Q:  Meds During Pregnancy

Dear Dr. Phelps,
I have been diagnosed with BP1 for 7 years. I have never had a full blown manic episode, however my doctor feels that without medication my symptoms would quickly escalate.
My husband and I are planning to try to start to have a family in the next few months. My doctor has told me that he would like me to remain on medication throughout the entire pregnancy. (I take 1000mg Depakote ER, 50 mg Zoloft and .25mg Klonopin)
Here's the question: Have you ever had a patient successfully remain on meds during pregnancy? What concerns should I have? Would you recommend a second opinion? I have seen so many contradictory articles, my head is spinning. Other than being bipolar, I am in perfect health.
Thank you!

Dear Nichole -- 
This is an understandable question, but you have already learned that it's a pretty controversial area in psychiatry.  This is too tricky a "risk versus benefit" ratio for me to try to sort out here for you personally, because there are factors which should go into this decision that would take nearly an hour to thoroughly explore.  These include:  

• how serious were your symptoms that led to this diagnosis?  (and starting a little further back, how certain are we you've got the right diagnosis? -- not so say you don't, but that would be where a good consultant would start; looking at the symptoms you had back then, your family history, your symptoms if any since, etc.)  

• how serious have been any symptoms you've had since, while on medications?
• how good a "safety net" do you have, if you were to start becoming symptomatic again?
• did you have insight into your illness when you were most ill?  i.e. did you know you had a problem and needed treatment?
• have you been on lithium, which causes abnormalities in unborn kids all right but at 1/100th the rate of Depakote?  Do we have any reason to suspect that you'd respond to lithium as well as Depakote?  or not so well? 
• were you hoping to breastfeed?  (lithium rules that out; Depakote is thought "safe" by the American Academy of Pediatrics but a few experts think that was based on too little data from too few kids)

Based on these and other questions we'd try to establish how much risk you might be taking to go untreated in your first trimester, i.e. stopping medication before you conceive, getting your folate levels up, and then starting a pregnancy (hopefully on the first cycle in which you're trying...) with clearly known timing, so that you could restart the medication in your second trimester.  That would be an approach some experts would recommend.  Lee Cohen at Harvard recommends not stopping lithium at all, if I've understood him correctly, at least when the risk of going untreated even for a short period of time is thought to be clearly quite high.  You could seek an expert consultation on this subject from the nearest bipolar/pregnancy expert you can find (Dr. Cohen's program at Harvard, which might be able to refer you to someone nearer your area, is http://www.womensmentalhealth.org/index.html ).  

If you can't get to an expert for consultation, you could seek a local second and third and maybe even fourth opinion until you seem to be getting the same answer from several folks whose opinion it seems like you can trust.  (Under no circumstances should you try to figure this out on your own and then tell your psychiatrist later what you're up to!  It's just too big a deal to go on your own.  You've probably figured out that much so far, eh?)

Good luck with your decision-making, and your pregnancy!

Dr. Phelps