APA Practice Guidelines

c) Prenatal monitoring.

cont. from

Women who choose to remain on regimens of lithium, valproate, or carbamazepine during pregnancy should have maternal serum a-fetoprotein screening for neural tube defects before the 20th week of gestation, with amniocentesis as well as targeted sonography performed for any elevated a-fetoprotein values. Women should also be encouraged to undergo high-resolution ultrasound examination at 16-18 weeks gestation to detect cardiac abnormalities in the fetus. Since hepatic metabolism, renal excretion, and fluid volume are altered during pregnancy and the prenatal period, serum levels of medications should be monitored and doses adjusted if indicated. At delivery, the rapid fluid shifts in the mother will markedly increase lithium levels unless care is taken to either lower the lithium dose, ensure hydration, or both. Discontinuing lithium on the day of delivery is probably not necessary and may be unwise given the high risk for postpartum mood episodes and the greater risk of recurrence if lithium is discontinued in women with bipolar disorder.

d) Postpartum issues.

The postpartum period is consistently associated with a markedly greater risk for relapse into mania, depression, or psychosis. For women with bipolar disorder, the rate of postpartum relapse is as high as 50%. Women who have had severe postpartum affective episodes in the past are at highest risk to have another episode of illness after subsequent pregnancies. Despite a paucity of studies, it is generally considered that prophylactic medications such as lithium or valproate may prevent postpartum mood episodes in women with bipolar disorder. Also, since changes in sleep are common in the postpartum period, women should be educated about the need to maintain normal sleep patterns to avoid precipitating episodes of mania.

e) Infant medication exposure through breast-feeding.

All medications used in the treatment of bipolar disorder are secreted in breast milk in varying degrees, thereby exposing the neonate to maternally ingested medication. However, as with the risks of medications during pregnancy, risks of breast-feeding with psychotropic medications must be weighed against the benefits of breast-feeding. Because lithium is secreted in breast milk at 40% of maternal serum concentration, most experts have recommended against its use in mothers who choose to breast-feed. Fewer data on breast-feeding are available for carbamazepine and valproate. Although it is generally considered safe, potential risks should always be considered. Little is known about lamotrigine exposure in breast-fed neonates; however, levels in the infant may reach 25% of maternal serum levels. Consequently, the potential for pharmacological effects, including a risk for life-threatening rash, should be taken into consideration. With other psychotropic medications (including antipsychotics, antidepressants, and benzodiazepines), there are few reports of specific adverse effects in breast-feeding infants. Nonetheless, these drugs are found in measurable quantities in breast milk and could conceivably affect central nervous system functioning in the infant.

3. Cross-cultural issues

Culture can influence the experience and communication of symptoms of depression and mania. Underdiagnosis or misdiagnosis, as well as delayed detection of early signs of recurrence, can be reduced by being alert to specific ethnic and cultural differences in reporting complaints of a major mood episode. Specifically, minority patients (particularly African and Hispanic Americans) with bipolar disorder are at greater risk for being misdiagnosed with schizophrenia. This greater risk appears to result from clinicians failing to elicit affective symptoms in minority patients with affective psychoses.

Ethnicity and race must also be taken into consideration when prescribing medications, since ethnic and racial groups may differ in their metabolism of some medications. For example, relative to Caucasian patients, Chinese patients have a lower average activity of the cytochrome P-450 isoenzyme 2D6. As a result, they typically require lower doses of antidepressants and antipsychotics that are metabolized by this enzyme. Similar deficits in average activity of the cytochrome P-450 isoenzyme 2C19 have been found in Chinese, Japanese, and Korean patients compared with Caucasians.

continue: Children, Adolescents and Seniors with Bipolar

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Written 4/02. Reviewed: 03/2006