Great Expectations: Considering Motherhood When You Have Bipolar Disorder
I never thought I wanted to have children. That insuppressible craving so many women experience, the deep want that has lived within them since childhood or emerged in adulthood, has never existed in me. But after my 35th birthday I became acutely aware of the fact that my decision to not have children would be final within a handful of years. If I was ever going to re-evaluate, it would have to be soon. And so I did. I imagined all the good and all the horrors, I spoke with women who had had children unexpectedly, women who longed for them, women who weren’t sure but went ahead anyway, and women who lived incredible lives without a thought to having them. I spoke with my partner about all the paths our lives could take if we had them and if we didn’t and I remained undecided. Then someone close to me became pregnant and I felt a new feeling about it. I was jealous. Suddenly, having children was not a theoretical concept, it was a desire that arose from an unfamiliar and disquieting place. It was not a burning, wild desire, but it was there and so was a harder question: should I have a child?
I have a nice life, a wonderful partner who would make an incredible parent, a pretty house full of furry creatures, a supportive family, and a great school around the corner. All perfect for having a child. I also have type II bipolar disorder and that—more than time, more than money, more than never sleeping in again—is the biggest barrier to parenthood for me. In the not too distant past, women with bipolar disorder were advised against having children. Today, better knowledge, treatment options, and support have dismantled many of the barriers to parenthood for women living with this illness and opened up options for those who want kids. But along with options come questions. Would my DNA act as a conduit for messy psychiatric instability, perpetuating my illness even beyond myself? Was I being fair? Would I be able to remain stable through pregnancy? What were the risks of my medications and what were the alternatives?
Bipolar Disorder, Hereditary Risk, and Ethics
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.[1. http://www.health.com/health/condition-article/0,,20275258,00.html] 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:[2. http://healthland.time.com/2012/06/05/should-depressed-people-avoid-having-children/]
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.
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Bipolar Disorder, Medication, and Pregnancy
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.’”[3. http://www.health.com/health/condition-article/0,,20274378_2,00.html] 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.”[4. http://womensmentalhealth.org/posts/evaluating-the-safety-of-first-trimester-exposure-to-lamotrigine-lamictal/] 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. [5. http://www.health.harvard.edu/newsletter_article/Prescribing_during_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.[6. http://mhc.cpnp.org/doi/full/10.9740/mhc.n110674]
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.
A Leap of Faith
What I learned from my personal research into having a child as a person living with bipolar disorder is that there are no easy answers. As with any pregnancy, there are risks and, as with any pregnancy, there may be great rewards. No one can tell you that you or your child will be safe, but bipolar disorder isn’t unique in that respect. What is unique are the specific ways we have for fortifying ourselves against negative outcomes through education, specialized clinical care, and comprehensive treatment designed to optimize our chances of successful pregnancies, parenthood, and overall well-being. If you are considering becoming a parent, connect with resources as early as possible to give you any guidance and support you need.
Bridges to Recovery offers the finest quality residential care for people living with bipolar disorder. Our psychiatrists are committed to developing medication protocols that are effective, well-tolerated, and compatible with your life goals. Intensive individual, group, and holistic therapies allow you to draw on your natural healing abilities to gain the insight and skills you need to enhance stability and harmony. Contact us today for more information about how we can help you or your loved one.