Review articleIs there consensus across international evidence-based guidelines for the psychotropic drug management of bipolar disorder during the perinatal period?
Introduction
The perinatal period poses additional challenges to women with bipolar disorder as it is associated with a significantly higher risk of illness relapse. Research has consistently shown that relapse rates of either a hypo/manic or depressive episode within the first 12 months of giving birth range between 25–55% (Doyle et al., 2012, Hunt and Silverstone, 1995; Viguera et al., 2011; Wesseloo et al., 2015). A smaller number of studies have focused on relapse rates during pregnancy and have reported more variable findings, with rates ranging from 22.7% (Viguera et al., 2011) to 71% (Viguera et al., 2007). While there are many effective psychotropic medications available to manage bipolar disorder and prevent such relapse, their safety during pregnancy and breastfeeding is a major management issue. ‘Safety’ issues theoretically include side-effects during pregnancy, teratogenic and dysmorphogenic risks, and any impact on neonatal adjustment and subsequent neurobehavioural development. Safety concerns combined with the high risk of relapse therefore create a conundrum regarding optimal management and treatment strategies during the perinatal period for those with a bipolar disorder.
Psychiatric management guidelines have been extensively developed over the last two decades to assist medical practitioners in the management of the bipolar disorders and many such guidelines have sought to provide specific information on perinatal management nuances. Guidelines may be either ‘evidence-based’ (and prioritize or be limited to efficacy-based data), and/or be ‘consensus-based’, where the data are considered but where consensus is more generated by the clinical views of those on the guideline committee with expertise in the domain (sometimes described as ‘eminence-based’ views). If evidence-based guidelines are truly based on the results of efficacy-based data, we would expect differing organizations to make similar recommendations in their guidelines, subject to the same evidence being available at the time of the review. In this paper we analyse a set of evidence-based guidelines for the management of the bipolar disorders, and report on the levels of agreement in relation to recommendations made about the use of psychotropic medication to manage bipolar disorder during the perinatal period.
Section snippets
Method
A literature search in the National Guideline Clearinghouse, the Cochrane Database of Systematic Reviews, PsycInfo and PubMed was performed using the search terms “bipolar disorder” and “guidelines.” The search was restricted to guidelines published or updated over the 2005–2015 period. This search identified 11 sets of evidence-based guidelines for bipolar disorder published by nine professional organizations. All were published in the English language and all were described as being
Results
Levels of agreement across the guidelines for topics integral to the management of bipolar disorder during pregnancy and breastfeeding with psychotropic drugs are now considered.
Discussion
We compared recommendations made across 11 international guidelines for the management of bipolar disorder during the perinatal period. While the psychotherapies have a clear role in managing bipolar disorder, we limited our review to psychotropic medication management. All guidelines were described as being “evidence-based” and thus it was expected that their recommendations would be consistent, subject to them being formulated from the same available empirical evidence. Against such
Conclusions
Bipolar disorder is associated with several serious risks for pregnant and breastfeeding women and their offspring, and therefore must be managed effectively. Many of the guidelines we assessed note that decisions concerning pharmacological treatment for women with bipolar disorder during this period should be made after careful consideration of the risk of bipolar relapse versus the potential risks psychotropic medications pose to the neonate. However, our analysis revealed that there is a low
Acknowledgments
None
Funding
The study was funded by a National Health and Medical Research Council (NHMRC) Program Grant (1037196).
Role of funding source
This work was supported by an Australian National Health and Medical Research Council (NHMRC) Program Grant [grant number 1037196]. The NHMRC did not participate in the study design, nor in the data collection, analysis, or manuscript preparation.
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