Women who wish to have a baby should have at least 2 yr of maintenance therapy with no episodes before a lithium holiday is prescribed. Lithium is discontinued in the 1st trimester to avoid the risk of Ebstein’s anomaly, a heart defect. Carbamazepine and divalproex should also be discontinued in the 1st trimester because they may cause neural tube defects. For a severe relapse during the 1st trimester, electroconvulsive therapy is safer. Mood stabilizers, if absolutely necessary, can be used during the 2nd and 3rd trimesters but should be stopped 1 to 2 wk before delivery and resumed a few days postpartum. Mothers taking mood stabilizers should not nurse because these drugs pass into the milk.
Psychoeducation and psychotherapy:
Enlisting the support of a family member is crucial to prevent major episodes. Patients and their significant others are often seen in group therapy, in which they learn about bipolar disorder, its social sequelae, and the central role of mood stabilizing drugs in its treatment. Patients, particularly those with bipolar II disorder, may not comply with mood stabilizer regimens because they report these drugs overcontrol them and make them less alert and creative. The physician can explain that a decrease in creativity is relatively uncommon, because mood stabilizers generally offer the opportunity for a more even performance in interpersonal, scholastic, professional, and artistic pursuits. Skillful dosing is necessary; the physician must be sensitive to the patient’s career while ensuring that relapses do not occur.
Individual psychotherapy may help patients better cope with problems of daily living and adjust to their new self-identities. Patients are unconsciously aware that their periodic tendency to lose control is costly, but they resent being controlled by the physician. For this reason, when appropriate, the physician should consider fulfilling some of the patient’s requests to modestly reduce the dose of mood stabilizers; the possibly greater risk of relapse is balanced by better compliance and a trusting relationship. Small doses of an antipsychotic (eg, thioridazine 50 to 100 mg) can be provided to be taken for a few nights if impending signs of relapse, such as a decreased need for sleep, occur. Interventions with the patient’s spouse or family can help moderate interpersonal crises. Patients should be counseled to avoid stimulant drugs and alcohol, to minimize sleep deprivation, and to recognize early signs of relapse. If a patient tends to be financially extravagant, finances should be turned over to a trusted family member. Those with a tendency to sexual excesses should be given information about the conjugal consequences (divorce) and the infectious risks of promiscuity (particularly AIDS).