Clinical Twisters: Treating depressive episode

A 28-year-old woman, S.A. (two months' pregnant), is brought to your ER by her husband, who believes she is suicidal. According to your health-system medical records, S.A. was diagnosed with bipolar II disorder several years ago. She was previously treated with lithium and lamotrigine (Lamictal, GlaxoSmithKline) separately but was noncompliant. Her psychiatrist is weighing a mood stabilizer and/or antidepressant therapy during pregnancy. He asks for your recommendation.

Assuming S.A. is deemed acutely suicidal, relatively safe and rapid treatment is essential. Electroconvulsive therapy (ECT) represents an attractive option. ECT is associated with high response rates, although there are inconsistent and infrequent reports of complications during pregnancy. The clinician administering ECT must know S.A. is pregnant to appropriately choose premedication.

Whenever possible, pharmacotherapy should be avoided during the first trimester of pregnancy, but risks must be weighed against the potential consequences of forgoing effective treatment. Given S.A.'s presentation, if ECT is not acceptable, pharmacotherapy appears warranted.

Kristine Steffen, Pharm.D. Postdoctoral Fellow James Roerig, Pharm.D., BCPP Research Scientist The Neuropsychiatric Research Institute Fargo, N.D.

American Psychiatric Association guidelines recommend lithium or lamotrigine as first-line treatment for bipolar depression; antidepressant monotherapy is not recommended due to risk of precipitating mania. For patients with suicidality, psychosis, catatonic features, inadequate intake, or treatment-resistant episodes, ECT may be warranted. As pregnancy does not appear to protect from mood episodes, appropriate therapy could be selected based on medication response history, symptom severity, and possible teratogenic effects.

The risk for cardiac defects appears highest 21 to 56 days after conception, which may limit S.A.'s risk for Ebstein's anomaly with lithium. Malformations with lamotrigine appear to be low; however, evidence is limited. Adjunctive medications may be necessary during lamotrigine dose titration. To minimize teratogenic effects, administer minimum effective dose. Both may require dose adjustments during the third trimester and at delivery.

ECT is most favorable in minimizing teratogenic effects, as the risks from anesthetic agents are relatively limited. In addition, complications from the procedure during pregnancy are uncommon. ECT could be used acutely, based on the severity of suicidal thoughts, as well as for maintenance during pregnancy.

Katie A. Carls, Pharm.D., BCPPPsychiatric Clinical Specialist University of Minnesota Medical Center-Fairview Minneapolis