Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7085 (Published 8 November 2012)
Cite this as: BMJ 2012;345:e7085

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This article is very interesting as it touches on an issue that has not been researched well enough and the information on the topic is quite scarce. Treatment of bipolar disorder during pregnancy can be problematic for a variety of reasons depending on the treatment regimes that we psychiatrists use. However, patient compliance that is universally a problem in bipolar patients is more serious among pregnant patients. I found some rather interesting information and articles on this topic on bipolar expert info website and NIMH (http://www.nimh.nih.gov/health/publications) that confirm the author´s viewpoint.

Competing interests: None declared

Eftekhar Iran, Psychiatrist

Tehran University, Tehran Uni, Iran

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During the 23 years of my psychiatric practice I have made the observation on numerous occasions that as soon as a woman has her first antenatal visit, the first precaution is to slash the “psychotropic medicines”, including the mood stabilizers. Although this happens with a good intention of protecting the fetus, yet most of the time it is without the realization that the risk of untreated bipolar illness could prove even more dangerous for the fetus and mother than the treatment itself.

Is the combined risks of having bipolar illness and being exposed to a mood stabilizer bigger than the relapse or risky behavior that a patient may develop if we withdraw the mood stabilizer?

This study adds to the fact that there are othersrisks that have to be kept in mind when we decide about the individualized care, assessment of risks and communication of those risks to our patients.

Competing interests: None declared

MN Siddiqi, consultant psychiatrist

Sindh Institute of Urology and Transplant, Babae urdu Road, Karachi Pakistan

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14 November 2012

Dr Grant raises an important question about nutritional deficiencies as an underlying cause of poor pregnancy outcome in her rapid response to our article. However, this research question is not possible to address with the available data in Swedish registers and was not within the scope of our study.

Competing interests: None declared

Robert Bodén, Consultant psychiatrist

Uppsala University and Karolinska Institutet, SE- 751 85 Uppsala

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Boden and colleagues finding of increased risk of adverse pregnancy outcomes in women with bipolar depression, treated or not, suggests that fundamental causes of both are not being addressed.1

In my experience over the past 40 years the commonest reasons for “unexplained “ infertility and recurrent abortions and poor pregnancy outcomes are deficiencies in zinc, magnesium, copper, selenium, B vitamins and polyunsaturated fatty acids.2 These are also common reasons for mental illnesses and low zinc and high copper levels can contribute to postpartum depression.3 Antidepressant medications can change amine metabolism, e.g. mono amine oxidase inhibitors, but do not replete essential nutrient levels or correct copper/zinc imbalance. Nutritional deficiencies in both bipolar depression and adverse pregnancy outcomes need to be treated.

There is no good reason for failing to investigate and treat the whole patient and restore her cell chemistry to normal.

1 Boden R, Lungren M, Brabdt L, etal. Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study.BMJ2012;345:e7085

2 Grant ECG. Pregnancy or preconception care for both parents. BMJ 9 June 2012

3 Grant ECG. Postnatal depression and low zinc and high copper levels. BMJ 21 August 2008

Competing interests: None declared

Ellen CG Grant, Physician and medical gynaecologistt

Retired, KT2 7JU

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