Dear Dr. SerVaas: I am bipolar and would like to start a family. I am on lithium. Have there been any studies about how lithium might affect the unborn?

Janice O'Brien
via e-mall

Dear Reader: We sent your letter to Dr. John Nurnberger, Jr., who is an authority on mood disorders. He responds as follows:

"There have been such studies. A lithium registry was developed by Dr. James Jefferson and colleagues at the University of Wisconsin. Their data, although it depended on reports from individual women and doctors, suggested that lithium was responsible for a slight increase in birth defects, especially heart problems. We should emphasize the word slight here, since the vast majority of babies born to women taking lithium were perfectly fine (recent data suggest that the added risk may be as small as one in 2,000). The primary alternative medicines for bipolar illness, valproate (Depakote) and carbamazepine (Tegretol), have also been associated with a small increased risk of birth defects. The newer medicines sometimes used for bipolar disorder are not as well-tested (e.g., gabapentin, lamotrigine, topiramate, olanzapine, risperidone). Some physicians will recommend small doses of the older tranquilizing medicines, such as haloperidol for problems with mania during pregnancy. For severe problems, electro-convulsive therapy may be used. Many physicians now would advocate low-dose lithium (with careful monitoring) as the treatment of choice if a woman has responded to it previously.

"Decisions about treatment during pregnancy would generally be made by a woman after discussion with her psychiatrist, her obstetrician, and her family members or significant others. Some women will wish to try to gradually discontinue medications prior to becoming pregnant. This, of course, has its own risks, and should only be done under the supervision and monitoring of a psychiatrist. These issues have also been discussed by Jay Amsterdam and colleagues (Psychiatric Annals, 32:397404, 2002) and by Lee Cohen in Currents in Affective Illness, 20:5-12, 2001."