Deciding to have a baby (or another one) is a big step for anyone. But, if you also happen to take antipsychotics for a mental health issue like bipolar disorder or schizophrenia, that may cause additional questions: Can your medications impact your fertility? Is it safe to be on those medications during your pregnancy? Is it safe to stop taking them? The answers aren’t always clear-cut, so talking to your doctor is essential. That said, here’s a primer that may offer some insight before your appointment.
First, let’s recap why antipsychotics are sometimes used to treat conditions like bipolar disorder and schizophrenia.
Psychosis is a state of becoming detached from reality. It can result in delusions (false beliefs) and hallucinations (seeing or hearing things that aren’t there), according to the National Institute of Mental Health (NIMH).
This can happen with certain mental health conditions, such as schizophrenia and bipolar disorder. Schizophrenia can often cause a difficulty interpreting reality, according to the Mayo Clinic. In addition to delusions and hallucinations, it can cause extremely disorganized speech and behavior, along with what’s known as “negative symptoms,” or difficulty functioning normally (like by maintaining personal hygiene or engaging socially).
Bipolar disorder, on the other hand, is a condition characterized by mood episodes, which can come in various forms. Someone may be experiencing a manic episode if they have an extremely elevated mood and energy level for at least seven days, according to the NIMH. (Or shorter than that if the symptoms are severe enough to warrant hospitalization.) Someone could be experiencing a hypomanic episode if they have elevated mood and energy levels for at least four days, but on a less extreme level than with a manic episode. Someone experiencing a depressive episode has feelings of sadness and hopelessness for at least two weeks, along with lowered energy levels. And someone experiencing a mixed mood episode would have persistent symptoms of mania and depression at the same time. Whenever a person’s depressive or manic mood episodes get severe, they may experience psychosis.
Antipsychotics are designed to help with the detachment from reality that illnesses like schizophrenia and bipolar disorder can cause. These drugs typically work by affecting the levels of brain neurotransmitters that impact mood, like dopamine and serotonin, Jamie Alan, Ph.D., an assistant professor of pharmacology and toxicology at Michigan State University, tells SELF.
Antipsychotics can be broken into two groups: typical (first-generation) and atypical (second-generation). Both can treat schizophrenia and bipolar mania, but only atypical antipsychotics can be used to treat bipolar depression as well, the NIMH says.
Research shows that antipsychotics may make conception more difficult.
This is because their effect on the neurotransmitter dopamine may have the potential to increase the levels of the hormone prolactin in the body, which can lead to anovulation in some people. If this happens to you, your body may not release eggs for potential fertilization, Dr. Alan explains. “The [changes in] prolactin levels fluctuate with dose, however, and it's hard to predict what change in prolactin will affect fertility in an individual,” she says.
Translation: Simply taking antipsychotics or having increased prolactin levels doesn’t automatically mean you will have trouble conceiving. What’s more, much of the research on how bipolar disorder medications affect fertility has been conducted on rodents (not humans), this possible connection hasn’t been studied with all antipsychotic drugs, and different antipsychotics may affect your dopamine levels to differing degrees.
Even with those caveats, we know this might sound discouraging. But it’s entirely possible to be on these medications and have no related problems conceiving, Jonathan Schaffir, M.D., an ob/gyn at the Ohio State University Wexner Medical Center, tells SELF. What’s more, finding the proper mix of bipolar disorder or schizophrenia medications can be necessary for being in the healthiest state possible before conceiving. If you’re taking antipsychotics and concerned about how they may affect your prolactin levels and fertility, ask your doctor to walk you through what you should know.
When it comes to taking antipsychotics during pregnancy, experts suggest discussing your specific case with your provider.
While doctors have a somewhat decent idea of how various psychiatric treatments can impact pregnancy, a lot of these medications haven’t been widely studied in humans because many pregnant people generally don’t want to sign up for this type of research, Dr. Schaffir says. So, that means a lot is uncertain when it comes to how antipsychotics may be related to birth defects. The overall medical consensus is that this is an important and nuanced topic that requires much more investigation, as many of the results so far have been inconsistent.
Some research has indicated that antipsychotics can indeed contribute to birth defects, according to the NIMH. (Especially in the first trimester, which is when many important organs and structures form.) However, much of this research has been small or conducted on animals, and there are so many potential confounding factors to eliminate in order to reach a solid conclusion. It’s ultimately hard to tease out how much of an effect antipsychotics may have in regards to congenital defects.
Also, most of the relevant antipsychotic/pregnancy research has been conducted on the typical antipsychotic haloperidol, which has not been concluded to lead to birth defects, the NIMH says. But researchers are still looking into how other antipsychotics might impact pregnancy.
To that end, a 2016 study performed on 1.3 million pregnant people and published in JAMA Psychiatry found that there was no significant increased risk of congenital malformation tied with any type of antipsychotic use in the first trimester. The only possible exception was the atypical antipsychotic risperidone, for which study authors found a small increased risk. However, the study authors note that this conclusion should be interpreted with caution because they could not prove causality and it could have been a chance finding. Instead of confirming that risperidone is linked with birth defects, the study authors note that this is simply something that warrants further investigation.
As study authors in a 2016 review in Obstetrical and Gynecological Survey note, any increased risk of birth defects with any antipsychotics may be tied less to the drugs directly and more to an indirect risk related to their side effects. Some antipsychotics are linked with metabolic side effects such as weight gain and increased glucose levels, which can then increase the risk for issues like neural tube defects, the review explains.
Beyond the question of antipsychotic use in the first trimester, there’s also worry that antipsychotics taken in combination with other medications may increase the risk of birth defects, according to the NIMH. For instance, many people with bipolar disorder take multiple medications, including mood stabilizers like lithium, which, unlike antipsychotics, has a known potential to cause birth defects.
Ultimately, since the potential link here is far from definitive, U.S. Food and Drug Administration (FDA) labels for antipsychotics generally do not state that they should not be used in pregnancy. There’s not a clear, evidence-based reason to think that using an antipsychotic during pregnancy is more likely than not to result in birth defects. Instead, FDA labels for antipsychotic drugs state that they should be reserved for cases where the possible benefits outweigh the possible risks. Even with the mood stabilizer lithium, which is more clearly connected with birth defects, its FDA label advises the prescriber to strongly weigh this possibility if a person is pregnant, along with monitoring them and their dosage if they continue using the drug during pregnancy—it doesn’t say pregnant people cannot use the drug.
That said, the FDA warns that there is a link between antipsychotics taken in the third trimester and newborn health issues.
Even though a lot is still unclear when it comes to antipsychotics and pregnancy, in 2011, the FDA issued a safety announcement on the subject.
The FDA said it had updated the “pregnancy” sections of all antipsychotic drugs to include more information about how antipsychotic use in the third trimester of pregnancy could affect newborns.
According to the FDA, there is a potential risk of abnormal muscle movements (this is known as extrapyramidal signs or EPS) and withdrawal in these newborns. Symptoms include agitation, hypertonia (too much muscle tone resulting in stiffness), hypotonia (too little muscle tone resulting in floppiness), tremors, drowsiness, and more. Many of these symptoms are known antipsychotic side effects, and it’s clear that antipsychotics can cross the placental barrier, according to the FDA. In newborns, these symptoms can abate in a few days even without treatment or may require hospital stays for treatment.
However, even with this possibility, it’s incredibly important that anyone taking antipsychotics—pregnant or not—does not stop taking these drugs without first talking to their doctor. Again, the medical consensus is not that all antipsychotics are contraindicated during pregnancy. It’s that sometimes the benefits of taking antipsychotics during pregnancy might outweigh the risks and vice versa. That needs to be the deciding factor.
For some people, it still makes sense to stay on antipsychotic drugs when trying to conceive or while pregnant. You can only know where you fall if you talk to your doctor.
“It’s important to keep in mind that we don’t have very detailed explanations of what the risks of these medications are weighed against the risks of the condition itself,” Dr. Schaffir says.
For example, being unmedicated when you have bipolar disorder increases your odds of engaging in risky, life-threatening behavior during manic episodes and suicidal thoughts during depressive or mixed mood episodes, Dr. Thase points out. The risks of taking certain medications “must be balanced with the risks of untreated mania or depression, which can be considerable,” he says. Same goes for schizophrenia.
If you’re taking antipsychotics and you want to try to get pregnant, it’s a good idea to have a conversation with your ob/gyn and psychiatrist first.
If you’re ready to try to conceive, your doctor may recommend switching your medication during this time to something that has a lower risk of impacting your future pregnancy, Dr. Thase says.
Once you do get pregnant, it’s important to keep an open dialogue with your doctor about how your medications are working and if there’s any concern about them passing to your baby through breastfeeding. “You really want to start these conversations before conception so you can have a plan in place,” Dr. Schaffir says.