Welcome to State of Mind, a new section from Slate and Arizona State University dedicated to exploring mental health. Follow us on Twitter.
If I were to get pregnant, our baby would be loved. But for weeks, before I would ever find out I was pregnant, she would be exposed to psychiatric medication that can cause serious birth defects—the same medication I take each morning and night to manage my bipolar disorder. By the time I found out, I would be terrified for her health. I would also be terrified that I would have to go off my medication. Our baby would be loved. I would want an abortion.
“Depakote.” My doctor sat beside me in the inpatient psychiatric unit, where I’d been for nearly three weeks. We weren’t seeing enough improvement in my mood, and she was adding a new medication to my regimen. To someone starved for the beauty of the outside world, someone on her third stay in the psychiatric unit that year, it sounded like the scientific name of a strange and beautiful type of seashell. The syllables caught my attention more than the side effects.
My doctor told me it was a mood stabilizer. I don’t remember what else she said about it. My mind was a smear, a smudge, a soupy stain. Maybe she said it was a last resort drug. Maybe she said something softer, something that didn’t imply that I was on the edge of unfixable. I don’t remember. My mind churned. I decided to try it. In that moment, it felt like the choice to hold the seashell of Depakote up to my ear, hoping to hear the peace of the ocean, of life, again.
Over time, I improved. Though I still struggled, I was much more stable. I had been on Depakote for two years before a specialist in reproductive psychiatry told me the medication was “teratogenic”—it has the potential to cause birth defects.
Being on teratogenic medications is not uncommon for women with my condition. “I’d guess that at least 30 to 50 percent of women with bipolar disorder are on one of the classic mood stabilizers—lithium, Depakote, or Tegretol. The biggest meds for bipolar disorder that are teratogenic are Depakote and Tegretol,” said Jennifer Payne, professor and vice chair of research in the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia, via email. Depakote, she told me, is “the biggest teratogen of the three classic mood stabilizers,” leading to adverse outcomes such as neural tube defects, limb and cardiac anomalies, cognitive deficits, and autism in up to 15 percent of pregnancies. “The risk is three-fold over the general population,” Payne wrote.
The reproductive psychiatrist I consulted with two years after I had initially been prescribed Depakote told me the drug, which is also used to treat epilepsy, is not typically prescribed for people of child-bearing age (even though the onset of bipolar often coincides with child-bearing years). She said it’s used as a last resort for women my age who have bipolar. I was shocked to hear this after being on the drug for years. But reflecting on my experience, I knew Depakote had been a last resort, whether my inpatient doctor had explicitly said so or not.
When I was prescribed Depakote at 26 years old, I had been on many medications in the seven years since my diagnosis. I had been hospitalized so frequently that all the psychiatric nurses would greet me by name when I came back into the unit. I had made plans to die when I was depressed or mixed. The illness worked me into an unsustainable state when I was manic. Depakote, lithium, and electroconvulsive therapy helped me climb out of a vicious and unrelenting mood cycle that nearly killed me. Knowing the risks Depakote and other medications could pose to a developing fetus and knowing I had tried nearly every other mood stabilizer, my inpatient doctor had prioritized my life. I will always be grateful to her. But now, with Roe overturned, I worry women in states with abortion bans and their doctors will not be able to make that decision.
I always wanted children. If I didn’t take medication and didn’t have bipolar, an unintentional pregnancy would be a happy surprise at this point in my life. But as a woman who relies on Depakote, it would be scary—for me, for my husband, for the fetus. I’ve tried to taper off of Depakote without success. I’ve relapsed each time. Eventually I stopped trying. Depakote, lithium, and other medications help me stay stable, healthy, and alive. I don’t know if we’ll ever have children. Each night, as I unscrew the caps of my medicine bottles and count out the tablets in my hand, I choose myself over a potential child. By swallowing the pills, I am prioritizing my health over the health of someone who doesn’t exist, who may never exist.
The day the Dobbs decision came down, many women thought about themselves, their sisters, their friends in states where abortion access would be threatened. I thought about all the women who, like me, rely on Depakote or other teratogenic medication to manage their illnesses, but unlike me, now live in a state where abortion is not an option. Many of these women live with serious mental illness. I met some of them when I lived in Georgia, when I spent time in a couple of hospitals and outpatient treatment centers there. I remember their faces, if not their names.
In the 12 states where abortion is now banned, the two with a six-week ban, and others where bans are in legal limbo or expected soon, many people will have to make agonizing choices between their own mental health and the health of an existing or potential fetus. It is the cruelest choice, especially in states where “pro-life” state legislators have vocally prioritized the life and health of a fetus over the life and health of the person carrying it. In these states, women are being treated as incubators for a more valuable, more sacred, more precious future human. The woman herself is disposable. In Tennessee, legislators have gone so far as to exclude mental health from the provision that allows abortion “to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman.” To Tennessee legislators, a well-functioning mind is not a major bodily function.
For Kinsey Harrison, who has been diagnosed with bipolar disorder, has experienced psychosis, lives in Georgia, is married, and takes lithium, Georgia’s six-week abortion ban is terrifying. “I’ve always wanted to be a mom. Long before the overturn of Roe … my one-liner about abortion was that ‘I’m pro-choice, but my choice would be ‘no,’ ” said Harrison. (I know Harrison from attending the same Georgia high school). “But now that I’m taking a medication that can cause birth defects, even before the overturn of Roe, I’ve been thinking this isn’t quite as simple as I used to think,” she said.
Georgia’s “heartbeat law,” which went into effect in July, bans most abortions after six weeks.
“I would have to find out that I was pregnant, find a place to get an abortion, get it scheduled, and have it happen in this six-week period that is not based in any real science,” Harrison said.
There are certain birth defects associated with lithium, including a heart defect called Ebstein’s anomaly, which concerns Harrison. People with this heart defect typically have significantly reduced lifespans.
Payne, of the University of Virginia, emphasized such heart defects are rare and that the benefits of treatment with lithium may outweigh the risks. “Lithium has a bad reputation but the actual risk of [Ebstein’s anomaly] is less than 1 percent,” Payne told me via email. “The relapse rate of bipolar disorder in women who stop lithium for pregnancy is 85-100 percent. People generally forget that being psychiatrically ill is not good for pregnancy outcomes.”
Still, Harrison worries about taking medication while pregnant or becoming unintentionally pregnant on lithium. I empathize. Even if you understand the risks of a drug like lithium versus the risks of being unmedicated during pregnancy, the choice to stay on less teratogenic medications still feels heavy when such a choice could directly affect your future child, your family, and the rest of your life. I understand wanting to minimize the risk of those rare complications, even as I know that being unmedicated and ill during and after pregnancy brings its own set of risks and complications. Even if you’ve made an informed choice to stay on a medication like lithium, I imagine it feels scary to swallow a handful of pills each morning and night when you are pregnant. You can know the facts and still feel the emotional pull of your own wishes.
While lithium carries less risk, for patients on Depakote, conversations about birth control are key. Julia Riddle, clinical assistant professor at the Center for Women’s Mood Disorders at the University of North Carolina, Chapel Hill, told me via email that in the field of reproductive psychiatry, it’s generally accepted that Depakote should be avoided unless necessary—and when someone who could get pregnant is placed on Depakote, it’s critical to integrate discussions of family planning into care. “It is not lost on us that we are placing women in even more fraught positions to make decisions about their mental healthcare now that reproductive decisions are being limited by law,” she wrote.
With Roe overturned, physicians have to work with their patients to have these conversations and calculate risk differently than before, especially in states with abortion bans. Given restrictions on abortion access, said Payne, patients are having to “think carefully about what they would do if they became unintentionally pregnant. … I think it also makes psychiatrists think hard about putting a woman on Depakote. I generally only use Depakote and Tegretol when I’ve exhausted other options for a woman of child-bearing age—yet others use it routinely in the inpatient setting.”
It’s hard to hear this, but I know it’s true. Every psychiatrist I’ve seen since age 18 must have been taking this last-resort approach to Depakote, because I didn’t start taking it until I had tried nearly every other option. Part of me wishes Depakote didn’t work for me, that a less teratogenic medication worked much better on its own. But it does work for me. As Payne told me, “there are plenty of cases where Depakote is one of the few options a woman has.”
I have struggled with breakthrough mood episodes even while on a combination of Depakote, lithium, and other medications. My mood has not been perfectly stable since I started taking Depakote. It hasn’t been a miracle drug. But when I think about the medications I’ve tried and what has worked best, Depakote is in the top three. It has changed my life—for better and for worse. If not for Depakote, my moods might be much more erratic. If not for Depakote, we might have a child.
For Harrison, the overturn of Roe has meant thinking through pregnancy with much more trepidation. “There are a couple scenarios I try not to play out in my head,” she told me. “The first is that I’m not able to get past the darkness of the (medication) withdrawal … and I go back to the medication I never asked to be on. Scenario B is scarier, and it’s that I push through the withdrawal and in the act of pushing through that become psychotic. The worst, Option C, is that I do get pregnant but through the stress of it all, have a miscarriage. If any of those three scenarios happened, I don’t know how I would ever attempt to go through that process again.”
I have my own scenarios. I don’t know how I would go off Depakote. I don’t know how I would deal with a major relapse while pregnant. I don’t know how I would forgive myself if my pregnancy had serious complications or if my baby was sick—either due to medication I chose to stay on or due to my unmedicated bipolar. It feels like a lose-lose scenario.
Riddle is concerned that people who become pregnant may stop their medication without consulting their doctor—which can be extremely dangerous both physically and mentally, and includes risks of post-partum depression, post-partum psychosis, and suicide, to name a few. They may also choose to preemptively go off their medication without consulting a doctor for fear of becoming unintentionally pregnant while taking a teratogenic medication. They may do so even if this medication is the only one that has worked.
“With severe bipolar illness that involved severe manias leading to hospital admission, valproic acid [Depakote] can be one of the most effective agents at controlling an acute mania. Unfortunately, we have no idea how many of these women are then discharged on Depakote with conversations about pregnancy,” Riddle said in an email. In states with limited reproductive choice, she said, doctors should communicate with patients about changing family planning options, and if necessary, trial other medications. (While Depakote clears the body in a matter of days, it needs to be tapered off, under close supervision from a doctor.)
Though Harrison does not take Depakote and takes birth control, she has considered going off lithium. “It’s a lot of uncertainty,” she said.
Riddle emphasizes that going off such medication can lead to other adverse outcomes. “Untreated mental illness is also associated with poor pregnancy and infant outcomes—so a pregnancy in someone struggling with mental illness but not on medication does not mean the pregnancy is suddenly ‘protected,’ ” she said.
In short, for people living with mental illness, abortion bans will have a devastating impact on mental health by making medication choices much more complicated and fraught.
These decisions are further complicated by a mental health provider shortage: According to the Health Resources and Services Administration, 155 million people live in designated mental health professional shortage areas. Specialized reproductive psychiatrists—which according to the Johns Hopkins Center for Women’s Reproductive Mental Health are “experts in the diagnosis and management of mood and anxiety symptoms that occur around the menstrual cycle, across pregnancy and in the postpartum, and during the perimenopausal years”—are even harder to come by.
Abortion, thus, is a particularly necessary fixture of the mental health care system. Being in control of one’s own life and body, being able to choose whether to take teratogenic medication for your own health without fear, being able to choose whether or not to continue with a potentially traumatic pregnancy—those things contribute to overall mental health and wellbeing. I live in a blue state, where I can choose to stay on Depakote, knowing its risks and knowing that I would be able to get an abortion if I needed one. Everyone should be able to have that security, autonomy, and agency.
For Payne, the interplay between psychiatric illness and abortion access is personal as well as professional. Payne’s daughter—who has schizoaffective disorder, bipolar type—takes lithium and Tegretol. “I have talked to my daughter, who decided long ago that she should not have children, and she’s pragmatic about it and says she would go to another state if necessary,” Payne said. “I stand ready to help her if that were to be the case.”
“Depakote.” Standing in the bathroom, I read the label, turn the cap, and shake two pills loose from the orange bottle. They join the other pills in my hand. Maybe I’ll come off of this medication one day, but not right now. I don’t know if we will have children, but I know that both abortion access and medication access are crucial for my ability be well. And my ability to be well is critical to my ability to someday, maybe, safely have children—or just exist as a woman, as a person. I deserve to be well either way.
I look at the pills, turning them over with my thumb. How can these pills cause so much damage? How can they do so much good? How can people ever understand the ache of this choice? As I swallow my medicine, I hold the seashell to my ear, hoping to hear affirmation.
Hoping to hear that I’m doing the right thing. Hoping to hear that my mental health matters, that my life is more valuable, more sacred, more precious than the life of someone who doesn’t exist.
I hear nothing.
I’ll say it to myself, then.
If you need to talk, or if you or someone you know is experiencing suicidal thoughts, text the Crisis Text Line at 741-741 or call or text 988 to reach the Suicide & Crisis Lifeline.
State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.
