Dr. Crystal T. Clark, Associate Professor of Psychiatry at the University of Toronto and Canadian Research Chair in Reproductive Mental Health, joins the podcast to discuss the evidence-based management of bipolar disorder across pregnancy and the postpartum period. Dr. Clark, recently appointed head of the Department of Psychiatry at Women's College Hospital, has built her research career around closing the pharmacokinetic evidence gap for the mood stabilizers and antipsychotics used during pregnancy.
For decades, clinical practice around perinatal bipolar disorder was shaped by stigma and a lack of data, leaving many women counseled to discontinue effective treatment or avoid pregnancy altogether. Dr. Clark reviews how physiological changes in pregnancy alter the clearance of lamotrigine, lithium, and atypical antipsychotics, why postpartum tapering requires close monitoring, how the Mood Disorder Questionnaire can help distinguish bipolar from unipolar postpartum depression, and what her research reveals about racial disparities in diagnosis among Black women.
🎯 KEY EPISODE HIGHLIGHTS:
🚫 THE STIGMA OF DISCOURAGING PREGNANCY [05:30]
“No, there's no data. This is all stigma.”
Dr. Clark names outright that generations of counseling women with bipolar disorder against having children was never grounded in evidence.
🧪 LAMOTRIGINE CLEARANCE CAN JUMP 300% IN PREGNANCY [16:00]
“Elimination clearance really increases during pregnancy as much as two hundred to three hundred percent.”
This pharmacokinetic shift explains why patients on a stable lamotrigine dose can relapse mid-pregnancy despite full adherence.
📊 HIGHER BIPOLAR PREVALENCE AMONG BLACK POSTPARTUM WOMEN [48:30]
“When you looked at bipolar disorder, there was a higher prevalence amongst Black women.”
This diagnosis-level finding, rare in perinatal mental health research, points to a gap in how bipolar disorder is recognized in Black patients.
CHAPTERS:
00:00 – Introduction: A Career Built on Closing the Evidence Gap in Perinatal Bipolar Disorder
02:30 – The Discontinuation Era and the Stigma of Childbearing with Bipolar Disorder
08:30 – Reweighing the Risk-Benefit Calculus: Untreated Illness as Its Own Danger
13:30 – From Residency to Research: Uncovering the Pharmacokinetic Evidence Gap
18:00 – The Pharmacology of Pregnancy: How Lamotrigine, Lithium, and Antipsychotics Are Metabolized Differently
22:00 – From Algorithm to Practice: Applying and Titrating Lamotrigine Across Pregnancy and Postpartum
28:30 – Lithium in Pregnancy: Monitoring Levels and Revisiting the Ebstein's Anomaly Risk
35:00 – Atypical Antipsychotics: Quetiapine and Risperidone Pharmacokinetics
40:00 – Distinguishing Bipolar from Unipolar Postpartum Depression with the MDQ
45:30 – Racial Disparities in Perinatal Bipolar Disorder Diagnosis
50:00 – Designing a Postpartum Monitoring Plan for High-Risk Patients
54:00 – Future Directions: Formalizing the Lamotrigine Algorithm and Black Maternal Mental Health Research
57:30 – Closing Reflections: The Path Toward Diagnostic Precision
LINKS:
Full transcript and show notes:
https://www.psychiatrist.com/jcp/ep18-bipolar-disorder-pregnancy-postpartum-crystal-t-clark/
Journal of Clinical Psychiatry
https://www.psychiatrist.com/jcp/
Publisher of peer-reviewed research discussed in this episode.
Dr. Crystal T. Clark – LinkedIn
https://www.linkedin.com/in/crystalclarkmd/
Rates of Major Depressive Disorder and Bipolar Disorder in Black and White Postpartum Women (JCP, 2024)
https://www.psychiatrist.com/jcp/rates-major-depressive-bipolar-disorder-black-white-postpartum-women/
The 2024 study discussed at length in this episode's chapter on racial disparities in perinatal bipolar diagnosis.
A Comparison of Symptoms of Bipolar and Unipolar Depression in Postpartum Women (J Affect Disord, 2022)
https://pubmed.ncbi.nlm.nih.gov/35041868/
The MDQ-based screening study Dr. Clark walks through when discussing how to distinguish bipolar from unipolar postpartum depression.
#BipolarDisorder #PerinatalPsychiatry #Psychopharmacology #PostpartumPsychosis #MaternalMentalHealth
