Mood disorder and pregnancy: Having children
Ann Tullgren and Meg Smith, with contributions from members of the Depression and Mood Disorders Association of NSW
November 2002

If you would like to comment on this paper or obtain more copies of this paper please write to:

Depression and Mood Disorders Association of NSW
41 Ilka Street
Lilyfield NSW 2040
or email m.smith@uws.edu.au

More publications from the DMDAcan be found on our website
www.mentalhealth.asn.au

The Mental Health Information Service
02 9816 5688 free call 1800 674 200
can tell you if there is a
support group for people living with mood disorder in your area.

This paper came out of a group discussion we had in the early 1980s in the support groups for people living with manic depressive illness (now known as bipolar mood disorder). Over 200 people came to a series of support groups held throughout the 1980s and 1990s at Gladesville, Leichhardt, North Sydney, Bondi Junction, Campbelltown, Wollongong and Riverwood

A number of themes emerged from our discussions. The issues for women living with manic depressive illness or other mood disorders were different compared to the life experience of men. Pregnancy, childbirth and related events affecting hormonal levels such as menstrual cycles, miscarriage or abortion appeared to be triggers for some episodes of mood disorder in women. Emotional support was different: many women had lost relationships or been deserted by partners during episodes of mood disorder.

Many of the women coming along to the support groups had been recently diagnosed as having manic depressive illness. Diagnosis usually followed a severe episode of either manic illness or depression following a history of milder episodes of mood disorder. The age of diagnosis was on average late 20s and early 30s with a period of ten to fifteen years of untreated and undiagnosed mood disorder before that.

Most of us had been in relationships during our years of living with untreated mood disorder. Mood disorder had disrupted many relationships and left us confused as to who we really were and what kind of relationship would work for us. Some of us had been adopted – our mothers had been forced to relinquish us because of their own mental illness. Others of us had been pressured to relinquish our own babies during episodes of post partum psychosis or depression. Most of us had been in relationships that fell apart during our episodes of mental ill health. Many of us had come from families where it was known that someone in the family had mental illness or who had vanished without trace or who had spent time in an institution.

Being diagnosed with a serious mental illness confronts you with a number of dilemmas and decisions to make. In one way, the diagnosis is a relief: what is happening to you is known about, other people have experienced it and survived and there is treatment. Since the late 1950s a wide range of drugs have been developed to treat episodes of manic illness, depression and to prevent further episodes of mood illness. Our mothers might not have had choices but with better diagnosis, treatment, information and support there were choices we could make. Changes in community mental health services mean that most people with mental health problems can be treated while living at home and do not need to spend long periods in psychiatric institutions.

The Changes

During my experience as a community member of the Guardianship Tribunal of NSW I came across Maude (not her real name). Maude had been hospitalized in her late twenties following what was probably a post partum psychosis. She had been sent to a large regional psychiatric hospital a long way from her home in a small country town. Her husband was discouraged from visiting her – and indeed the difficulties in getting to the hospital were a further discouragement. Her son was told that she had died while he was a baby. Maude lived all her life in the psychiatric hospital. She was active in ward activities and apart from periods of depression, had no recurrence of the severe illness that was the reason for her admission. She had no relatives listed on her hospital file and had no contacts outside the hospital. Maude was part of a group of hundreds of patients living in psychiatric hospitals in the 1960s and 1970s. People who had spent so many years in institutions that they no longer had any contacts outside the hospital and had little or no experience of living as an independent adult in the community. During a review of patients at the hospital and their legal status, the members of the Guardianship Tribunal noted that Maude was about to have her 100^th birthday. A telegram from the Queen was organized and the story appeared in the regional newspaper. Her son recognized Maude and made contact with her. Maude is now living in a nursing home close to her son and other family members.

What would Maude’s life be like had she been born fifty years later? Better medications could have limited her illness. Better community support would have meant that she may have been able to be cared for at home. Local hospital mental health services may have meant that she remained close to her family while receiving hospital care. A single episode of illness would not have meant a lifetime in institutional care.

Changing attitudes

Attitudes about parents with mental illness have changed to some extent but a diagnosis of mental illness today still means that there is an assumption that parents living with a mental illness might be unfit parents. There is still a lack of services to adequately support parents living with mental health problems. A partner’s mental health can still be raised in bitter acrimonious custody battles.

But with the right support and information, many of us do successfully choose to have children and have combined management of our illness with a happy family. We hope this booklet will inspire some of you to have children and to take action to get better supports and medical services for people living with mood disorder.

Should we have Children?

The question "Should we have children?" is one that causes many people with manic depressive illness and their partners a great deal of anguish. Some of these concerns are:

• Can we pass the illness on to our children?

• Can my partner and I cope with children and mood disorder?

• Will rearing children make the mood disorder worse?

• Will it be too stressful?

• For women who have episodes of mood disorder: will I need to take medication during the pregnancy? Will this cause deformities in the baby? How will I cope with the birth? Will I have an episode of manic illness or depression after the birth?

This booklet looks at these and other issues. It isn’t a definitive booklet on pregnancy - there are plenty of excellent books around that deal with general issues of pregnancy. This booklet refers mostly to bipolar mood disorder (or manic depressive illness), but, because some members of the Depression and Mood Disorders Association experience depression (unipolar affective disorder) some information on depression and medication is also included.

Manic depressive illness can affect either the mother or the father. Either parent can pass on the genetic material that gives an individual the predisposition for mood disorder. So the decision about whether or not to have children is not just the concern of the woman in the relationship. It’s a decision to be made in tandem. Pregnancy shouldn’t be an automatic response to getting married or settling down, or other people’s expectations that you must have a family, or the fact that you’re fertile, or that it’s natural and you’d better have a baby before it’s too late. It’s a decision that needs to be thought through by both partners - carefully.

The gene gamble

The question "Will our son/daughter inherit manic depressive illness?" is often posed as the central issue in deciding whether or not to have children. But it isn’t the main issue for a number of reasons:

• At this point in time it is impossible to predict if a child will develop mood disorder. Whether or not your child inherits the predisposition to manic depressive illness or other mood disorders depends on a complicated set of factors. Just as you can’t predict whose nose or chin or temperament your child gets, so too no one can say for sure if your son or daughter will develop manic depressive illness.
  
• As yet there is no scientific test that will tell you whether or not the foetus carries the gene or genes for manic depressive illness or depression. It is not known for certain yet which gene or genes carries the predisposition to develop manic depressive illness. Amniocentesis, a procedure where a needle is inserted into the amniotic sac and fluid is withdrawn can tell you if the developing baby has Down’s Syndrome and some other genetic disorders. But at present there is no test that can determine if the baby is carrying the genes for mood disorder.
  
• Even if such a test were developed which could show if the foetus carried the gene(s) for mood disorder the baby won’t necessarily go on to develop it - other factors play a role. Emotional or environmental stress, physical trauma and a number of medical illnesses are known to trigger episodes of mood disorder: some people can carry the genetic predisposition to mood disorder but never develop a serious episode of mood illness.
  
• Researchers don’t yet know exactly how manic depressive illness is genetically transmitted. Some researchers think that it is a polygenic illness: that is, that a number of genes interact to predispose a person to mood disorder. The studies of the Amish community in the United States suggest that it is passed on by a dominant gene that has ‘incomplete penetrance’ (sometimes hits, sometimes misses). Some studies in the 1960's and 1970's suggested that mood disorder is linked to colour blindness, the X chromosome, or certain blood groups. These studies haven’t been proven. However, in some families mood disorder is linked to other traits - such as colour blindness. In families where some of the men have red green colour blindness, it is known that some other members of the family will develop depression or manic depressive illness. But it is still not known why certain members of these families develop mood disorders and other family members are not affected.
  
• The genetic risk for inheriting manic depressive illness is low. About 7% of the first degree relatives (immediate family members) of people with manic depressive illness go on to develop the illness.
  
• Mood disorder can provide positive experiences. Mild mania can mean improved self confidence and creativity, increased sexual pleasure and a wonderful feeling of social ease. A 1983 study at Oxford University by psychologist Kay Redfield Jamison surveyed 47 top British artists and writers. 38% of the subjects had sought treatment for affective disorders. Other studies have confirmed a link between mood swings and creativity – particularly in music, poetry and art.
  
• Medical advances will hopefully mean that manic depressive illness will be better treated in the future - even prevented in people known to be ‘at risk’. At the present time, many younger people diagnosed with bipolar mood disorder are able to get earlier and better treatment than the drugs that were available twenty years ago. Newer medications with less side effects mean that many younger people with manic depressive illness have fewer and less severe episodes of mood disorder.
  
• Even if you knew for sure that your foetus or unborn baby carried the gene for the illness would you decide not to go ahead with the pregnancy? Mood disorder is a treatable illness and likely to become more so in the future.
  
• Some forms of manic depressive illness are particularly severe: they’re hard to treat and very disruptive to everyday life. But others are less severe: the episodes occur less frequently, are less traumatic and respond well to medication. There are different forms of mood disorder in different families. What sort of mood disorder do you have in your family? If your grandfather only had one episode and your cousin only had a couple then it is likely that the type of mood illness your family carries is a mild one.

Working out the odds: here are some ‘facts’ about the inheritance of manic depressive illness:

• Although about 1% of the population (that is one person in every one hundred) will develop manic depressive illness, mood disorder tends to cluster in certain families. That is, it is passed down from generation to generation along with other family heirlooms, such as the family chin, nose, or hair colour.
  
• The actual incidence of manic depressive illness may be greater than 1% because some people with mood disorder are never diagnosed, or are mis-diagnosed as having schizophrenia. People with mood disorder often use alcohol to relieve some of the symptoms so may risk becoming dependent on alcohol or other drugs. Other people with mood disorder are regarded as eccentric because the mood swings and accompanying symptoms such as withdrawal, overactivity or creativity are not understood by people around them
  
• Roughly the same number of males as females develop manic depressive illness - although women are more likely to seek medical treatment than men so are recorded more in public health statistics.
  
• About 7% of the close relatives of people with manic depressive illness develop a mood disorder
  
• If one identical twin had manic depressive illness, there is an 80% likelihood that the other twin will develop it.
  
• If a non-identical or a sibling (a brother or a sister) has manic depressive illness, then there is a 20% chance of the other twin, or other children developing it.
  
• Adopted children: an adopted child will only develop manic depressive illness if his or her biological parents carried the gene(s). Many women who had a psychiatric illness were pressured to relinquish their child up to the 1960s and 1970s so many adopted children may not know if their mother or father had manic depressive illness. Mothers who relinquished their children commonly experienced serious depression because of the trauma of the loss of the child but did not necessarily have a genetic mood disorder.

These figures suggest that while genetic factors are important, other factors play a role in the development of mood disorder. These may be environmental, such as a highly stressful living situation, how well you handle stress or whether you’re unfortunate enough to have several catastrophic events occurring at once (deaths of people you care about, illness in close family members, serious physical illness or accidents) which trigger the latent gene(s) into action.

Some other pertinent questions:

UNIPOLAR AFFECTIVE DISORDER

(Endogenous Depression or Major Depressive Disorder)

Some researchers say that unipolar affective disorders and manic depressive illness don’t run in the same families - that is, that they are different illnesses and are inherited in different ways. Others say that people who experience recurrent cycles of depression are in fact experiencing the same physical illness as people with manic depressive illness. Medical science has quite a way to go before we know everything about manic depressive illness and mood disorders.

Here are some vital statistics about depressive illnesses:

• It is thought that some depressions may have a genetic base whilst others do not. Strong emotional feelings such as reactions to loss, trauma and grief can produce the same symptoms as depressive illness. People with a biochemical predisposition to depressive illness may take longer to recover from loss or grief and have more symptoms of depression than someone who does not have a genetic predisposition to mood disorder.
  
• About 5% of the population will develop a major depressive illness at some stage in their lives. Like manic depressive illness, many depressions aren’t diagnosed or are mis-diagnosed, and so the real incidence may be higher.
  
• More women than men experience major depressions. Approximately 8-11% of men and 18-23% of women will be clinically depressed at some stage in their lives and will experience more than two weeks of depression severe enough to disrupt daily activities. Depression is sometimes called the common cold of psychopathology! Not all of these people will have a family history of severe recurrent depression which seems to come out of the blue - that is, depression which has a genetic or biological base.
  
• Where the depression is inherited about 10-15% of first degree relatives will experience at least one major episode of depression.
  
• If one identical twin has a Unipolar Depressive illness there’s a 40% chance that the other twin will. So the genetic transmission of the illness isn’t as strong as in manic depressive illness.
  
• For non-identical twins and siblings there’s an 11-19% chance that the other twin or brothers and sisters will develop such depression.

These statistics will indicate to you that the genetic link in unipolar affective disorders is not as strong as in manic depressive illness The environmental factors are very important in determining whether someone will experience a major depressive illness.

Deciding about having a family

Here are some questions and issues to focus on when you are deciding whether or not to have children:

• How severe is your illness? Do you have frequent episodes of mood disorder or have you had only a few episodes?
  
• When were you diagnosed? Early episodes of mood disorder tend to be the worst since it takes some time to recognise that it is an illness, get into treatment, work out which medication works best and learn how to avoid triggers to mood illness.
  
• How clinically manageable is your mood disorder? Some people respond very well to medication; other people have great difficulty with side effects of medication and even then, the medication does not control the mood swings completely.
  
• If you’re a woman, could you go off medication for part of your pregnancy? No medication is known to be safe during pregnancy but the first three months of pregnancy are the most crucial since that is when the baby is most likely to be affected by medication taken by the mother.
  
• How much support can you give your partner or expect from your partner?
  
• How do you cope with everyday life now? Can you hold down a job? What’s your financial situation like? Early episodes of mood disorder can hold people back and many people find that it takes longer to complete schooling, get job training and get started as an independent adult after episodes of mood disorder.
  
• How do you think you’d cope with a baby? Try to imagine yourself with one, or try looking after a young baby for a few hours or days to see how it would be for you. How would you react to sleepless nights? Try to balance out in your mind the joys and strains of child rearing. Talk to other parents who have small children and find out what is involved. Experience helps: people who have had to look after their own small brothers and sisters do make better parents.
  
• Remember that babies don’t solve life problems or stabilise jaded or difficult relationships. Mood disorder can create stresses in relationships and having a baby in addition can add more stress.
  
• What sort of social supports can you count on during your pregnancy and the first months after the baby arrives? Will family and friends be able to help out if the going gets rough? What would help you cope better?
  
• How are you placed financially? The stress of poverty doesn’t help either one’s mood disorder or parent-child bonding.

Hypomania, sexual activity and getting pregnant

If you decide to have a family then you’ll need to plan ahead, so avoid accidents. Many people with mood disorder are more active sexually when they are hypomanic or manic: this can be the worst time to get pregnant accidentally. Women who get pregnant during a hypomanic or manic phase may experience serious depression during the pregnancy.

If either partner is manic depressive, but especially if you’re female and have had episodes of manic depressive illness, it’s best to plan your pregnancy. Having children is not a step to be taken lightly. Raising them requires fine-tuned survival skills - especially if you have episodes of mood disorder.

1. To avoid giving birth in an ‘at risk’ period. Some women have predictable mood swings and can say with some certainty that the risk of becoming manic or depressed is greater during certain times of the year. Try to plan your pregnancy so that you avoid giving birth in these times.

2. It is better for the mother-to-be to avoid taking all drugs during the pregnancy that are not essential for the maintenance of life or well-being, since it is not known what the effects of many drugs are on the baby. The first three months of pregnancy are the most sensitive so if you are on mood altering or mood stabilising medication and become pregnant accidentally, this can create health problems for you and the baby. Planning to fall pregnant during a non ‘at risk’ time and planning to stop all medication while you are trying to get pregnant gives both mother and baby the best chance of a healthy pregnancy.

Partner understanding and support is important: make sure both partners recognise the importance of safe and reliable contraception.

If you’re male and taking lithium you won’t need to stop taking it during the pregnancy! It will have no ill effect on the foetus. However, animal studies have suggested that men who take lithium may not be as fertile as men who don’t. If you and your partner have been unsuccessfully trying to have a baby you may like to discuss this with your doctor.

LITHIUM DURING PREGNANCY

Lithium is, generally speaking, a safe and effective drug which is used to prevent mood swings. Some people call it their miracle drug although for others it doesn’t work so well. The effectiveness of lithium has undoubtedly resulted in the preservation of many marriages that would previously have been disrupted. It may even have increased the birth rate in families where one or both partners have been successfully treated. It improves the prospects of a reasonably stable and nurturing family for children.

As a general rule of thumb, avoid taking any drug (and include nicotine and alcohol here) during pregnancy. This is because they may cause deformities in the baby or have other unwanted side effects on either the mother of the child.

However, although it is important to weigh up the potential risk to the baby, it is also vital to recognise any potential risk to the mother-to-be of not taking lithium during the pregnancy. Manic depressive illness is a serious illness. Sometimes psychiatrists and other health workers do not appreciate the suffering of people who experience mood swings or the risks of uncontrolled manic or depressed behaviour. So the individual woman needs to consider her situation. Some women know from past experience that they become severely manic or depressed if they stop taking lithium. In such cases the risk of deformities in the child needs to be weighed against the risk to the mother.

If you think that you ought to continue taking lithium or other mood stabilising medication during pregnancy then you will need to discuss this with your doctor. She or he may suggest that you take other medications such as neuropletics or anti-depressant medication instead as these are thought to be safer during pregnancy. Even if lithium is the drug of choice, don’t despair because most babies whose mothers took lithium during pregnancy had no ill effects.

The doctor who is caring for you during your pregnancy needs to understand what manic depressive illness is and should liaise with the doctor who is treating you for mood disorder.

It is best to avoid taking lithium during the first three months of pregnancy (the first trimester). During this period the organs of the foetus are being formed. Lithium crosses the placenta easily so the baby gets as much lithium as you do. So obviously if you plan to fall pregnant it’s best to go off lithium before conceiving. Remember, you’ll need to come off lithium slowly.

Using lithium in the first trimester increases the likelihood of having a baby who has Ebstein’s Anomaly (a rare heart condition) and other cardio-vascular abnormalities. Major heart defects have been reported in about 8% of babies born to mothers who took lithium in the first trimester. Because abnormal births are reported more often than normal ones, the actual incidence is probably lower than 8%. In fact most experts agree that this risk isn’t great enough to justify a therapeutic abortion.

If you’re taking lithium during these first three months you’ll need to:

1. See the doctor regularly because the dosage may need to be adjusted from time to time.

2. Take your daily dose of lithium, in 3-5 small equal doses. This avoids fluctuations in the serum level and reduces the risk to the baby.

It is best to avoid taking lithium in the second and third trimesters (months 4-9). Even though the danger period for causing birth defects is over it is hard to maintain therapeutic lithium levels.

The lithium content of the body is determined by intake (dose) and renal (kidney) excretion rate (how much you pee out). In pregnant women lithium is excreted more rapidly. During the second half of pregnancy you excrete 30-50% more lithium than you would normally. This means that a pregnant woman needs to take a higher lithium dose in order to keep a therapeutic level. You’ll also need more frequent serum lithium levels done as well.

• The lithium level should be kept as low as possible (the lowest level that will keep you stable).
  
• Avoid low salt diets and diuretics. If your GP or gynaecologist says that you’ve got hypertension (high blood pressure), or oedema (water retention, puffy fingers or ankles) and wants you to take diuretics or go on a low salt diet (which will help you pee more) make sure that she or he knows that you’re taking lithium and get them to discuss this with your psychiatrist.
  
• Have your thyroid and kidneys checked - this will require a simple blood test.
  
• Avoid heat: sweating and the loss of sodium and potassium will disrupt lithium levels.
  
• The signs of lithium toxicity are the same for pregnant women as for others. Bear in mind that some of the normal symptoms of pregnancy (nausea, vomiting, water retention) are similar to the signs of lithium toxicity. If in doubt – consult your doctor or health worker.

During the last months of pregnancy lithium is excreted more rapidly through the kidneys. Therefore it may be necessary to increase your dose in order to keep your lithium level constant and your mood stable.

However, immediately after delivery, the renal clearance level (how much you excrete) rapidly falls to pre-pregnancy levels (normal rate of excretion). The serum lithium level increases rapidly. To cope with this either of two approaches is adopted:

1. Some doctors lower the lithium dose about a week before delivery.

2. Others lower the dose or stop it briefly as soon as labour starts.

Once the baby is born you should be taking the same dose as before pregnancy. Of course it will need to be carefully monitored until your body gets back to normal functioning. It is essential that your gynaecologist/obstetrician is aware that you are taking lithium. He or she must liaise with your psychiatrist.

Lithium can potentiate (or make stronger) the effects of anaesthetics and muscle relaxants which may be given during labour. So tell everyone who is working with you during the birth that you are taking lithium.

If the mother took lithium during pregnancy, the baby will be born with lithium in its blood stream. Often this poses no problems but occasionally babies are born with signs of lithium toxicity. The signs of lithium toxicity in babies are: lethargy; cyanosis (blueish skin colour); poor suck; enlarged liver; floppiness; shallow breathing; hypothermia. The baby will recover within ten days as the lithium is excreted.

Because new born babies often get dehydrated (through not drinking enough or vomiting) and because their temperature can fluctuate, the doctors and nurses will keep a close eye on the baby.

The large majority of babies born to women who took lithium during early pregnancy are completely normal. The main risk to these babies is that they may develop cardio-vascular abnormalities - Ebstein’s Anomaly is one such problem.

This can be diagnosed when the foetus is about 25 weeks old by an echocardiogram, a test which will show up many cardio-vascular problems. After the birth the baby can undergo other tests, such as an electro-cardio-gram or a cross section echocardiogram, if the doctor thinks that there is any risk to the baby. Ebstein’s Anomaly and many other cardio-vascular defects can be corrected surgically.

Professor Mogens Shou who researched the use of lithium to treat mood disorder has followed up many babies born to women who took lithium during pregnancy and who had no visible malformations at birth. He found that they did not develop any problems later in life because they were exposed to lithium in the uterus.

If you take lithium during the first three months of pregnancy you are urged to send details of the baby to an International Lithium Register in the United States of America.

The address is:

The Lithium Register,
Langley Porter Psychiatric Institute
401 Parnassus Avenue
Box 38C
San Francisco
California 94143

BREASTFEEDING

Lithium is readily transferred to the baby through breast milk. Some researchers say that since the baby was exposed to lithium in the uterus then it is all right to breastfeed but to carefully look for signs of toxicity in the baby. Breastfeeding carries lots of benefits for both the mother and the baby:

It is emotionally satisfying.

It helps the baby to fight off infection by transferring the mother’s antibodies to the baby.

It’s nutritionally sound.

It helps mother-child bonding.

Other doctors advise mothers who are taking lithium not to breastfeed, especially if they did not take lithium during pregnancy. Research on animals suggests that a new-born baby’s kidneys may be abnormally sensitive to lithium and as a consequence may be damaged by it.

Breastfeeding isn’t straightforward even for women who aren’t taking medication. Some babies have no problems taking to the breast but others do. Breastfeeding can be physically quite draining for the mother. So if you decide not to breastfeed, you do not need to feel guilty.

• Avoid taking lithium during the first three months of pregnancy (the first trimester).
  
• The danger of not taking lithium and becoming ill with mood disorder must be kept in mind.
  
• The lithium dose taken should be the lowest that will maintain a minimum therapeutic level. You will need to have frequent serum lithium levels done because as pregnancy progresses your kidneys will excrete more lithium, requiring you to take a larger dose.
  
• Wide fluctuations in maternal serum lithium levels are to be avoided since they are transmitted directly to the baby. Pulses or surges of lithium may put the baby at risk of developing problems. Therefore you should take your lithium in small doses, three to five times a day - slow and steady.
  
• Since low salt diets and the use of diuretics can cause lithium retention, and will make your serum lithium level rise, they must be avoided during pregnancy.
  
• The dose of lithium must be lowered either before delivery or during delivery.
  
• Avoid breastfeeding.
  
• Have your thyroid function and kidney function tested.
  
• Find an obstetrician who is knowledgeable, sympathetic and prepared to liaise with your psychiatrist.

OTHER MEDICATION AND TREATMENTS DURING PREGNANCY

Serotonin-specific Reuptake Inhibitors (SSRI's)

These drugs, along with the tricyclic and tetracyclic drugs and the monaomine oxidase inhibitor drugs are considered the major antidepressant drugs; they are also effective in a wide range of disorders, including bipolar I disorder, dysthymic disorder, eating disorders, panic disorder, obsessive-compulsive disorder, and borderline personality disorder. Because they generally have fewer adverse side effects than other classes of antidepressants they are more widely prescribed;

The most common adverse side effects involve the central nervous system and the gastrointestinal system; they include headache, nervousness, insomnia, drowsiness, anxiety, agitation, nausea, diarrorhea, anorexia, and dyspepsia. More rarely people taking SSRI drugs may experience sexual dysfunction – difficulty getting an erection or getting aroused or difficulty getting to orgasm. or allergic reactions (rashes). These drugs are generally considered to well tolerated, and some adverse symptoms may lessen or disappear with continued use. Some of the generic names follow (trade names in parenthesis)

These drugs have been in use for over twenty years so have been reasonably well researched. These are considered to be relatively safe for use during pregnancy, but try to avoid using them in the first trimester.

Tricyclic and tetracyclic antidepressant drugs

Neuroleptic and antipsychotic medications

These are also considered to be relatively safe to use during pregnancy. Again try to avoid the first trimester - especially weeks 6-10. They are a good alternative to lithium. If you use them up until time of delivery you will need to watch for withdrawal signs in the baby. These may not occur until 3-6 weeks after the birth. The signs in the baby are: jitteriness; irritability; excessive crying and sucking. If these occur you must keep the baby quiet; reduce stimuli; provide a dummy between feeds so the baby has something to suck on; hold the baby in an upright position if you pick it up.

Neuroleptic drugs are transferred in breast milk. If the mother is taking large doses, the baby may become sedated and this may have long term effects on its developing nervous system. Your doctor will need to advise you about what is appropriate.

Neuroleptic and antipsychotic drugs

Newer antipsychotic drugs have fewer unwanted effects than the older drugs and may also be more effective in helping with depression.

Newer antipsychotic drugs

These drugs are used to improve sleeping, reduce muscle tension and reduce anxiety. Avoid taking these in the first trimester. Avoid taking them at the time of delivery. Avoid taking them while breastfeeding, especially if combined with other medication. Intermittent use is probably OK as is taking small doses. Use other medication preferably. Sedative drugs can mask a developing manic episode and won’t stop the manic episode from getting worse. If you are having difficulties sleeping, these drugs may work as a short term solution but a mood stabilizer should also be considered to prevent a manic episode.

DRUGS USED TO TREAT ANXIETY AND TENSION

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is considered relatively safe for use during pregnancy. ECT releases a number of neurotransmitters in the brain and can lift depression, or, if given during acute mania, end the manic epsiode without the need for high doses of neuroleptic drugs. It can work far more quickly than medication and is most often used when the person is severely distressed and cannot take mood altering medications such as antidepressant or neueroleptic drugs.

If this procedure is used the baby’s heart beat will need to be monitored both during the ECT and for several hours afterwards.

MOOD SWINGS AFTER THE BIRTH

Many women experience mood swings following the birth of their babies. Their feelings can range from detachment ‘is this baby really mine?’, to great joy and satisfaction, to weepiness, to feeling let down. These mood swings are caused by the huge physical and emotional stresses of childbirth. If you talk to other mothers, you’ll find that these experiences are very, very common.

Women who have previously experienced episodes of bipolar affective disorder have a much greater risk of experiencing post natal mania or depression than other women with no history of affective disorder. Approximately 40% of women who have previously had episodes of mania and depression may experience a major episode after the birth of their baby.

Some women who have no personal or family history of psychiatric illness also experience psychosis after childbirth.

Plans to make to avoid a potential crisis

Plan beforehand what to do if you do develop symptoms of serious mood disorder.

• What drugs can you be given safely to control the mood illness without affecting your breast milk?
  
• Breast feeding is the main reason for women who refuse to be treated for mood disorder after childbirth. .Is breast feeding so important to you that you want to risk your own health? Episodes of mood disorder can be controlled quickly if medication is taken early enough. Could you expel your milk anyway and begin real breast feeding after a course of medication to control your mood disorder symptoms?
  
• What sort of support and help can you be given to reduce the physical and emotional stress of childbirth – for example can you stay in hospital a few days longer, can you get home help?
  
• Loss of sleep is a major trigger for manic episodes. Long labour and difficult delivery can interfere with normal sleep patterns. What plans can you make to ensure that the baby is looked after while your body recovers. Staying in hospital a few days longer or convalescing in a supported environment can help.

Having children - Our Stories

It was a planned and wanted pregnancy, totally normal, I was disgustingly healthy and had a normal labour...About a month after the birth, I was totally incapable of doing more than feeding the baby and washing nappies.... I had a feeling it wasn’t just tiredness but didn’t know what to call it. David (husband) was fed up with me and we were both at a loss as to what to do next. I saw a succession of doctors, about six or so and a social worker. The doctors were all pretty quick with the drugs and the social worker suggested I join a club! I was also doing some odd things. I would go shopping and load the trolley with all the orange (or red or green) objects I could find, then leave it laden and leave the shop without buying anything.

Things came to a head when the Mother’s and Babies Sister came to see me and find out why I hadn’t taken (baby) Eleanor to the clinic. She told me about a very understanding doctor who would help me...I was admitted to Sunshine Psychiatric Hospital and spent 7 weeks there... I saw my psychiatrist 3 times during my stay. She answered none of my questions and would explain nothing...It was never explained why I might have suffered p.n.d...My husband ended up discharging me.

• Lack of understanding of p.n.d. by most professionals
• Reaction of most friends (all thoroughly disgusted with me)
• Effect on first child (Claire)
• Treatment by the psychiatric hospital and staff.

• Love and support of my husband
• One doctor who took time to listen to me.

So You Want To Have A Baby…

I have written this article from the woman’s point of view BUT I believe any couple planning a pregnancy should consider these issues. If the man has bipolar (manic depressive) disorder, then issues of financial security, stability and permanency of the relationship, capacity to cope with normal day-to-day issues and personal differences are the FIRST issues to assess and consider. If financial stability, lack of family/friend supports or erratic/unpredictable/difficult to monitor and treat mood swings are COMMON, then extra thought should be taken. An unplanned pregnancy will require immediate medical and counselling advice.

MY STORY

I was 36, (my husband also), married and busy in my work (qualified social worker). We had not married in order to have children. We knew each other more than two years, we were busy and believed that God would know what was best considering in our lives, my medical past.

I had one major horrific depression followed by a short manic episode at 25 years of age, then a long and difficult recovery before getting back to work part time. Then after successful control and maintenance on lithium for 7 years, I won an international scholarship to study overseas. I believed I was well enough to stop the lithium there. I was in a country where I could speak the language. With a massive manic episode, wanderings around the country (having forgotten all I knew) caught by the police, horrific hospitalisations for many months and finally rescued by my parents, I returned home to another very lengthy period of recovery and rehabilitation and back on the lithium etc and eventually job hunting. After 15 months in the job and early on in our courtship, I had a less severe manic episode. I was on lithium and it helped to take me out of the psychosis speedily with several other medications and excellent therapy from my psychiatrist (I had been with him 14 years altogether). I was ready to believe (with God’s help) that we could bring a child into the world and that my husband and I could manage with help: we were both 39 and had observed that our well younger friends did not find the parenting business easy either.

We thank God that our children are 10 and 6 (both breast fed to about 17 months and 3 miscarriages in between them) and that we are now into the next stage of parenting, ’taxi service’ to after school activities and the issues of discipline! We take it all as it comes.

FIRST - a meaningful relationship with your psychiatrist, if you haven’t got one, find one preferably one who has visiting rights to the obstetrics hospital you have found or are planning to choose. Someone who will be willing to work together with you, your husband and your obstetrician and who is able to assist you in your decision to have a child. You should present or prepare a written history of your health, illness, and episodes. This may include at least one joint session with you and your husband.

SECOND - a joint discussion with a doctor, gynaecologist, obstetrician BEFORE conception (if possible). Besides having bipolar disorder it is important to discuss other genetic issues, discuss fertility, gynaecological issues, other medical problems that may occur as well as present information of your psychiatric history. Check out his or her views on planned caesarean delivery, concerns of natural delivery, their knowledge or willingness to obtain information on lithium. Lithium and breast-feeding, eg. last episode, frequency, severity etc family and other supports.

Note: An unplanned pregnancy (or unwanted by one party) or other complications surrounding the pregnancy and subsequent birth of a child into an unstable or shaky relationship can increase the likelihood of depression and future breakdown etc. Ensure that the obstetrician will be able to cooperate with the psychiatrist during and after delivery (if signs of depression etc appear)

THIRD - consider the role of your family doctor/GP who may be able to make some suggestions on choice of specialist and relative possibilities of shared care etc and assist in pre planning eg recommend to go to Tresilian or Karitane Mother Craft Hospital (note: you can contact these services. A social worker or director will give details and the father can stay overnight as well. According to your Health Fund, the baby is the ‘patient’, check first.

FOURTH - Consider contacting a paediatrician at a children’s hospital. If you plan to breast feed in the light of the literature, the paediatrician can monitor mother’s milk and blood samples of the baby from birth to satisfy all the parties. The amount of lithium crossing into the milk supply and then into the baby (compared to body weight of the newborn) is extremely small and should not affect the baby.

FIFTH - If you have any other health problems, allergy, diabetes etc, it is important that all doctors etc know about everything. Blood tests such as serum lithium level may be needed every three months starting immediately after birth - especially if lithium is reintroduced after delivery and especially if continued throughout pregnancy. If over 37 years old, your obstetrician will recommend other tests to check the progress of the pregnancy.

SIXTH - Reading. It is most important to be well informed about all these areas to reduce the risk of difficulties related to mood disorder. as well as pregnancy, delivery and the post natal period.

Note: That much of the literature still says that a woman with M.D. should not become pregnant and definitely should not breastfeed. You should learn about:

• Conception (how, problems of and suggestions),
• Pregnancy (including specific issues of each trimester eg nausea, identity and body image, giving up work? Sleep disturbance, physical discomfort, delivery, pain management and coming home’ issues including Tressilian (Karitane or other community early childhood Baby Health Centre supports). Other supports and services.

Details of these services can be found at your local council, social worker, antenatal clinic etc.

It is important to have a good knowledge of bipolar mood disorder. Your own pattern is unique so you should to discuss this with your doctor(s).

Together with your husband/partner, try to analyse your pattern so that if there is a change throughout the pregnancy, the objective input from the partner will be important to the doctor(s)

Learn about lithium and other mood stabilisers and the reasons that medical literature and psychiatrists are very careful in using lithium or other mood stabilisers in pregnancy. During pregnancy especially the first trimester and during breast feeding, postnatal reaction, merits of planned caesarean -vs.- natural delivery, are also important to reduce possible extreme postnatal depression.

You must have total support of a partner e.g. consider the baby in bed together, mastitis and other breast-feeding problems (including serious infections, expressing and storing) complimentary feeding. Also other supports in learning lactation right from the start. Lots of advantages in winter and going out, but needs correct help to get a good start. Consideration of bottle-feeding requires correct sterilisation, who will do it, getting up in the night to warm bottles? Correct formula? Advantage, another person can assist so that you can get more sleep.

Other Resources include Early Childhood Centres, Community Nurse, Day Stay and Long Stay, Family Support Services, Play Groups, Community Mental Health Centre, Nursing Mothers Association (Local Groups).

An update

Since this booklet was originally written, the women involved in the working group have all made our choices. Ann and Meg decided not to have children. For both of us, our relationships with our partners and our work provided satisfaction and achievement and we didn’t want to risk more episodes of illness. Fran has a beautiful family and has inspired three other women from the group to go ahead and have a family.