Effects of Bipolar Disorder Therapies on Women of Child-bearing Age

In Part 2 of this podcast series, Psych Congress 2021 co-chair, Julie Carbray, PhD, FPMHNP-BC, PMHCNS-BC, APRN, clinical professor of psychiatry and nursing, University of Illinois at Chicago; administrative director, Pediatric Mood Disorder Clinic, Pediatric Brain Research and Intervention Center, Department of Psychiatry, Chicago, Illinois, moderates an audience question and answer session with Joseph F Goldberg, MD, clinical professor of psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, from his session, “Personalized Medicine for Bipolar Depression: Combining Evidence and Clinical Wisdom to Improve Clinical Outcomes.”

Dr Golberg answers the question, what are your “thoughts on treatment options for sexually active women of child-bearing age who are rapid cycling?”

In Part 3 Dr Golberg tackles side effects of poor metabolizing therapies for bipolar disorder, as well as how stimulants play a role in navigating treatment options.

In Part 1, Dr Golberg discussed L-methylfolate for the treatment of bipolar disorder, as well as how sleep comorbidities and weight gain phobia impact treatment options.

Read the transcript:

Dr Julie Carbray: Some thoughts on treatment options for sexually active women of child bearing age who are rapid cycling?

Dr Joseph F Goldberg: Do not give divalproex or carbamazepine is the first thing that you think about because of the potential for teratogenicity, and it's a relative contraindication. My reproductive psychiatry colleagues would probably say it's a really big relative contraindication.
In reality, there are women who certainly become pregnant on divalproex or carbamazepine, and they get Level 3 ultrasounds and they have uneventful pregnancies, but you would like to avoid that altogether. That moves you more toward lithium. It may move you toward lamotrigine. The combination of which can be synergistic certainly in bipolar depression.

In rapid cycling, I showed you that slide about lithium plus divalproex working twice as well as either one alone. You might wonder, "How about lithium plus lamotrigine in rapid cycling?" There's data with lamotrigine in rapid cycling. That's a very rational-based combo if you wanted to add on the second-generation antipsychotic du jour.

Some have a little better data, perhaps, in rapid cycling than others in terms of long term effects. Rapid cycling, mostly, people study it by saying, "If you had it in the last year, how's your response compared to placebo now?" whereas looking for an anti rapid cycling effect over the next 12 months, no one's done that study before.

There, you might make decisions about adding on a second-generation drug based on its antidepressant values, such as lurasidone, or now, lumateperone, and maybe less so for some of the drug or cariprazine. Maybe less so for some of the drugs that have less in the way of an antidepressant than antimanic effect if the patient is more depression prone.
Last but not least, thyroid hormone does have its data in rapid cycling to the extent there's a seasonal component, we're now in the autumn. There's data with bright light therapy in bipolar depression regardless of a history of rapid cycling. IPSRT, social rhythm therapy, thinking beyond pharmacology, but it can be tricky. Rapid cycling is one of the hardest things to stabilize.

Joseph F Goldberg, MD, is Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai. He attended college at the University of Chicago, graduate school in neuroscience at the University of Illinois, and medical school at Northwestern University. He completed his residency and chief residency in psychiatry, and fellowship in psychopharmacology, at the Payne Whitney Clinic, New York Presbyterian Hospital, where he later served on the faculty and was site Principal Investigator at Weill-Cornell Medical Center for the NIMH STEP-BD program. He has published over 220 peer-reviewed papers on topics related mainly to the treatment and clinical features of bipolar disorder, as well as 4 books on bipolar disorder and psychopharmacology, most recently, "Practical Psychopharmacology: Translating Findings From Evidence-Based Trials Into Real-World Clinical Practice," with Stephen Stahl, MD, PhD, published in 2021 by Cambridge University Press. He serves on the Board of Directors for the American Society of Clinical Psychopharmacology and serves as a field editor for the Journal of Clinical Psychiatry and for CNS Spectrums. His research has been awarded funding from NARSAD, NIMH, the Stanley Foundation, and the American Foundation for Suicide Prevention. Dr Goldberg is a Distinguished Fellow of the American Psychiatric Association and has been listed for many years in Best Doctors in America and Castle Connolly's "America's Top Doctors."