and may be linked to traits I deeply value, particularly creativity, linguistic proficiency, and intelligence. Several years ago, Maia Szalavitz wrote a thought-provoking piece for Time in which she explored the question of whether or not depressed people should avoid having children. She argues that:

If you eliminate the genes that carry these mental-health risks, you may also do away with their associated benefits. As we as a society get better at identifying the genes that contribute to depressive, schizophrenic or autistic traits, we need to consider not just disabilities but potential. By selection against our ‘worst’ genes, we may run the risk of losing our greatest gifts.

While there are very real and legitimate fears about passing on bipolar disorder, understanding the illness in a more nuanced and complex way that acknowledges the full scope of its potential can make it a less threatening proposition. All parenthood is a leap into the unknown. Of all the things that can go awry, bipolar disorder is the one I know best and already have the resources to address.

But there was another, more immediate concern to be addressed. The reason I am emotionally stable enough to even consider parenthood is only due to the miracle of modern psychotropic medication. My medication regimen was not developed quickly or easily and the thought of losing the stability brought about by this carefully concocted mix of pharmaceuticals greatly concerned me. A 2007 study published in the American Journal of Psychiatry found that women who stopped using mood stabilizers during pregnancy “spent over 40% of their pregnancy in an ‘illness episode.’” Having learned about the negative effects of depressive episodes—my primary symptom—on fetal development, my doctor and I determined that finding medication compatible with pregnancy was the best option.

Because the illness can present in such a wide variety of ways and each person responds differently to pharmaceutical intervention, there is a range of medications you may already be taking or may consider taking during pregnancy. These are generally considered the safest mood stabilizers for use amongst pregnant women who decide they want to remain on medication:

Lamictal (lamotrigine): Lamictal is an anticonvulsant drug used as a mood stabilizer and antidepressant and classified as a category C drug. According to data gathered from GlaxoSmithKline’s International Lamotrigine Pregnancy Registry, babies exposed to Lamictal monotherapy in utero showed malformation rates “similar to those observed in the general population.” While one study from the North American Anti-Epileptic Drug Registry showed a market increase in oral cleft (8.9 per 1000 births vs. 0.37 per 1000 births), other registries have not replicated these findings.

Latuda (lurasidone): Latuda is an atypical antipsychotic used as a mood stabilizer and is one of the few drugs approved for the treatment of Bipolar I depression. It is also remarkable in that it is a Category B drug, meaning that it no harmful effects have been demonstrated in animal studies. However, as a relatively new drug, some feel there is not enough information about potential effects in humans.

Lithium: Lithium is an older mood stabilizer that has long been considered one of the safest options for pregnant women with bipolar disorder and is a Category C drug. Although it carries increased risk for congenital heart defects, the risk is smaller than originally thought. Modern epidemiological studies suggest that in utero exposure to lithium in the first trimester leads to congenital heart defects in one out of every 1,000-2,000 babies. The risk may be reduced if lithium is discontinued during the first trimester and reintroduced after the first 12 weeks of pregnancy. Babies born to mothers taking lithium may display hypotonia, respiratory distress syndrome, lethargy, depressed neurological status, and weak sucking reflexes after birth, but these naturally reverse within hours or weeks in the vast majority of cases.

The risk presented by some medications may be minimized by discontinuing or lowering dosage during particularly critical times of fetal development. Monotherapy can also be a way of reducing chances of negative fetal outcomes. Prenatal supplements of essential nutrients such as folic acid may also offer protection against potential damage from perinatal psychotropic exposure.