Dr. Viguera and Colleagues Reply

To the Editor: We thank Dr. Rifkin for raising important issues regarding the optimal care of pregnant women with bipolar disorder. We found that two-thirds of illness recurrences during pregnancy after discontinuation of maintenance lithium treatment were depressive and that depression is the major source of morbidity and mortality in bipolar disorder (1). Optimal management of bipolar depression, even in nonpregnant patients, has only recently been studied in a systematic fashion. However, the suggestion by Dr. Rifkin that prophylactic antidepressant treatment theoretically might be beneficial in the absence of coadministration of a mood stabilizer raises obvious concern with respect to risk for induction of dangerous maternal affective instability with attendant morbidity and uncertain effects on the fetus. In the study group on which we reported, we noted that reintroduction of lithium monotherapy was most often sufficient to restore euthymia. For patients who relapse into mania during pregnancy after discontinuation of a mood stabilizer, reintroduction of the mood stabilizer with adjunctive antipsychotics can also be used with relative safety. ECT may also be used to treat mania as well as depression during pregnancy when expeditious treatment is imperative (2).

Dr. Rifkin’s reluctance to prescribe lithium at all in the first trimester of pregnancy is shared by many clinicians given concerns about the real but relatively small (0.05%) teratogenic risk associated with prenatal exposure to lithium during fetal heart development. We do not advocate arbitrary use of lithium for pregnant women with bipolar disorder. Whether and when to prescribe lithium during pregnancy requires a careful weighing of the risks of fetal drug exposure versus the risks of an untreated disorder. The morbidity associated with Ebstein’s anomaly is, as Dr. Rifkin points out, high, but the absolute risk of the anomaly after first-trimester exposure is small (3). The revised teratogenic risk estimates with lithium (3), as well as the high risk of recurrence after discontinuation of lithium (particularly when done abruptly) (4), encourage balanced consideration of rational options and challenge the traditional view that pregnancy requires immediate cessation of early fetal exposure to all drugs.

We believe that the role of the psychiatrist who chooses to manage the treatment of women with bipolar disorder during pregnancy is to inform patients of the relative risks associated with and without treatment with medications; only then can women make informed decisions. Dictating care precludes adequate patient participation in extremely important and personal treatment decisions. Decisions about what constitutes “reasonable risk during pregnancy” requires shared responsibility but ultimately rests with the informed pregnant patient. Well-informed choices coupled with close clinical follow-up, which Dr. Rifkin advocates, is an ideal formula for collaborative care, particularly when managing psychiatric disorders during pregnancy.