Bipolar and the Decision to Have Children

Women & experts discuss factors in the decision to have children when they are living with bipolar disorder.

Photo: Pexels.com

Candace was diagnosed with bipolar disorder when she was 23. With its irrational highs and soul-wrenching lows, the illness threatened to steal everything she cared about: her relationship with her loving husband, her nursing career, and her lifelong dream to have children of her own.

“I was so frustrated with the illness,” says Candace, now 34, who has been hospitalized nearly a half-dozen times since her first episode in 1995. “First, bipolar took away my job and, at times, my dignity. In the end, I decided my illness had cost me so much—I wasn’t willing to let it cost me anything else.”

In August 2003, Candace, formerly a labor and delivery nurse, embarked on the most challenging journey of her life: to become a mother herself. Candace, who lives in Canada, faced many obstacles, including a manic episode during the first trimester of her pregnancy that led her to attack a doctor and left her screaming on a locked psychiatric ward.

“Dealing with mental illness and pregnancy was such a trial,” says Candace, mother to Kaitlyn, who was born in April 2004. “But the first time I saw my daughter, I knew I’d do it all over again in a second.”

For Candace, and indeed for any woman considering motherhood, planning a pregnancy involves many considerations and requires giving up a number of foods, caffeine, smoking, drinking alcohol, and avoiding many kinds of over-the-counter or prescription medications. Of course, it also involves taking care of one’s general well-being and eating healthily.

But for women who have bipolar, the list of considerations is even longer. They need to consider questions such as: Should stabilizing medications be discontinued? Will my baby have this disorder? Will pregnancy cause an episode? Am I at an increased risk for postpartum depression? Should I breast-feed if I am taking medications? Will my illness impact my ability to care for my child?

Near the end of 2006, bp Magazine decided to explore the complicated questions of pregnancy and parenting when bipolar disorder plays a role. The responses from readers to an email query published in the Winter 2007 issue and one posted on bphope.com were staggering. Within weeks, the magazine received hundreds of responses from men and women in the United States, Canada, and across the world. (Click here to see their comments.)

Each story is unique. All are thoughtful, reflective, and intimate. Many of our correspondents respond that they have chosen not to have children, ever. For the women with bipolar who want to become pregnant, there is, unfortunately, no definitive body of scientific data that provides a worry-free roadmap. While some stabilizing medications may not have significant impact on developing fetuses, others do. The decision to stay on medications during pregnancy may be necessary but should be made only with expert advice.

Keerthy Sunder, MD, a psychiatrist practicing in San Francisco, California, says careful planning can help women manage their illness to minimize symptoms and avoid risks to their unborn child. Dr. Sunder has dual training as an OB/GYN and psychiatrist with expertise in perinatal psychiatry. He was on the faculty at the University of Pittsburgh School of Medicine and Magee-Women’s Hospital and Western Psychiatric Clinic in Pittsburgh until June 2006, when he moved to San Francisco. He has published articles on the use of psychotropic medications during pregnancy and the postpartum period in several medical journals, including the American Journal of Psychiatry, Bipolar Disorders, Journal of Clinical Psychiatry, and Progress in Obstetrics and Gynecology.

“The bottom line is about the risk vs. benefit of continuing treatment,” Dr. Sunder says. “They’re competing needs. Do you control the illness or simply consider the baby?”

Indeed, deciding to stop taking medications altogether also has risks, including a relapse of the illness that can prove dangerous for both the mother and her unborn child. Ultimately, the decision of whether or not to use medications during pregnancy boils down to a personal decision that must be made based on a woman’s specific circumstances. Many decide, however, that the joy of parenthood is worth the risk—both to themselves and their children.

Candace’s story— weighing the dangers

Candace had her first manic episode in 1995 while in nursing school. At the time, she and Collin had already been dating for five years. She was hospitalized for nearly five weeks. The couple didn’t let the episode stop them from marrying, which they did in June 1996.

Candace was hospitalized in fall 2002 after stress from a job interview left her extremely manic. The following summer, she and Collin, a chiropractor, decided that despite her mental health, which depended largely on lithium, they wanted to start a family.

Women with bipolar disorder must weigh their decisions concerning their own treatment during pregnancy against the competing needs of their health and that of their unborn child. It can often seem like an impossible choice. By choosing in favor of their own needs, risks to the infant can include congenital malformations, including those of the heart; intrauterine death, premature birth, low birth weight, neonatal syndrome (when a baby is born with seizures or other medical problems), and long-term neurobehavioral problems.

During her second trimester, Martha of St. Louis Park, Minnesota, for example, lost her baby due to severe heart defects, a well-documented risk of taking lithium during pregnancy. “We were devastated,” she says. “We want to try to have another child, but I am frightened that my drugs will hurt my next child. I, too, am afraid of having a major episode while pregnant if I go off my drugs. I’ve been suicidal before and never want to go back there again.”

Like Martha, Candace, too, was aware of the risks. “I did a lot of research,” she says. Before she and Collin decided to get pregnant, she read more than 300 articles on bipolar and lithium in pregnancy. “There was a risk for cardiac anomalies [with lithium], but we decided we were willing to take the risk,” she says.

Most experts agree that it is very important to avoid sudden changes in medication during pregnancy because such changes may increase side effects and risks to the fetus, as well as a risk of relapse of mania, depression, or both before or after the woman gives birth.

Many people “panic and abruptly stop their medications,” Dr. Sunder says. “It’s disastrous to do that. It may well be that the medications must be discontinued. But the overall risk of a new episode of mania is significantly greater after rapid discontinuation rather than gradual discontinuation.”

With input from her doctor, Candace eased off her antipsychotic medication, but stayed on lithium “with the hope that I would stay well and the baby wouldn’t be harmed.” Then something unexpected happened. During her first trimester, she experienced excessive vomiting and couldn’t keep down her lithium. While she was hospitalized for her physical symptoms, she had a full-blown manic episode.

“I was completely delusional,” she says. “I was screaming out at times. A psychiatric resident walked into my room and I attacked him. Once they got the vomiting stabilized, I was transferred to the psychiatric unit.”

She said it was a very difficult time. “I have an amazing husband,” she says, adding that the couple had anticipated what plan of action they would take if she became sick during her pregnancy. “The best thing that happened for our marriage is that he saw me manic and sick before we ever decided to get married. We went through a troubled time. In the end, we decided we could battle [the illness].”

Candace says her psychiatrists had no choice but to put her back on her antipsychotic medication during her second trimester. Before long, her mania dissipated. “I was on high doses of it,” she says. “And I was fearful because I had no idea what this might be doing to the baby.” The next few weeks moved by slowly, a mix of fear and agony. Then, at the end of her pregnancy, “the vomiting got really bad again and I was hospitalized,” Candace says. “I had to take intravenous fluids to keep my medications down. While I was there, my water broke.”

The first look at her baby—pink, squalling, and healthy—brought Candace to tears. “Everything was fine with her and it was a huge relief,” Candace says. “We’d been through such a trial with the mental illness, it was just an amazing moment.”

Candace recently completed her second difficult pregnancy. She delivered a son, Rylan, in December 2006. Armed with the lessons of her first, Candace’s second pregnancy was much easier. She remained on a low-dose antipsychotic throughout. “I love having two kids,” says Candace. “My life is so much fuller than I ever dreamed it would be. I would tell anyone with this illness considering [pregnancy] that it’s not easy, but it was worth it—so worth it.”

Karen’s story— more than just the baby blues

Women who have bipolar disorder are particularly vulnerable during the postpartum period. According to Dr. Sunder, at least 50 percent of women who have bipolar disorder relapse during the first few months after childbirth. While most women exhibit depressive symptoms, there is also a significant risk of hypomania, mania, mixed states, and postpartum psychosis.

Karen, 50, who lives in Georgia, encountered debilitating postpartum depression after delivery of her first child. She and her husband, both with demanding careers, had put off having children until she was 39.

The postpartum depression “was insidious,” says Karen, now the mother of Rachel, 11, and Chloe, 8. “It builds and builds and you don’t realize how bad it is until you’re just severely depressed. I would be sobbing and crying and I felt very isolated.”

Karen, a former technical illustrator who has bipolar II, says she stayed off all medications during her pregnancies. She mostly remained in good mental health until the last trimester when “that nesting instinct kicks in.” That instinct, she says, kicked her into mania. She found herself walking for hours on end, spending big money at baby stores. “I was on a mission,” she says. “I would work all day then shop all evening, walking, walking, walking through all the stores. Babies R Us … you name it. I was on a nesting mission.”

But after delivery, “I started slipping and sliding into a depression,” she says. “My husband was at work and we have no relatives here. It just went from bad to worse.” Dr. Sunder says he often recommends that his patients remain on a mood stabilizer during the postpartum period. However, taking this medication creates yet another dilemma: whether or not to breast-feed.

After several months breast-feeding, Karen says her depression became so severe that her doctor urged her to stop just so she could go back on her medications. “I probably should have stopped a month before I did,” she says, “but I just hung in there. Once I got back on the antidepressants and the mood stabilizers, it straightened out fairly quickly.” She said she was better prepared for the depression when she had her second child, but the postpartum period was still “debilitating.”

All medications are secreted into breast milk, although their concentrations appear to vary, Dr. Sunder explains. Lithium, for example, in breast milk is found at relatively high concentrations and there have been reports of toxicity in nursing infants exposed to lithium in the breast milk. Other mood stabilizers may cause liver damage in the nursing infant, which is a serious and potentially life-threatening complication.

“The decision whether or not to breastfeed should be made in consultation with an expert,” Dr. Sunder says. “Although there are risks of breast-feeding while taking certain medications, it is also very well known that breast milk has tremendous benefits. The decision to continue or discontinue should be based on solid research evidence for each individual medication, rather than on intuition.”

Some women pump and freeze their breast milk while they’re off medications. Some who stay on medications have their breast milk tested to gauge the level of medications secreted into the milk to which their babies will be exposed. Some, like Karen, feel strongly that they don’t want their infants exposed to the medications and stay off them as long as they can.

Breast-feeding raises concerns for another reason. For an infant, breastfeeding means multiple feedings during the night. Sleep deprivation is destabilizing for those who have bipolar disorder and may bring on a relapse. For women who have bipolar disorder, Dr. Sunder recommends that someone else take over the nighttime feedings to protect the mother’s sleep and to increase her chances of staying well.

Katie’s story—will my children inherit this illness?

One of the most paralyzing fears these women with bipolar face when finding themselves pregnant is whether or not they will pass the condition on to their children through their own genetic disposition, or that of the child’s father. More than two thirds of people with the disorder say they have at least one close relative with the disorder or with unipolar major depression, suggesting a genetic component, according to a study published in the May 2003 issue of Archives of General Psychiatry.

Katie, 28, of Illinois, gave birth to twins, a boy, Rylan, and a girl, Kylie, in November 2006. Katie has a family history of bipolar disorder. Her sister, who suffered from the disorder, committed suicide. Her boyfriend, the father of her twins, also has been diagnosed with bipolar.

“I worry about my twins,” says Katie, who became pregnant within months of her first psychiatric hospitalization. “They have two parents with bipolar. The odds are pretty good for the babies to struggle with the illness as well.”

Katie says she’s had “up and down” episodes since she was a teenager. Her younger sister was never diagnosed, but “fit all the classic signs.” She committed suicide in March 2005.

“This set off for me a serious depression, followed by a serious manic episode in which I made horrible decisions that didn’t reflect who I am,” says Katie, who also has three other children, ages 7, 5, and 3, from a previous marriage. “I filed for divorce. I left my husband and kids and started a whole new life like the old one didn’t exist anymore.”

Katie says her lowest moment came when she planned to commit suicide on the one-year anniversary of her sister’s death. The only thing that stopped her, she says, was getting pulled over by the police and being charged with DUI. She spent a week in a psychiatric hospital and several weeks at an intensive outpatient treatment program for people with mental disorders and co-occurring substance abuse problems.

A few months later, she discovered she was pregnant. Her boyfriend, Jason, 28, had been diagnosed with bipolar disorder 10 years earlier. They met through mutual friends and bonded over the “common ground” of dealing with a major mental illness. “We just really understand each other,” Katie says.

As the months have passed since her diagnosis, Katie has made great strides to improve her life. She splits parenting time with her ex-husband, who cares for the three children he shares with her. Katie, meanwhile, lives with her boyfriend, who is supporting her and the twins. She recently passed her certification program after nursing study and plans to work as a nurse when the twins are a little older.

“I think about my whole family—me, my sister, Jason,” she says. “And I wonder what kind of legacy I’ve put down for my children. In the end,” she says, “there is nothing I can do about it but to be informed, involved, and really watch them closely. We at least have the knowledge to help them if [a problem] occurs.”

Hope, a 52-year-old divorced mother of two from New Jersey, agrees. Hope was diagnosed with bipolar disorder several years after she gave birth to her children, now ages 24 and 21.

Had she known beforehand, she says she still would have chosen to become a mom. “Dealing with the management of my disease is a daily battle,” she says. “But I can tell you without a doubt that if I had it to do all over again, I would not want my life without my children. They are my greatest blessing.”

Hope says she doesn’t understand the controversy over whether or not women with bipolar disorder should become mothers. “No couple should be denied the incredible gift of becoming parents just because of this disease,” she says. “There are too many wonderful resources available in the way of psychiatry, better medications being developed every day, and nutritional and fitness regimes. With all these proven methods of managing life with this illness, I believe successful pregnancies and the joy of becoming a family are achievable.”