Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation

OBJECTIVE: This study estimated the risk of recurrence of mood episodes among women with a history of bipolar disorder who continued or discontinued treatment with mood stabilizers during pregnancy. METHOD: In a prospective observational clinical cohort study, the authors determined recurrence risk and survival-analysis-based time to recurrence of a new episode in 89 pregnant women with DSM-IV bipolar disorder. Eligible subjects were euthymic at conception and continued mood stabilizer treatment or discontinued treatment proximate to conception. RESULTS: The overall risk of at least one recurrence in pregnancy was 71%. Among women who discontinued versus continued mood stabilizer treatment, recurrence risk was twofold greater, median time to first recurrence was more than fourfold shorter, and the proportion of weeks ill during pregnancy was five times greater. Median recurrence latency was 11 times shorter after abrupt/rapid versus gradual discontinuation of mood stabilizer. Most recurrences were depressive or mixed (74%), and 47% occurred during the first trimester. Predictors of recurrence included bipolar II disorder diagnosis, earlier onset, more recurrences/year, recent illness, use of antidepressants, and use of anticonvulsants versus lithium. CONCLUSIONS: Discontinuation of mood stabilizer, particularly abruptly, during pregnancy carries a high risk for new morbidity in women with bipolar disorder, especially for early depressive and dysphoric states. However, this risk is reduced markedly by continued mood stabilizer treatment. Treatment planning for pregnant women with bipolar disorder should consider not only the relative risks of fetal exposure to mood stabilizers but also the high risk of recurrence and morbidity associated with stopping maintenance mood stabilizer treatment.     

Lithium in breast milk and nursing infants: clinical implications

OBJECTIVE: Current practice guidelines discourage use of lithium during breast-feeding, despite limited data. This study aimed to quantify lithium exposure in nursing infants. METHOD: In 10 mother-infant pairs, the authors obtained assays of lithium in maternal serum, breast milk, and infant serum and indices of infant renal and thyroid function. RESULTS: Maternal serum, breast milk, and infant serum daily trough concentrations of lithium averaged 0.76, 0.35, and 0.16 meq/liter, respectively, each lithium level lower than the preceding level by approximately one-half. No serious adverse events were observed, and elevations of thyroid-stimulating hormone, blood urea nitrogen, and creatinine were few, minor, and transient. CONCLUSIONS: Serum lithium levels in nursing infants were low and well tolerated. No significant adverse clinical or behavioral effects in the infants were noted. These findings encourage reassessment of recommendations against lithium during breast-feeding and underscore the importance of close clinical monitoring of nursing infants.     

Lamotrigine in bipolar disorder: efficacy during pregnancy

Objective:  Clinical management of bipolar disorder (BPD) patients during pregnancy is a major challenge. The high risk of bipolar depression during pregnancy encourages consideration of lamotrigine (LTG). We therefore compared recurrence risks among pregnant women with BPD treated with LTG to those discontinuing mood stabilizer therapies.
Methods:  We compared risks and weeks to new DSM-IV illness-episodes among 26 initially clinically stable pregnant women diagnosed with DSM-IV BPD who continued LTG treatment to those discontinuing all mood stabilizer treatment during pregnancy.
Results:  The risk of new illness-episodes with LTG was 30% versus 100% after discontinuing mood stabilizers, and survival-computed time-to-25%-recurrence was 28.0 versus 2.0 weeks (χ² = 17.3, p < 0.0001; hazard ratio = 12.1; 95% confidence interval = 1.6–91.7).
Conclusions:  Discontinuing mood stabilizer treatment presents high risks of illness-recurrence among pregnant women diagnosed with BPD. LTG may afford protective effects in pregnancy, and its reported fetal safety compares favorably to other agents used to manage BPD.     

Academic Help-Seeking Behavior Among Student Pharmacists

Objectives. To identify factors associated with academic help-seeking behavior among student pharmacists at a public university.Methods. Semi-structured focus group interviews were conducted to explore in depth perceptions of facilitators of and barriers to the help-seeking behavior and academic achievement of student pharmacists who had received a D or F grade in any year. A 4-part survey instrument was developed and administered to all student pharmacists and included sections for (1) attitudes and academic help-seeking behavior, (2) health status, (3) demographics, and (4) open comments. A structural equation modeling approach was used to assess relationships among domains of interest.Results. Three student focus groups noted that helpfulness of faculty members and school administrators were 2 prominent facilitators of help-seeking behavior and academic achievement. Diminished quality of life caused by stress and depression was the primary barrier to help-seeking and achievement. Three hundred four (68.6%) student pharmacists completed the survey instrument. Academic help-seeking behavior was influenced mostly by perceived academic competence and perceived faculty helpfulness. In contrast, ambivalence and perception of help-seeking as threatening were 2 factors that were negatively associated with academic help-seeking behavior.Conclusions. Academic help-seeking behavior was positively related to greater perceived academic competence and positive relationships among student pharmacists and faculty members.