Bipolar and soon TTC. I'm worried about postpartum depression/psychosis

[ReadAllTheThings]

TL;DR: I have a history of severe bipolar and I'm worried pregnancy/motherhood will make me crazy again. What's your experience?

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Would love to hear any stories from bipolar mums.

I have bipolar and I'm preparing for TTC. Really excited (and a bit nervous) to start a family. My DH and I are planning to start in a few months if everything is still stable. So I'm starting to eat better, exercise a bit more, quit vaping, monitor my cycle, etc. And as per my username, read all the things about TTC!

I've been pretty much stable for about a year, but I have been stable for this long before and relapsed. I'm especially worried because I had a really rough time with bipolar 2015-2018. My mania isn't so bad (mainly I just work obsessively and get quite creative, once I thought God spoke to me), but my depression can be severe with paranoia and delusions. I'll spare you the details, but I was hospitalised for months 4 times with depressive/psychotic episodes, sectioned once, ECT 3 times (ECT works like a miracle, but memory loss is an issue)... my episodes are long, like 3-6 months.

So my doc says I'm at high risk of postpartum depression/psychosis. They seem to have a good perinatal psychiatric team here, and I had an initial appointment with them. I'm still on medication and in "monitoring" private therapy. Luckily, they said I don't have to change my meds (lamotrigine and sertraline) for TTC.

But I'm still so worried about relapse in pregnancy or after. I couldn't handle anything back when I was severely depressed or psychotic, and I can only imagine how bad it would be if I had an episode as a new mum (or as a mum at any time, really)! There are mother and baby units here if it gets bad, but no idea what they're like. A psych ward seems like no place for a baby - they're awful. And if I had ECT again, it should work quickly so I could get out of hospital and live reasonably normally again for a while, but I might forget some of my DC childhood! :(

Can you relate? If you have bipolar (or know someone), did you relapse after/during pregnancy or stay well? What happened? Any tips for avoiding relapse?

OP, very few mums actually need admitted for PND, so the odds are in your favour. You are doing all the right things, in optimising your health and taking your meds, and you will be carefully monitored by the psych team.
I think the only other precaution you can take is to arrange for good support for the baby’s first few months, to make sure that you can get some sleep. I’d get DH on board now, to agree to do half the night feeds, for example, and see if someone would mind the baby for a regular slot to give you an afternoon nap if you need to catch up.
Make sure you are not isolated at home with the baby- arrange outings, plan to meet with friends or attend mum/baby groups, or go to a part time job.
Even mothers with no history of depression can struggle a bit with the exhaustion, sleep deprivation and isolation of a new baby. Plan ahead to make it as stress free as possible. If your finances permit, consider hiring a maternity nurse for the first month or two.
Finally, try to look forward to the baby! It’s v sensible to plan for crisis management, but don’t lose the joy and excitement in the process. My best wishes that all goes well.

@Babdoc thanks so much! Sounds like really good advice

Hi @ReadAllTheThings how did you get on? I’m emerging from severe PND (I’m bipolar too). Would love to meet some more people like me. All the best, Georgia

I would just encourage you to keep talking with your doctor. Ask them these questions. Ask about the risk of illness during pregnancy and what help you can get. Knowledge is your friend.

I don’t have bipolar but I have ptsd so I signed up with a maternal psychiatrist before I got pregnant and she liaised with the obstetrician to ensure a good plan was in place e.g. private room in hospital, elective c-section, night nurses for first three months. The obstetrician himself had lost his son as a newborn and was incredibly understanding. People want to help, they want you to be well. Don’t be shy to ask any and all questions. And if the worst happens and you do have a relapse, you will have help on hand right away.

Hello. I work with women who have birth trauma. That's what a lot of post natal depression really is, trauma from the way people were treated and things that were said around them and over them and not to them. My best advice is to get a doula to be with you for the birth and post birth. They know the system and keep you the person connected.

Sorry I do know a mum that struggled with severe mental health (depression/psychosis as you have mentioned) but it’s probably not the kind of story you want to hear. I’ve known her for a very long time and we used to be really close so I’d been there with her during her worst MH points. She never really wanted a child but eventually gave in due to her husband really wanting one. When they did have their DS she had PND quite severely and would leave her child at my house quite frequently even when he was really little. I could tell as he got older she never really bonded with him so her DP took on most of the childcare. He’s now 20 and NC with her. I think the situation would have been largely helped if she had got the support she needed. So I now say to anyone who wants to have a child when they suffer from MH to put the right support in place before baby is here.

I have bipolar and was absolutely fine after my babies, thank de fuck. In your position I would have a conversation now with your boyfriend and get him to understand that he might need to take over the majority of the night time duties. For me one of the biggest triggers is lack of sleep which obviously is a bit inevitable with a baby. I would consider mixed feeding from day one (if you want to breastfeed) this means that your DP can do the majority of the night feeds. Consider having an extra room you can sleep in, or DP when the baby is small so you can both get a decent amount of sleep. Also should the very worst happen and you're unable to look after your baby you know that your baby will be able to feed from a bottle (it can be really hard to get them to feed from a bottle otherwise).
I found being very open with everyone helped. I had mild PND with DS2 and managed to talk my way out of it.
Having a newborn is mind-blowing tough. Just about everybody finds it hard and at some point feels really low. Just keep talking. Eat to be the perfect parent because there's no such thing exists.

Hi, I'm OP but I lost access to my account.

Thanks all so much for your feedback! I did end up with post partum psychosis in a mother and baby unit. It was harrowing, but we got through it. I now have an adorable toddler and I couldn't manage life without him. I've been stable since the few weeks after his birth. It's like being a mum has forced me to take better care of my mental health, but I certainly couldn't handle the trauma of his birth (4 day labour, emergency c-section, nightmare)

Ah that's so lovely to hear you've been fine for so long! Sorry you got PPP sounds like they did get you better v quickly. Did you take an AP? We are deciding whether or not to go again. I got v unwell last time for 10 months, and unrecognised hypomania before that for 5 months after my son's birth. It's so hard to decide what to do. Sorry lamotrigine and and sertraline didn't keep you well. It didn't for me either.. so if we had another I'd stay on lithium...

I had been on an antipsychotic (is that an AP? I wasn't sure!) before all this happened and I stayed on it, but they increased the dose. I think time and sleep in hospital was what I needed the most. I stayed there a couple weeks. The mother and baby unit was amazing, miles better than any other hospitalisation I've experienced (and there have been a few!).

We've decided to TTC again recently. I'm scared, but I think if I have a planned c-section rather than a 4-day labour it will be better. Best of luck on your journey, whatever you decide. Keep me posted x

Omg yeah a 4 day labour will do it... if we have another then I'm going to have an elec C section too. Finding thinking about it all v stressful in itself, mostly because of being on lithium. How old is your child? My son is 2.5. I got very very unwell though, I was at the MBU for 7 weeks and moved in with my mum for a bit too. But the idea of staying on lithium to protect myself is scary - as then am I prioritising my own health and risking my baby's health. It's so hard.

Also if im honest I've not been stable.. I've reduced my lithium and had a wobble from that.. all to prep for TTC really.. proving I really can't stop taking lithium! I know you're supposed to be stable for a while before TTC but I don't want such a big age gap and im 36 so it may not happen as quickly this time round.

Omg I'm 36 too! I'm lucky to be on less risky medication for babies, though my aripreprizole means I can't breastfeed, which is sad. I also worry about the age gap. My little one is almost 3. Did the doc tell you how risky lithium is?

Ahh how funny! I've read that the age gap can be a really good thing in many cases. I wouldn't have been able to cope with 2 in 3 years anyway so it's a moot point. What does your partner / husband think? Does he work full time? I've read every scientific paper there is about lithium and pregnancy... but there's no "right" answer which is v frustrating... our doc appt is 3rd Nov...

Hi I'm glad to have stumbled across this post today. I have a 3 year old and bipolar. After my daughter was born I developed severe treatment resistant depression and pyschosis. It took 2 years to recover and we had a stay in a MBU.

Last week I agreed a treatment plan with my consultant to reduce 2 of my medications over the next 6 months in order to TTC if all goes well. I have been in treatment for my mental health for half my life but this was the first time that treatment didn't work which was terrifying. We haven't completed decided if we do want a second child but now is the first time we feel braver enough to explore the idea. I also turn 36 in a few months

Hi @Superscientist it's so lovely to hear from you. We spoke a lot when we were both unwell & your advice was invaluable regarding the MBU admission and therapy. Which meds are you on now? So sorry that it took 2 years to get better. Do you know what you would do differently next time around? V grateful to have this group going on here xxx

Hi Georgia, I'm glad it was helpful.
Things did get a lot better around 14months but I was in therapy until 2 years and in need of that support.
For me it was some many factors that all came together in a bad way. Combination of the pandemic, my parents being full time carers for 3 85+ yos so couldn't help or support or, my in laws had a stage 4 cancer diagnosis so became extremely vulnerable and had to shield. They were a 4h drive away too so they couldn't help and certainly couldn't visit and my daughter had health problems with severe reflux and lots of allergies.
All my grandparents have now passed so my parents would be able to support or and my in laws are now in remission, as long as this remains the case they will be able to offer support. We have learnt so much about reflux and allergies and have a really good peer support network so I think we would handle that better the second time around. So then it "just" leaves by bipolar to cause chaos! They were quite hesitant to admit as I had never had an admission before. It was first suggested at 3months pp and it was 10 months pp when I went in. I think I would be more likely to get offered a bed earlier if I needed and might accept it earlier too.

I'm currently on lithium, quetiapine and mirtazapine. I am coming off the mirtazapine and then the lithium staying on quetiapine through pregnancy. I could have stayed on the mirtazapine up to pregnancy but I had concerns about being on it without the lithium as well. It's the only time in 15 years that I have managed to stay on an antidepressant for longer than 3 months as they usually sent me high quite quickly - my record is 12h! I was also on lamotrogine too but I came off that in January.

This all sounds incredibly difficult. I'm sure anyone without bipolar would have got very unwell.. let alone...
did your psych say you had to come off lithium? Was this a perinatal psych?
X

Thanks it was a very tough 2 years. I genuinely wanted to switch off my phone so I couldn't get more bad news. Aside from my mum breaking her back in January 2023 has been much calmer!

Yes due to the heart defect risk especially given the high doses I have needed for stability. My uncle was born with a heart defect in the 50s and died in infancy so it's been decided the risk is too significant due to personal situation. My partner also has a family history. If I need I can restart it at 6 months pregnant, I want to breastfeed so I will be only restarting it if I really need too. This is broadly the same as what the perinatal psych said when I was in the MBU. Prior to the postnatal episode I had been on just quetiapine for 8 years so there is good evidence that I can be stabilised without the lithium.

It's so complicated isn't it! I work in drug discovery and reading about recommend treatment plans rarely cover this is the individual circumstances of person A or B or C!

Ah yes sounds like being on quetiapine monotherapy is the right call. What's your lithium level when it's working for you? I'm considering dropping a little bit for the first trimester or at least weeks 4-8 which is when the heart forms. All tbc as we have our appt in a few weeks' time. How did you find coming off lamotrigine? What an interesting job you have!!

My levels had to be at 0.9 for it to be effective whilst depressed.
Coming off the lamotrogine was fine. I wasn't convinced it ever did anything tbh it was the last medication I was put on whilst waiting for my mood to respond to everything else. It was that or ECT which I didn't want.
Yeah it's really interesting I am a bit of a science geek! I would have loved to into medicine but it wouldn't have been good for me. I really enjoy working towards improving potential treatments for diseases.

That sounds like a good plan or once you stop taking precautions. From some of my reading it's can be before some women know that they are pregnant that the need to reduce but your Dr will be best place for working out the best timings for you. Things have come along way since my uncle was born and the defects can be easily repaired if they do occur and you would get lots of extra monitoring. With these things knowing there is a potential risk is a big plus because they can keep an eye out for signs etc.

Are you just on the lithium?

I'm on a dose of 700mg lithium which gives me a 0.54 level. At 800mg I get a 0.64 level. Tbh I'm on 700mg to test if I can stay well that low but I think I've proven I do need 800 as had a wobble recently. I'm also on 150mg lamotrigine but worried about removing it as I got unwell in pregnancy having come off it (I wasn't on anything for the first trimester and then got to a 3/10 depressed and went back on at 12 weeks. I'm not really willing to risk coming off either. I should probably go back up to 800mg and then wait to get a "BFP" on a pregnancy test as they love to say here before dropping to 700 again as that massively reduces the risk (levels >0.6 only increase heart defect risk by 10% rather than doubling it). Still we are talking about small %s which you will know as a scientist!

Know what you mean about lamotrigine being a v gentle medication - I don't think it does much for me when I'm in a depression and it has limited powers to prevent one (it doesn't do anything for a high and 80% of my lows follow a high, so can't be prevented). It does seem to help standalone lows which are few and far between. I'd be worried to not be on it postpartum but could risk being off it TTC. Maybe that's what my doc will say. I know he doesn't really want me on >1 med.

I'm on 800mg which puts me at 0.8-0.9. I was on 1000mg but I went toxic at 1.2.
For my gran is was put down to a rubella infection in pregnancy but who knows really they didn't do much investigations in the 50s.
A known risk is so much better than the same risk from an unknown source. You can be on it getting a test with first suspicions and the sonographers will be more on it to get the right images and all that.

The first time I was on lamotrogine with moderate dose olanzapine one dose of an antidepressant sent me from suicidal to manic in 12h. I was immediately taken off both! I wouldn't have gone back on it this time but I was running out of options. It was my 7 medication combination in 8 months! As soon as I was stable I wanted to go closely followed by the mirtazapine as antidepressants generally are just bad for me. From that perspective the preparation for TTC isn't dissimilar to the existing plan. I moved areas in Aug 21 and my new psych wasn't a fan of 4 high dose meds which suits me too. Like it gave me my life back but longer term I wanted a bit more from life than being medicated. Stress is a big trigger for my moods. If the stress is from August to February I get depressed, if the stress is March to June I go high. Without stress I have low levels of depression in the winter and I'm somewhere between bright and bubbly and low levels of hypomania through spring and summer.

It is good to stay on lithium if the other risks can be managed as each time you restart lithium there's a chance it won't work as well as it the previous times. For most people it's a small difference that they barely notice but it's generally not a medication that they want you on and off it multiple times a year. It is a very effective medication albeit with some annoyances and it's been used lots with women that have had lots of healthy babies!

My husband's on board and luckily very supportive. He does have a demanding job, so we'll have to arrange for good childcare so I can rest.

Best of luck with your appointment Georgia! Let us know how it goes xx