Bipolar in Perinatal Setting

CE / CME

eCase: Treatment Considerations for Bipolar in a Perinatal Setting

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Social Workers: 1.00 ASWB ACE CE Credit

Pharmacists: 1.00 contact hour (0.1 CEUs)

Psychologists: 1.00 APA CE Credit

Nurses: 1.00 Nursing contact hour

Physicians: Maximum of 1.00 AMA PRA Category 1 Credit

Released: December 22, 2022

Expiration: December 21, 2023

Joseph F Goldberg
Joseph F Goldberg, MD

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Margaret is a 30-year-old woman who was hospitalized for a manic episode during her freshman year in college and stabilized on a combination of lithium, divalproex, and aripiprazole. She had a remote history of alcohol use disorder and cannabis use disorder in high school, which predated her manic episode; these substance use disorders have since been in remission. She remained well on her pharmacology regimen for several years until experiencing a depressive episode at age 25, which responded to replacement of aripiprazole with quetiapine 300 mg/day. During the next 2 years, her mood remained euthymic but she gained 25 lbs and was diagnosed with prediabetes (hemoglobin A1C 6.3%). Now married and planning to become pregnant, her psychiatrist advised stopping both lithium and divalproex before conception due to concerns about possible teratogenic effects or obstetrical complications. Approximately 4 months after discontinuing those medicines and remaining solely on quetiapine, she has not conceived and has become increasingly depressed and passively suicidal. Her psychiatrist added sertraline up to 150 mg/day but produced no benefit and has advised switching the sertraline to venlafaxine for “broader antidepressant coverage.” Margaret now presents for a second opinion consultation. Her mental status exam at that time is notable for the following:

  • Depressed mood with sad affect
  • Slowed speech
  • Passive suicidal ideation without intent or plan
  • Initial and middle insomnia with next-day fatigue
  • Poor concentration
  • No signs of psychosis or mania

Laboratory values are pertinent for normal thyroid function, complete blood count, and comprehensive metabolic profile.

What would you advise Margaret as a next step in her care?