Must clinicians presume that all their female patients of reproductive age are potentially going to become pregnant? And if so, what treatment option should be offered?
Nearly all psychotropics are teratogenic to some degree, or must be presumed so in the absence of good evidence to the contrary. The latter caveat applies to all atypical antipsychotics, for example. Valproate is thought to be about 10 times riskier than lithium and is commonly discouraged for reproductive-age women; also, polycystic ovarian syndrome may be induced by valproate in as many as 10% of this group, perhaps an even better reason to avoid it.1
In that context, a study by McCrea and colleagues2 at University College London has found that lithium is frequently discontinued when a woman becomes pregnant. Of 52 women who were taking lithium before conception, 66% were no longer taking it beyond the sixth week of pregnancy. Those who continued to it at that point tended to continue it through the rest of the pregnancy.
The authors’ introduction provides a brief summary of the literature on the risks of lithium in pregnancy. They note that the National Institute for Health and Care Excellence (NICE) 2014 antenatal guidelines advise that lithium should not be offered to women who are planning pregnancy.3
Thus, this UK study illustrates a problem: according to the guidelines, women who are planning pregnancy should not be taking lithium; this is to avoid becoming pregnant while taking the medication and then discontinuing it. But in the US, only about one half of pregnancies are planned.4 Must clinicians presume that all their female patients of reproductive age are potentially going to become pregnant? And if so, what mood stabilizers should be offered-only an antipsychotic, and a first-generation one at that? Is it perphenazine for all, then?
Overstating the case thus makes the point: at some point, the woman herself must be allowed into this discussion. If she is not planning pregnancy, many options are open (perhaps best not valproate, as above). But these data from the UK remind us that planning is not always successful.
At minimum, we can conclude that specific inquiry about a woman’s reproductive plans is warranted when teratogenic medications-which include nearly all our medications-are used. In Oregon, a program is promoting “One Key Question”: “Would you like to become pregnant in the next year?”5 And Oregon’s Medicaid program now provides extra funding to communities that improve effective contraception among women at risk for unintended pregnancy. Psychiatry can help by making One Key Question routine in our practices.
Dr Phelps is Director of the Mood Disorders Program at Samaritan Mental Health in Corvallis, Ore. He is the Bipolar Disorder Section Editor for Psychiatric Times. [full bio]
1. Nonacs R. Polycystic Ovarian Syndrome in Women Taking Valproate. MGH Center for Women’s Health. http://womensmentalhealth.org/posts/polycystic-ovarian-syndrome-in-women-taking-valproate. Accessed May 26, 2015.
2. McCrea RL, Nazareth I, Evans SJ, et al. Lithium prescribing during pregnancy: a UK primary care database study. PLoS One. 2015;10:e0121024. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4368741. Accessed May 27, 2015.
3. National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. http://www.nice.org.uk/guidance/cg192/chapter/1-recommendations#treatment-decisions-advice-and-monitoring-for-women-who-are-planning-a-pregnancy-pregnant-or-in-2. Accessed May 26, 2015.
4. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84:478-485. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3338192. Accessed June 1, 2015.
5. One Key Question. Would you like to become pregnant in the next year? http://www.onekeyquestion.org. Accessed May 26, 2015.