Managing lithium in pregnancy
Reprinted from "Having a Baby" issue of Visions Journal, 2012, 7(3), pp. 16-19
Having children was always one of my goals. Because I’m a woman who was diagnosed with bipolar affective disorder when I was a teenager, this goal was eventually questioned—not by those who knew me, but by those who believed some of the myths that still exist. Yes, doubts continue to linger regarding the limitations of people with mental illness.
I was well aware of the stigma but chose to follow my heart and be the mother I knew I could be, regardless of my diagnosis, my ‘scarlet letter.
Me and meds
I respond well to medication and have been a compliant patient from the time I was 13, when I was hospitalized for what was considered a stress breakdown. Depression and anxiety have plagued me more than any other health issue. Early on I was treated with antidepressants, which later complemented lithium treatment. I've had brief periods of mania, although years apart. I've also been diagnosed with post-traumatic stress disorder, which I believe directly affects my symptoms of bipolar affective disorder. It has been eight years since I've been hospitalized for mania; I've dealt with depression out of hospital. Currently I experience a pattern of mild depression in the winter months, but function quite well despite this.
Pregnancy—stigma was the hardest part
Becoming pregnant unexpectedly in my last year of university was a very difficult experience, largely due to stigma. It took enormous strength to get through it.
At the time of my first pregnancy, I was being treated with lithium and Tegretol. My physician at the time recommended abortion. Her stated rationale was that this pregnancy was inconvenient: I was in my graduating year, and my fiancé was temporarily unemployed. She never expressed what I considered to be legitimate concerns, so I felt her reason for recommending abortion was my mental health diagnosis. I didn't agree with her recommendation, and was left feeling overly anxious.
Doing some research of my own was critical for peace of mind—I didn't have an appointment to see my psychiatrist until the second month of my pregnancy. In a few days of research at the university library I found no convincing argument for ending my pregnancy.
After graduating, I moved back to my hometown and saw my family doctor there. I was six months pregnant at this point, so abortion wasn't even a possibility. But she would not have recommended abortion, and I felt much more at ease in her care.
However, I did feel some underlying stigma regarding having more children.
Since I was a child, I had dreamt of having at least two children. I've found that the general practitioners I've seen over the years were much less supportive than my psychiatrist was. The stigma was subtle, and maybe it was just that they were less familiar with the territory, but I sometimes felt that my doubts were supported better than my dreams.
During my third term, someone I knew well suggested that I might give birth to a deformed child. This kind of comment was deeply offensive, even though I knew in my heart that this had no basis. When my daughter was born, my family doctor exclaimed how beautiful she was, and she was in excellent health.
Managing the lithium
I tapered off Tegretol right away, but my psychiatrist and I decided I should continue with the lithium. Early on my psychiatrist evaluated the latest research and I was informed of the risks and benefits of taking lithium and what could be done to resolve them. We agreed that a manic episode that would likely take six to 12 months to recover from emotionally outweighed any benefits to my child if I were to discontinue this medication.
My psychiatrist had explained that I could continue with the pregnancy with minimal risk as long as I complied with more frequent blood testing. She worked closely with me to monitor my lithium levels, to prevent toxicity for me and my baby, but also to ensure that the levels were high enough to be effective. Some of the things that happen in pregnancy physiologically, like holding water, can affect the levels. Blood tests were taken more frequently (from one to four times a month, compared to once every three to four months), and my lithium dose was adjusted appropriately. During this time I felt stabilized and excited about the birth of my child.
My psychiatrist did not recommend breastfeeding. It would have been an option if I had agreed to regular blood testing of my infant to prevent toxicity. But I decided to use formula rather than put my baby through this regimen. I was content to follow her recommendation. My only regret is that I missed out on the convenience and cost benefits of breastfeeding. However, this was a small price to pay for the reassurance that the medication I took would not cause concern for my baby after birth.
Having found a successful route with the first pregnancy, subsequent pregnancies flowed smoothly with the same treatment plan. My second and third births were much less anxiety provoking. When I lost a fourth child mid-pregnancy due to a ruptured appendix, my doctor—a different GP than I’d had for my first child—shed tears along with me. I didn't experience depression or mania during or after any of my pregnancies.
Each of my children was at least a pound heavier than I was at birth and all born very healthy. I experience significant weight gain with lithium and have wondered if this medication affected my babies in a similar way. My children are now ages six, 10 and 13 and all are of normal weight. They don't appear to have been adversely affected by my being medicated while pregnant.
Working to eradicate the stigma
It has been a joy to have children. Overcoming my fears has proven very rewarding! I would never look back with regret on my decision to have children despite the stigma that so clearly exists in our society.
We must question myths and stereotypes! Eradicating this stigma can only benefit others on similar journeys. I am currently involved with mental health programs that target stigma and provide support to individuals affected by mental illness. I share my story to help erase the stigma—I'm living proof that the myths are not warranted in every case. It's when people see me only as my illness that I’ve experienced discrimination. People who know me are confident in my ability to parent well.
I understand how the decision to parent (or not) causes conflicted feelings. A concern commonly expressed is passing on "defective genes." I often sense that others think it's selfish to have children and risk passing on a disorder. When speaking for themselves, they say that not having children is the "responsible" choice, and my views are often met with awkward silence. I've also heard regret from those who chose to not have children. They wish they had overcome the fear and had children, as they've managed their illness quite well.
Research shows about a 15% risk of a parent passing on bipolar disorder.1 Genes are part of the package, but so are environmental factors. There is an interaction between biological and environmental factors. Chronic stress and trauma can result in the emergence of a disorder if the individual has a genetic risk. This needs to be acknowledged and more attention needs to be given to prevention.
As a parent, I'm very mindful of my children's emotional health. I can do my part to maintain an emotionally supportive household and help reduce stress. If my children do develop a mental illness, I will be there to support them in every way. I didn’t have this kind of support, but it can make all the difference to health management.
Despite the challenges inflicted by mental illness, those of us who follow our treatment plans are able to have successful pregnancies and are absolutely capable of raising our children in a healthy environment. My children and I tell each other often how much we love and appreciate one another. It is possible to have children responsibly and dispel the myths that still exist. One day, fear and stigma will be a thing of the past.
About the author
Julianne is a 36-year-old mother of three, who coordinates a peer-based mental health program in the Okanagan. She completed a Bachelor of Arts in Psychology in 1999
Centre for Genetics Education. (2007). Mental illness and inherited predisposition: Schizophrenia and bipolar disorder (Fact sheet). www.genetics.edu.au/Information/Genetics-Fact-Sheet/MentalIllnessandInheritedPredispositionsFS58