Pregnant While Bipolar

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Photo by Nuno Ibra Remane. Used with permission under a Creative Commons License.

Going through pregnancy while bipolar is tricky. Bipolar disorder symptoms can worsen during pregnancy. According to WebMD, “Pregnant women or new mothers with bipolar disorder have seven times the risk of hospital admissions compared to pregnant women who do not have bipolar disorder.” As I’ve stated before, depression can lead to low birth weight in newborns, and stopping medications abruptly can harm both the bipolar sufferer and their unborn child. Manic episodes can contribute to poor decision making, such as smoking cigarettes or drinking while pregnant. And there are several medications which treat bipolar which can harm infants both in utero and while breastfeeding, contributing to neural tube defects as well as others.

People with bipolar disorder who wish to become pregnant need to closely monitor their health, even more so than people without mental illnesses. Especially because there is a clear link between bipolar disorder and post-partum psychosis.

Thankfully, there are steps you can take. There exists medication that can be safely taken during pregnancy which treat depressive and manic episodes. Lithium needs to be closely monitored, as it can cause a rare heart defect in the first three months of pregnancy for about 1 in 2000 births. Talk therapy poses no risk to the baby. Added structure during the day can contribute to good sleep habits, which can be disrupted during pregnancy. Sleep is a serious factor in whether a bipolar sufferer will succumb to a mood episode, so it’s important that a pregnant woman gets enough. Exercise, which is crucial in maintaining good mental health, will aid a pregnant woman in controlling her moods.

If you are planning a pregnancy, talk to your obstetrician and psychiatrist to make a comprehensive plan. Your treatment team will help you. Good luck!

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Executive Dysfunction and Bipolar Disorder

students

Credit to flickr.com user Jeff Peterson. Used with permission under a Creative Commons license.

Do you constantly abandon projects and leave messes around the house, such as unfinished crafts or dirty dishes? If you have bipolar disorder, you may be suffering from executive dysfunction. Executive dysfunction is used interchangeably with a lack of cognitive control, and is the inability to set and meet goals and to self-monitor.

When people’s brains work without dysfunction, they can analyze tasks and create timelines in which to complete them. People with executive dysfunction stemming from bipolar disorder, however, are often overwhelmed because they can’t break tasks into steps. Judging from the chaos around the house and the missed doctor’s appointments, people might sometimes blame laziness. But executive dysfunction isn’t laziness; it’s a symptom of a broken brain.

In individuals with bipolar disorder, executive dysfunction appears most prominently during in the manic phase. Racing thoughts, a hallmark of bipolar, tend to interfere with recall and thought organization. The manic person might also have trouble prioritizing important details. Everything is perceived to be important. And for sufferers of bipolar disorder with a history of psychosis, managing executive functioning is even more difficult because their brains are wired differently.

Symptoms of executive dysfunction manifest in children similarly to adults. For example, children often don’t know when they’ve overstayed a welcome at a friend’s house, while adults sometimes can’t function at the workplace due to an inability to read social cues. Children usually can’t follow instructions, and may change to a new task before completing the first one. Adults are frequently late and misplace possessions. If you have trouble remembering the names of people you’ve known for years, you might be suffering from executive dysfunction.

The good news is that executive dysfunction can be managed with ideas like these:

• Consciously break projects up into steps.
• Use time management tools such as colorful calendars and stopwatches.
• Schedule repeating reminders on your computer, using sites like Remember the Milk.
• Set goals in advance to coincide with ingrained habits, such as flossing your teeth right after brushing.

With tips like these, executive dysfunction can be coped with. Many people with bipolar disorder learn to successfully deal with their executive dysfunction.

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Safe Medications To Take While Breastfeeding

Breastfeeding is one of the best ways to provide a healthy start for your baby. The benefits are well researched. Unfortunately, the postpartum period is a dangerous time for bipolar mothers. Bipolar disorder can even be triggered by childbirth. There is a 50% chance of relapse during the postpartum period, primarily into depression, but there is also a significant risk for hypomania or mania. Fortunately, there are safe medications to take while breastfeeding.

Medication should only be taken if the benefits outweigh the risks of exposure to the infant. All psychotropic medications studied enter breastmilk. It’s just a matter of how much will pass to your baby. Medications that have a 10% or less exposure rate–how much of the maternal dose is passed to the infant–are deemed “safe”, or at the very least safer.

breastfeeding

Credit to flickr.com user myllissa. Used with permission under a Creative Commons license.

Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), are largely considered safe for breastfeeding mothers and their babies. A great deal of the research on medication use during breastfeeding is concentrated on SSRIs. Of the tricyclic antidepressants (TCAs), paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft) have a limited exposure to newborns. There have only been a few cases where infants showed adverse effects to antidepressants.

Anti-anxiety agents exhibit similar results to antidepressants, with a great deal of the data pointing to few adverse reactions in infants, and low exposure rates. Many mood stabilizers, on the other hand, are secreted in high amounts in breastmilk and show a risk for toxicity in infants. There is very limited data on antipsychotics, especially atypical antipsychotics, but olanzapine, Risperidone (RisperiDAL), and quetiapine (Seroquel) show promising results.

Here are some of the most common choices for breastfeeding mothers:

Lithium

Lithium is concentrated in breastmilk–secreted between zero and 30% of maternal dosage–and there is a risk of lithium toxicity in in infants, so breastfeeding is discouraged unless the mother doesn’t respond to other medications on the market. A 2000 case review reported lithium toxicity in two cases out of eleven. Symptoms of toxicity include hypothermia, poor muscle tone, and lethargy. The pediatrician will take blood draws to monitor the baby’s thyroid, creatinine, and blood urea nitrogen (BUN) every six to eight weeks.

Olanzapine

Breastfeeding while taking Olanzapine has been studied much more than other medications due in part to a database collected by the manufacturer. There was a study which reported that the exposure rate is roughly 1.8%. Adverse reactions showed up in 15.6% of the babies, including tremor, insomnia, and irritability.

Quetiapine (Seroquel)

Quetiapine does not easily pass through breastmilk, with studies reporting 0.09% of the maternal dosage excreted. Unfortunately, a study found that one third of the babies reviewed showed some neurodevelopmental delay, but the mothers were taking other medications at the time, so no one knows for sure if it was the quetiapine that contributed.

Lamotrigine (Lamictal)

Lamictal is considered one of the safer medications for breastfeeding mothers, despite a study measuring up to 9.2% of the maternal dosage in breastmilk. The only adverse effect reported was thrombocytosis. The downside with Lamictal is that it takes four to six weeks to reach a therapeutic dose, so doctors recommend that medication use starts during the pregnancy.

Valproic acid (Depakote)

Depakote is also considered safe for breastfeeding. Only 1.7% of the maternal dosage passes into breastmilk due to its high plasma protein binding. Some adverse effects, such as liver damage, have been reported. However, because pediatricians prescribe Depakote to children, it has been deemed compatible with breastfeeding.

Risperidone (RisperiDAL)

Approximately 2.3% to 4.7% of the maternal dosage of Risperidone is secreted through the breastmilk, and no adverse effects have been reported in infants.

All medications taken while breastfeeding will be closely monitored by the baby’s pediatrician, especially lithium. Medication should only be considered for a breastfeeding mother after all of the risks have been discussed. In most cases, stability in the postpartum mother outweighs the risks of medication to the infant.

Did you take any medications while breastfeeding? Why or why not?

[Editor’s note: I could not have written this post without the invaluable article, “What to Tell Your Bipolar Patient Who Wants To Breastfeed,” by Wende Wood.]

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Stabilizing Medications: Risperidone and Wellbutrin

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Risperidone, Wellbutrin, and a prenatal vitamin. © Cassandra Stout and The Bipolar Parent under a Creative Commons License.

I’ve covered lithium, Depakote, and Lamictal in the past, because that’s what I was taking. But I’ve since switched gears to Risperidone, an antipsychotic, and Wellbutrin, an antidepressant.

RisperiDAL (Risperidone)

Risperidone is an antipsychotic medication used to treat schizophrenia and bipolar disorder, as well as irritability in people with autism. It is an antitypical psychotic which can be taken orally or injected into a muscle, and no one knows exactly how it works. Common side effects include weight gain, headache and dizziness, feeling hot or cold, and stomach pain. There are quite a few side effects, most of which I didn’t have to deal with, thankfully. Serious side effects include tardive dyskinesia, which is a slow-onset movement disorder involving the involuntary jerking around of the head or body as well as grimacing, rapid blinking, or lip smacking. The increased risk of suicide is also a concern. Risperidone costs between 100 US dollars and 200 per month.

Bupropion (Wellbutrin)

Wellbutrin is an antidepressant known as a norepinephrine–dopamine reuptake inhibitor (NDRI). This means that it blocks the reabsorption of the neurotransmitters norepinephrine and dopamine, leading to more of them present in the cells, which contributes to more stable moods. The most concerning side effect is an increase in risk for epileptic seizures. Because it’s an NDRI, Wellbutrin does not contribute as much to sexual dysfunction or weight gain as much as other antidepressants. Wellbutrin also reduces cravings for cigarettes.

Taking these medications has helped me maintain a stable lifestyle. A more “normal” lifestyle. I took them while I was pregnant, and avoided serious depressive or manic episodes during my pregnancy.

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A Brand New Year, A Brand New Baby

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Claire Stout, 1 day old

Boy, has it been a while since I last updated! Many changes have happened to the Stout household since 2015. I’ve recently given birth to a healthy little girl, with no ill effects post-partum. I am stable and healthy myself, taking Risperidone and Wellbutrin–both of which I will cover in the next post.

My pregnancy was as easy as could be expected, despite my suffering from hyperemesis–which means I threw up almost everything I ate from day one to the day before I gave birth. I lost thirty pounds, and regained twenty. Still, Claire was seven pounds and thirteen ounces at birth, with no health issues except for a touch of jaundice.

My son, Nolan, is now a fiercely independent eight-year-old, finishing up third grade. I’ve completed my book, Committed, and am working on the second round of edits before attending the 2017 Pacific Northwest Writers’ Association’s conference to pitch to agents. I have also entered the PNWA literary contest with a stand-alone chapter of my book. Wish me luck!

As for The Bipolar Parent blog, 2017 is a new year, so I plan to update every Friday. Keep an eye on this spot for new content each week.

I hope your year has been as fruitful as mine has been. Thanks for reading!

 

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Changes and Hopes for 2015

Credit to Flickr user Christopher Lance. Used with permission with a Creative Commons license.

Credit to Flickr user Christopher Lance. Used with permission with a Creative Commons license.

Many changes have happened in the Stout household over the past year. My son, Nolan, is six and a half, and blasting through first grade with aplomb. I have finished Committed, my novel about my post-partum psychotic breakdown. And my partner and I have decided to try for another baby.

Becoming pregnant, with or without bipolar disorder, is a tall order, and a lot of responsibility. With bipolar disorder, however, there are additional complications. Untreated depression can lead to low birth weight, and if a bipolar person stops their medication abruptly, that can harm them and their unborn child.

Some medications, such as Depakote, carry the risk of spine or heart defects, so I’ve weaned off of anything harmful. I will be taking medications during my pregnancy: lithium, Risperidone, and Celexia–the latter of which are antidepressants. Lithium will not harm the infant in utero, but will harm the baby while breastfeeding, which I would like to do. I’ll be going back onto Depakote during that time.

There’s also the risk of post-partum depression and psychosis. The main risk factors for a relapse for me is 1. being bipolar, and 2. a previous history of psychosis. I have a support team ready to spot signs and treat me if necessary, and to guide me through my pregnancy and beyond–and my partner has been educated. I look forward to a healthy pregnancy.

What changes have happened for you this past year?

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What is Bipolar Depression?

My apologies for setting the blog aside for so long without an announcement–and what a post to leave it on! I’ve been grappling with a severe depressive episode which has

Photo by Manarianz5. Used with permission under a Creative Commons license.

Photo by Manarianz5. Used with permission under a Creative Commons license.

escalated over the past year, leaving me not wanting to die, but just bereft of desire to participate in life.

Depression is often described as being miserable, down in the dumps, or–my favorite–trapped in a black, sucking hole of apathy. According to the Kübler-Ross model, also known as the five stages of grief, depression is one of the normal responses to a traumatic life event. Clinical or bipolar depression, however, rears its ugly head due to chemical imbalances in the brain, medication, or genes–meaning that it can strike at any time not connected to stress or winter blues. So what are depression’s signs and symptoms, and how are they treated?

Depression’s signs differ from person to person, but largely include a combination of these factors:

  • Persistent feelings of hopelessness
  • Poor concentration
  • Memory loss
  • Lack of energy
  • Isolation
  • Inability to sleep
  • Missed showers, meals
  • Suicidal tendencies

Over the past year I’ve isolated myself and my five-year-old, confining us both to the house due to both anxiety and depression. I’ve only just begun to emerge from the fugue, armed with new medications and new coping strategies, as well as an attempt to shuck off old habits.

Due to the advice of a dear friend, I found that doing things makes me want to do more things. It’s counter-intuitive, but making sure that I do the dishes and pick up the living room every day has worked as the best anti-depressant I’ve ever had. Staying in bed until I have to pick up my kid from kindergarten is a sure-fire way of destroying the rest of the day. Getting up and getting dressed is that first, difficult step, but I am better off when it’s done.

That said, I have to keep moving. How do you stay out of the sucking hole?

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Bipolar and Suicidal? You’re Not Alone

Trigger Warning: Suicide

Suicidal thoughts–also called suicidal ideation–are a not uncommon part of everyday life. Traumatic events like divorce, witnessing violence, or the death of a loved one can all rattle even the strongest of foundations.

Depressed in Paris by Toni Birrer

Image credit to flickr user Toni Birrer. Used with permission.

In my case, it was having a baby. His arrival kicked off a psychotic break and subsequent postpartum depression, which rocked me to my core. I actively planned to die for three years, and didn’t start living until I was medicated properly.

Due to mood swings, panic attacks, and deep depressions, people with mental illnesses are predisposed to consider self-harm as a viable alternative. According to Kaplan and Sadock’s Synopsis of Psychiatry (2007), one out of three people with bipolar disorder attempt suicide, and many complete it. The annual average suicide rate is nearly 20 times that of the neurotypical population (0.4%).

In a highly dangerous mixed state, the blend of self-loathing from depression and high energy from mania means that sufferers are far more likely to successfully carry plans of self-harm. However, due to its stabilizing effect, lithium carbonate successfully reduces incidences of suicide, which sharply decreases the mortality rate of the disorder.

Typical warning signs of suicide include impulsiveness, hopelessness, withdrawal, weight changes, alcohol use, rage, and sleep issues. Depression tends to be a better marker than mania, though not all depressed people are suicidal. In persons with bipolar disorder, anxiety and agitation are at the forefront.

People with fleeting thoughts–what would happen if I stepped out in front of that bus?–are considered “not at immediate risk”. If you’re at this stage, please talk to a counselor regardless. If you’ve been role-playing or fantasizing about a plan, run–don’t walk–to the nearest phone. Call a crisis line. Set up an appointment with a counselor. Low cost help is out there. And you are worth pursuing help.

Then, let other people know.  When you’re alone, it’s easy to let dark thoughts dominate your mind and kick off a spiral of rationalizing. Call a crisis line.  Make a post–anonymous or otherwise–on an online community you frequent, and ask for stories and support.

If you’re not in an immediate crisis, call up a trusted friend on Team You. You can also call a national warmline. These are call centers run by people who are recovering from issues like depression. They can commiserate with you anonymously about topics like loneliness and isolation.

You’re not alone. Our lives are stressful. We have depressions, and with that, suicidal thoughts. It’s okay that you feel like crap right now. These feelings are not uncommon. But they’re not normal, either.

Your life can and will be so much better than this.

Not meant to take the place of a medical professional.

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The Gold Standards of Bipolar Medication, part II

Photo of medication by Cassandra Stout. © 2013 under a Creative Commons License.

© Cassandra Stout and The Bipolar Parent under a Creative Commons License.

As I explained in part one, the two most often prescribed medications to manage symptoms of bipolar disorder are lithium carbonate and valproic acid.  In part one, we covered lithium.  Now we’ll take a look at Depakote and Lamictal.

Valproic Acid (Depakote, mg)

Valproic acid, commonly known as Depakote, is an epilepsy medication which also treats migraines. Researchers have now discovered an additional use: treating manic symptoms in persons with bipolar disorder. Depakote works by affecting the neurotransmitter GABA, which helps with relaxation. The medication is compatible with breast-feeding but not pregnancy, as it can lead to birth defects like spina-bifida.

Side effects include nausea, weight gain, and dizziness. You will need recurring blood tests to measure the efficacy of the drug and potential damage to the liver. Also, stopping the drug abruptly may lead to seizure, so please make sure you’re under the supervision of a medical professional while taking it.

As I wrote about in part one, lithium kicked me out of a depression and evened out my moods. Depakote, on the other hand, brought me back from the brink of a manic state cum psychotic episode.

I was first prescribed Depakote during my stay in the mental hospital shortly after Nolan was born. Without it, I don’t know if I would have recovered. I certainly wouldn’t have stabilized in time to care for my son while he was still an infant—and I may not have been able to keep him. I am now lucky enough to act as the primary caregiver for him while he marches off to preschool.

Lamictal (Lamotrigine, mg)

Lamictal is an anti-depressant [Editor’s Note: It has been pointed out in the comments that Lamictal is an anticonvulsant with mood stabilising properties. My apologies.] frequently prescribed for epilepsy and bipolar II. According to studies in 2007, it can treat depression without triggering mania in some patients. Lamictal works by blocking sodium ions in cell channels. Interestingly, because it blocks so many different types of ions, it is known as a broad-spectrum blocker. Its side effects include dizziness, headache, blurred vision, and rash. It also may interfere with hormonal birth control, causing estrogen-based products to be less effective.

I don’t have much to report on Lamictal, because three months is too short of a history with a drug. But I can say that its effect has thus far been positive. Like lithium, it has jump-started my system and brought me up to a more even level. A more “normal” level. One could almost say my life is a bit boring now, but it’s nothing like the sucking apathy of depression.

It’s a hard, long road to find a combination that works, and there are always side effects. But I’ve found that for me, taking the pills helps just enough to be worth it. I’m starting to recognize in therapy the parts of my diseases and what are my own unproductive habits, which I wouldn’t have been able to separate out before. Don’t let anyone shame you at the outset into not going after something that may help you, and do advocate for your own health. Help is out there, regardless of where you are in life.

You are worth exploring this option.

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The Gold Standards of Bipolar Medication, part I

Photo of medication by Cassandra Stout. © 2013 under a <a href="http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US">Creative Commons License</a>.

© Cassandra Stout and The Bipolar Parent under a Creative Commons License.

Behold, the marvels of modern medicine, and the chemicals which have saved my life.  I make no bones about how privileged I am to be alive.  Finding this semi-stabilizing nightly cocktail took nearly five years of searching, countless visits to a slew of psychiatrists, and an amount of money I don’t even want to tally right now.  I’ve tried SeroquelAbilifyOlanzapine, Geodon, and I’m sure I’m forgetting a few others.  Most made me so sleepy I couldn’t lift my head.  One made me break out into hives.  Abilify worked perfectly–for about six months.

Not all pills work for everyone, and some people who search are unlucky enough to not find any.  Sometimes the side effects are just too awful to handle.  But there are two heavy-hitting, more-likely-to-work drugs which tend to come up first in a conversation regarding symptoms of bipolar disorder: lithium and valproic acid.

Lithium carbonate (Eskalith, Lithobid)

Lithium carbonate is largely considered the “gold standard” for controlling symptoms of mania. Unfortunately, despite prescribing it for the past seven decades, no one knows exactly how it works.  A 2010 study in the Journal of Lipid Research found that lithium both reduces inflammation in the brain and helps metabolize the omega-3 fatty acid DHA, which has anti-inflammatory properties.  These new findings are inspiring scientists to expand  their research and use the drug more effectively.

Unfortunately, the side effects are nasty.  They can include weight gain, hand tremors, acne, gastro-intestinal issues, excessive thirst, tics, and the likelihood of damage to your thyroid with long-term use.  Due to the dangers of lithium toxicity, you will need to be monitored carefully by a licensed professional.

But this drug made my life worth living again.  When Nolan was a baby, I was obsessed with breastfeeding him.  Since lithium passes through the breast milk, I stubbornly refused to take it.  Shortly after Nolan turned two, I realized that most of my waking hours were spent writing suicide letters and frantically plotting out care arrangements for him after my death.

I chose the pills.

The change was immediate.  It was like someone had opened all the windows of my brain and let the fresh air in.  My moods and feelings felt like they’d lost some of their intensity, and of course there were heavy side effects, but I no longer felt like a strung-out zombie.  Whatever murky film that kept me from connecting with my loved ones dissolved.  It truly is my miracle drug.

On the rare occasions when I miss even a fraction of a dose, I’m thrown back into my manic fugue and have to take at least a week to recover, depending on how many milligrams I missed.  Like Depakote, I’ll gladly take this drug for the rest of my life–even when it destroys my thyroid.

What do you take, if anything?  Stick around for the next post, where we’ll cover Depakote and Lamictal.

Not meant to take the place of a medical professional.

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