Category Archives: Antepartum depression

Just Talkin’ Tuesday 10.27.09: What’s YOUR Postpartum Mood Disorder Story?

women talking in sunset

Original Photo taken by tranchis @ flickr

This site was started to help me re-frame an unexpected pregnancy after two rather nasty experiences with Postpartum OCD. Turns out that by doing so I not only helped myself but managed to help a lot of other women along the way.

There was a point during my suffering when I dreaded having to retell my story. Looking back I should have just typed the whole thing up and kept copies on hand – kind of like a resume. (Hey – not a bad idea if you end up having to hunt for a decent doctor!) But there came a turning point where my story began to foster a sense of strength and self. Finally I began to bloom.

We’re all at different points on our journey. Some of us are right in the thick of it, some of us a bit further out, others are fully recovered, some have relapsed and are struggling right back out thanks to the path we carved out the last time we fell down. But we are all in it together.

Rather than retype my entire story here (cuz that would take some time!), you can click here to read about “The Day” I was admitted to psych ward. And if you’re brave enough (ie, preferably not in the thick of it or relapsed) you can read another piece I’ve written here about some of the thoughts I had when things were so dark I couldn’t even see my hand in front of my face.

For me and for many others, telling our story or even venting has become a powerful source of personal therapy. It’s a way to just get some of the stress out of our body, our mind, and even possibly work through issues.

So let’s get to just talkin’ here. I want to hear your stories. I want to know what you’ve gone through/are going through. Speak up. We’re here to be supportive, compassionate, and lend our hearts.

I can’t wait to read what you have to share!

Danish research and SSRI use during pregnancy

An article at medpage.com heralds a new study released September 25, 2009 by Danish researchers. The article carries the sensationalized title “SSRIs in Pregnancy Hike Risk of Heart Defects.”

While the title itself raises eyebrows, the researchers themselves state that they were unable to conclude if the results were because of medication or the underlying depression. Also important to keep in mind is that this research is based on women who had prescriptions filled for SSRIs but does not appear to have checked to see if these women actually took the medication. Instead, they rely on data from a national registry.

Pedersen and colleagues analyzed national registry data on more than 493,000 births in Denmark from 1996 to 2003. The data included prescriptions filled by mothers-to-be as well as the medical status of their babies at birth.”

And directly from the study:

Our results, however, depend on a correlation between redemptions of prescriptions and drug use. Non-compliance might be a problem for this type of exposure definition and could mask true associations if some of the “exposed” were in fact unexposed.

The most interesting piece to come out of this research is that of the studied SSRI’s, Paxil appeared to have the least risk of septal heart defects. I find this very interesting considering that Paxil is the only SSRI to currently carry a heart defect specific warning.

As with all studies and research, you should always examine all sides and aspects and educate yourself rather than relying on the word of others when making your final decision. Ask yourself if the person presenting the information has your best interest at heart or is merely trying to frighten you with inflated facts and figures. (Click here to read a previous post full of tips on how to find solid medical advice on the web.)

Dr. Shoshana Bennett, author of “Pregnant on Prozac” released this statement regarding this research:

Finally, treatment for the serious and potentially life-threatening illness of prenatal depression (for both mom and therefore baby) is being formally discussed. Fifteen percent of clinically depressed pregnant women try to take their lives – a bit more risky for the baby than mom taking an antidepressant, wouldn’t you say? If the pregnant woman can be non-depressed without a medication, that’s optimal. Some form(s) of treatment, however is essential. If natural and alternative approaches to wellness are not enough, it is regarded by those in the know to be safer for her (and her developing baby) to take an antidepressant than to remain depressed. Depression itself – it is quite clear from the research – crosses the placenta and alters the uterine environment causing negative consequences to the baby. In the latest research there appears to be low (0.9%) chance of a septal heart defect in babies whose mothers had taken certain antidepressants. However, what fear-mongers do not report, is that the researchers themselves could not be sure whether it’s the antidepressant or the underlying depression itself that caused the defect. Women need all relevant information and education about options for treatment during pregnancy so they can make the best decision for themselves and their family. Watch out for alarmists who are not interested in actual data – they are simply invested in promoting fear in women who are at their most vulnerable.

Shoshana Bennett, Ph.D.

http://DrShosh.com

Increased risk was determined by “redemption” of more than one SSRI prescription. Those who redeemed more than one prescription had infants with a higher percentage of septal heart defects. But again this begets the question of whether or not this result lay with the SSRI or the underlying depression/mental illness/stress the mother may have been experiencing in order to receive said prescription.

Bottom line here: Don’t think for a second that becoming a Mom starts at birth. It starts at conception. And we owe ourselves AND our infants the best start possible. This means researching by asking questions and seeking out solid answers. It means finding physicians who will be your co-pilot instead of an uncooperative Auto-Pilot unaware of the pot-holes facing them. It means putting together the best support you can with what you have access to at the time. I happen to agree that a SSRI free pregnancy is absolutely optimal. I also think you should run (not walk) out of any doctor’s office if said doctor is quicker with the script pad than the warm shoulder. But we have to remember that every situation is different. Every person is different and every pregnancy is different. And sometimes we may just have to take medication. It doesn’t make you weaker, it doesn’t make you stupid, and it doesn’t make you a bad mom. And above all, remember that the decision to take or not to take a SSRI during pregnancy is your decision. Make it with an empowered spirit, stick to it, and don’t look back.

PPD Survivor Shares her Story for the first time

On Tuesday, this was a comment left by a mom who had never shared her story with anyone besides her husband (who lived it with her). I emailed her to ask if she would be comfortable with me giving it a post of it’s very own. Her story begins when she is 34 weeks pregnant and continues through to postpartum. I hope you find it as inspiring and as strong as I did…..

This is my first time to share my story in any capacity…. I don’t know if I’m ready, but here goes nothing…

My depression started around 34 weeks into my pregnancy… I had never heard of PPD and I didn’t know what ante partum depression was… I started to realize something was wrong somewhere between 30 – 34 weeks. I’m not afraid of medication, and think of it as an aspirin would be to a headache.

I have had depression and anxiety before so, I somewhat, recognized the signs. I told my husband that I wasn’t quite feeling right, and he encouraged me to speak with my OBGYN. At my next appointment I told my doc that I was worrying excessively, and not feeling quite right. It was really a whole new type of depression for me.. I never could and still have difficulty describing the way I felt. But worry was a BIG concern. The OBGYN said it wasn’t a big concern, and not to worry lots of new mom’s worry a lot.

My husband is a member of the “mind over matter” club. While he, I’ll say, tolerates, my need for meds to get my depression under control, he definitely is one of those, “Just push through it,” kind of people.

I saw my OBGYN on Tuesday, and she prescribed me Prozac, I ended up going to the E.R. on Sunday because I felt very overwhelmed; with what exactly, I do not know… They gave me an Ativan shot, made sure I calmed down and sent me on my way, with no real information. Or possible expectations. I then saw my OBGYN again on Wednesday, explained what had transpired over the weekend, and she prescribed me some Xanax. I felt so horrible that day, that we went straight to the nearest pharmacy and filled the script so I could take one. That Sunday I woke up and I felt worse than I thought I ever could. I told my husband that he had to take me to the E.R. So they could take the baby out so that no harm would come to her, if I did end up harming myself.

I thought this was a completely rational thought process; and was even more distressed when they told me that instead of delivering my baby early, they were sending me to the Nut House. All of this scared my husband to death, not only was he in fear of losing his wife, but that there was a possibility that he could end up without a wife and a child, or raising a baby on his own. And it was definitely one of the two, because the baby could not stay in me anymore.

I think that is when he realized, after two weeks of doctors and E.R. visits, that something was really wrong and a real threat existed not only to my life but to our unborn daughter’s life as well! I went to the psych. ward at a private hospital, where they were fairly knowledgeable about pregnancy related depression. The one thing that is VERY FRUSTRATING in my case, is that, since I was pregnant I was having a OBGYN come in and check on me daily, and since I was high risk (because of a blood disorder) I had a specialist coming to see me daily as well. They kept telling me it would be okay for me to get some Ativan, which had provided tremendous relief at the E.R. Visits, but the psychiatrist that was assigned to me when I arrived, REFUSED to give me anything other than Benadryl and Celexa, neither of which were providing any immediate relief.

As I have learned over the past year and a half since this all occurred, most psych. Wards have limited visitation, and mine was no different. My husband could come to the evening visitation and spend an hour with me. The first few days all I did was cry the whole time he was there. He was so scared. I was breaking his heart and that just made me feel even worse. I really just wanted to give him the baby and leave (you know d-i-e…) I didn’t want to burden him with all of my problems anymore. The thought of me not being around anymore, was the thing that was really bothering him. He got it in those moments.

I got out of the hospital and managed to hold it together until 38 weeks!!! YAY ME!!! When my OBGYN, asked if I wanted to go ahead and deliver, I practically took myself straight to the hospital right then. Coincidentally, I went into labor on my own the day I was scheduled to deliver. My delivery was easy… But there were some complications with my epidural, which lead to added stress. It is the most horrible feeling in the world to think back onto that day and to look at pictures and to know in those moments there was no joy, no love, and no want, for my beautiful, brand new baby girl. You can see the blankness in my face and the fakeness in my smile in all of the pictures… It breaks my heart to think of it. Will she understand, what was wrong with me then? Will she know how much she has ALWAYS been loved and wanted!

This was my husband’s first baby, but my second. I have a, now 10 y.o., daughter from a previous relationship, so I had been through the nursing and diapering and everything before. I was uncertain of myself because of my depression and anxiety, but I knew what I was doing automatically. My husband second guessed everything I did. He questioned my positioning of the baby while nursing, and was convinced that she was not getting any milk, despite the fact that the nurses had told him multiple times that everything was going fine. As one would assume this only compounded the problem I was dealing with.

A couple of days out of the hospital and other than the epidural complication I thought I was feeling much better! I look back now and think that the depression was just masked by the Vicodin they were giving me for pain after the delivery. I probably had about a weeks worth of Vicodin, and within a few days after that, I was back in the E.R. I won’t go into all of the how I was feeling… But I ended up back in the psych. Ward.

Telling my husband the second time felt easier to me… With the flawed logic of depression, It seemed very simple. I leave (aka die) and then he doesn’t have to worry about me, he now has his child, life will be easier without me… Yada yada yada… The same visitation schedule existed, naturally, I had just been there little less than a month before… My husband came to all the visitations and brought our daughters. (the first time I lied to the oldest about where I was, she still doesn’t really know why I was there either time) again, in the moment, he was understanding, apologetic, and sympathetic. He just wanted me to do what ever I need to do to get better, and come home to our family.

We had tough decisions to make. Since I was nursing, and since I had the same psychiatrist that I had had previously, she was equally unwilling to provide me with any REAL meds, until I agreed to stop nursing ( as I type that, I think I hate her for that!) Up until the point in which I agreed, I pumped and dumped, my milk every few hours in my room there in the ward. That too was heartbreaking, but I was finally at a point mentally where I knew I had to get better and go home, and without me at home, there wouldn’t be breast milk anyway! So I stopped pumping and finally got some relief!!!

When I first came home my husband was great!!!! He did the laundry without being asked, he made sure there were meals for everyone, he helped out with our new daughter a lot. But as time passed and things have gotten better his back to his same old self. Mind over matter. He really does spend a lot of time wondering what the hell is wrong with me.

I’m glad to report, that I’m now doing great, as long and I don’t have to talk about the time around my daughter’s birth, (this post has resulted in the need to take some Ativan!) And you don’t talk to me about having another baby, which my husband definitely wants to do, and I’m not so sure I can handle it… I can’t even type out what happened to me without having a panic attack!!!! But for the most part I’m GREAT! ;o) I’m down to 30 mg of Cymbalta a day, and Ativan as needed (which is rare!). We are working on weaning off the Cymbalta, but I’m in no hurry! I want to be well and I want to be here with my family.

I’m looking forward to sharing this post with my husband. I think I have stated fairly well, what I will need him to do better next time. I have also printed of a “Me First” letter (got it from a post on a PPD site) and will be well armed if we decide to have another baby! I wish my husband had a better understanding of depression. I which he could remember how VERY REAL everything we went through during our daughter’s birth was. Maybe then he would have more compassion for my now fleeting struggles, and be WELL prepared for the next time!

Low Omega-3 Fatty Acid Intake from Fish correlates with High Levels of Depressive Symptoms in Pregnancy

Published in the July issue of the Journal Epidemiology, researchers put to the test the relationship between fish intake and depression based on the observation that “Although common in western countries, depression appears to be virtually absent in countries with high seafood intake.” (Abstract, High Levels of Depressive Symptoms in Pregnancy with Low Omega-3 Fatty Acid Intake from Fish)

The researchers collected data from women as they progressed in their pregnancy during 1991-1992. At 32 weeks, the women then completed a questionnaire which included symptoms of depression as well as a food frequency questionnaire from which the amount of Omega-3 Fatty acid from fish was calculated.

The results? Both adjusted and unadjusted analyses showed that lower maternal intake of omega-3 from fish was associated with high levels of depressive symptoms.

So just how much fish do you have to eat in order to achieve these results? Women consuming more than 1.5g of Omega-3 from seafood vs. those consuming none were less likely to have depressive symptoms. And how much fish equals 1.5g of Omega-3 fatty acids? FDA guidelines suggest women and children eat up to 12 oz of fish per week. Some of the healthier fish to eat (in order to avoid mercury build-up) are: Anchovies, Catfish, Crab, Herring, Mackerel, Mussels, Wild Salmon (Alaskan), Sardines, and Whitefish (source: Fish Intake During Pregnancy, Dietriffic.com)

What if you don’t like fish? You can take a supplement and there are non-fish sources of Omega 3 such as walnut, kiwi-fruit, flax seeds, pecans, hempseed, hazel nuts, and butternuts. Eggs and milk from grass fed chickens and cows are also higher in levels of Omega-3 fatty acids than other eggs and milk. But remember this particular study dealt specifically with Omega-3 from fish.

You can also check out the following blog, Rebuild from Depression, for additional sources and information regarding Omega-3 fatty acid sources.

I have been taking Omega 3/6/9 for quite some time now as part of my regular routine. I can tell when I forget to take my supplement as well. (So can my husband!) Make sure you talk to your physician before adding a supplement to your routine though. Also discuss adding more fish to your diet as well to make sure it fits with your particular situation.

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TIME Magazine misfires debate on MOTHER’S Act

Awhile back, I was contacted by Catherine Elton regarding an article which was to examine Postpartum Depression and the Mother’s Act. The email somehow got buried and I did not get a chance to participate in the discussion.

It seems that it would not have mattered if I had been able to discuss my story with her.

Time published the story this week. While the online version has been modified to correct an error with Ms. Amy Philo’s story, you can still see the original version in the hard copy. (Which by the way, I am personally asking you to boycott – even asking if you can take the copy of TIME home from the doctor’s office in order to keep other moms from reading it! And make sure you ASK – because just taking it would be stealing and that’s illegal.)

The original version, entitled “The Melancholy of Motherhood” includes one quote from Carole Blocker, the mother of Melanie Blocker Stokes, a mother who tragically committed suicide after unsuccessful treatment for severe postpartum depression after the birth of her daughter. The quote reflects Ms. Blocker’s confusion as to how someone could oppose the MOTHER’S Act, a bill which is designed to increase public and professional education regarding Postpartum Mood & Anxiety Disorders. Frankly, I’m confused right along with Ms. Blocker.

The only survivor story featured in this article is that of Amy Philo, one of five recipients of an Outstanding Achievement for Mothers’ and Children’s Rights awards from the Citizens Commision on Human Rights or CCHR. CCHR was founded in 1969 by none other than the Church of Scientology, well-known to oppose the entire psychiatric field.

Amy has tirelessly worked against this bill for quite some time now but continues to be tragically misled. Few discussions with her have led to quite the round robin with Amy unable to come up with legitimate research to back up her claims. When asked for said research, Amy refers to her own websites instead of to specific research articles supporting her claims.

I happen to know that Ms. Elton did indeed interview fellow survivors who support the bill. One has to wonder then, why did their stories not make it into the article? Was it length? Was it editing? Or was it intentional? Regardless, the finished piece as published presents a very frightening and deceiptful picture of what new mothers face is this bill is passed. To begin with, the MOTHER’S Act no longer mandates screening. It requires a study to be completed by the Secretary of Health and Human Services (Kathleen Sebelius) as well as funds for an educational campaign for both caregivers and the general public.

I agree that just because a new mother shows emotion she should not immediately be diagnosed as having a PMAD. I also believe that a woman should have free choice when it comes to her treatment decisions and should NOT be judged for those choices. I chose to take Anti-depressants. My first prescription did not work out. But my second one did. Just as with any other medication, sometimes they don’t work so well with your system. So you try another one. You don’t suddenly take your own care into your hands – that’s ridiculous. Would you try to heal a broken leg or diabetes on your own? No? I didn’t think so. So why would you rely solely on self-care when it comes to mental illness? Self-care should be part of the picture but it shouldn’t be the ONLY part of the picture.

I am so tired of being judged and accused of not having informed consent. You know what? When I made my decision to go on Anti-Depressants, I had carried around an informational packet about AD’s & Breastfeeding given to me by the NICU Lactation Consultant with me for a week. I read that thing through and through. I was exclusively pumping for my daughter at the time and did not want to jeopardize her receiving my milk if I ended up having to take something. But I couldn’t function. I couldn’t take care of my family, I couldn’t take care of myself, and a lot of the same thoughts were coming back. Negative, scary thoughts about knives and hurting myself and my family. Yet I wasn’t on anti-depressants. I needed to be able to function. So I made a very informed decision to do so, one I do not regret to this day.

TIME – I am very disappointed in your lack of sharing both sides of this debate. Very very disappointed.

Tips on Identifying Reliable Health Information on the Internet

If you’ve landed here as a result of a Google, Yahoo,  Bing, or other search engine, you already know how many results you can get in mere seconds and even sometimes nano-seconds. Thousands! So you wade through the results hoping for reliable and trustworthy information. Unfortunately, not everything out there is reliable and trustworthy. And even if it is reliable and trustworthy, you should ALWAYS check with a professional prior to implementing or stopping any treatment.

Here are some general tips to help you tell the good from the bad (source: Medical Library Association):

1. Sponsorship
  • Can you easily identify the site sponsor? Sponsorship is important because it helps establish the site as respected and dependable. Does the site list advisory board members or consultants? This may give you further insights on the credibility of information published on the site.
  • The web address itself can provide additional information about the nature of the site and the sponsor’s intent.
    • A government agency has .gov in the address.
    • An educational institution is indicated by .edu in the address.
    • A professional organization such as a scientific or research society will be identified as .org. For example, the American Cancer Society’s website is http://www.cancer.org/.
    • Commercial sites identified by .com will most often identify the sponsor as a company, for example Merck & Co., the pharmaceutical firm.
  • What should you know about .com health sites? Commercial sites may represent a specific company or be sponsored by a company using the web for commercial reasons—to sell products. At the same time, many commercial websites have valuable and credible information. Many hospitals have .com in their address. The site should fully disclose the sponsor of the site, including the identities of commercial and noncommercial organizations that have contributed funding, services, or material to the site.
2. Currency
  • The site should be updated frequently. Health information changes constantly as new information is learned about diseases and treatments through research and patient care. websites should reflect the most up-to-date information.
  • The website should be consistently available, with the date of the latest revision clearly posted. This usually appears at the bottom of the page.
3. Factual information
  • Information should be presented in a clear manner. It should be factual (not opinion) and capable of being verified from a primary information source such as the professional literature, abstracts, or links to other web pages.
  • Information represented as an opinion should be clearly stated and the source should be identified as a qualified professional or organization.
4. Audience
  • The website should clearly state whether the information is intended for the consumer or the health professional.
  • Many health information websites have two different areas – one for consumers, one for professionals. The design of the site should make selection of one area over the other clear to the user.

MLA’s guidelines are an excellent starting point and should be used by anyone searching for Medical information on the internet. Many caregivers will also tell you to not search the web for information, especially if you have a Postpartum Mood Disorder. If you have a question and feel overwhelmed with doing research on your own, get in touch with a Postpartum Support International Coordinator, your midwife, or your doctor, and ask for help in doing research. Sometimes you may come across research or news stories that are not applicable to your situation that may cause triggering thoughts or increase your fear and anxiety without justification.

Another great way to check the reliability of a website is to do so through HONcode. HONcode, Health on the Net certifies websites with healthcare information. Their standards are pretty high and they certify on a random basis once a website has been accepted. (I’m currently working on acheiving this certification for this blog myself). Through HONcode, as a patient/consumer, you can download a toolbar or search directly from their site and will only be given websites that have been approved by them. Click here to learn more about the safety process at HONcode.

I also want to take a moment to mention that a good doctor or advocate will be compassionate, understanding, and work with you regarding your desired route of treatment. Good Caregivers and Advocates are able to stay objective and not allow personal experience to cloud their aid to those who seek their help. This does not dismiss advocates who have specialized knowledge of certain types of treatment however – what I mean by this statement is that if you approach and advocate with a question regarding an Anti-Depressant, they should direct you to research regarding that particular medication and encourage you to also speak with your caregiver. They should NOT bash said medication because they’ve had a bad experience with it. If the caregiver or advocate is not compassionate but instead dismisses or attacks your desired treatment methods, it’s time to find another caregiver or advocate for support.

As a Postpartum Support International Coordinator myself, I work very hard to support the journey the mother is on and the treatment route that best fits with her personal philosophy. I encourage the involvement of professionals – including her OB or midwife, a psychiatrist, and a therapist. I also encourage Mom to take time for herself, something we all forget to do from time to time, but is very important for our mental well-being.

So please remember to:

Thoroughly check the source of the information you are reading online using the above guidelines from the Medical Library Association as well as searching via HONcode for your information.

Double-check any information regarding starting treatment or stopping treatment with your professional caregiver prior to implementation.

Make sure your caregiver respects your opinion regarding your body. (You are of course, your #1 expert in this area!) If he/she fails to respect you, although it may be difficult, find another caregiver who DOES respect you!

Take time for yourself as you heal.

Adrienne Einarson responds to Vogue’s “Pregnant Pause”

On April 29, I posted a piece entitled Thoughts on exploring a “Pregnant PauseFocused on an article appearing in this month’s Vogue magazine, I methodically refuted and balanced the article’s bias against medicating with anti-depressants during pregnancy.

Yesterday morning I woke up to find an email notification regarding a new comment on the piece. The author? None other than Adrienne Einarson, one of the most dedicated researchers in the field of SSRI usage during the prenatal period. Adrienne currently serves as Coordinator for the International Reproductive Psychiatry group at Motherisk in Toronto. She has published several studies in her areas of interest which include psychiatry, nausea and vomiting of pregnancy, and alternative medicine. Her RN specialities include psychiatry and midwifery.

Adrienne’s comment deserves its own post. Her voice deserves to be heard. She states up front that she does not often comment or blog but that the bias of the Vogue article upset her so greatly she felt the need to speak out. This letter has been sent to Vogue but has not received any response as of yet. (I have also submitted my piece directly to Vogue but also have not received a response.) She has granted permission for me to share her letter directly with you.

“I do this because I care about women who have to go through this and if my research can help, I will continue doing it.” ~Adrienne Einarson~

Without further ado, I give you Adrienne Einarson’s response to Vogue’s “Pregnant Pause”:

I am writing to you on behalf of an international group of individuals who are involved with reproductive mental health, as either clinicians, researchers and in some cases both. We would like to voice our concerns regarding your recent piece entitled “Pregnant Pause,” which we felt, did not achieve a balanced perspective on this issue, which was surprising to us, coming as it did from such a highly esteemed publication as Vogue.

We appreciate that you decided to do a piece on this often controversial issue, which can make deciding whether or not to take an antidepressant when pregnant, an extremely complicated decision for both the patient and her health care provider. However, we were very disappointed by the extremely biased approach that you took when writing this article. First of all, the data that you quoted is not as recent as you stated, these studies were published in 2005/2006, they were preliminary and the results have not been confirmed in more recent published papers, which you brushed off as not being important.

It is unfortunate that the women you quoted in your piece, thought that they had a baby with a heart defect because they took Paxil® and are suffering unnecessary guilt because of it, as if women don’t have enough to feel guilty about already in these complicated times. You acknowledged that there are probably 250,000 pregnant women taking antidepressants in the US, and you must understand before you can make any conclusions, that 1-3% of all pregnancies involve a baby with a birth defect of some kind, whether a woman takes any medications or not and 1/100 babies are born with a heart defect. That is why, researchers who conduct the best quality studies, use a group of exposed women (taking an antidepressant) with a group of unexposed woman (not taking an antidepressant) and compare the rates of adverse events in both groups. The studies that were conducted in this fashion, did not find a difference in the rates of malformations between the groups, including heart defects with Paxil®. Bottom line, if you do the simple math, it is evident that a large number of women would have had a baby with a defect whether they took an antidepressant or not, including the women in your article.

Another disturbing theme that came up several times in the article, is that physicians hand out antidepressants like candy, and physicians in our group were most offended by this statement as they are very careful about prescribing antidepressants and would not give them to someone who not does not require treatment. Every decision is made with great care, all the while weighing the risks/benefits of antidepressant treatment, and especially with pregnant women, ultimately to ensure the best possible outcome for both the baby and the mother.

Finally, and I am sure this was not your intention, several of our group members who are psychiatrists have reported that their pregnant patients have decided to stop taking their antidepressant since they read your article and I will leave you with one example of the damage you may have caused by this highly biased and often inaccurate article.

After reading this article, a woman called her psychiatrist and informed her that she was not going to take her Prozac anymore. She had had no less than seven consultations with psychologists and psychiatrists and all had agreed that she needed to be on medication because of her severe depression and possibility of suicide and concern in the post-partum period. She had finally agreed to go on the medication and at 34 weeks she was doing very well and looking forward to the birth of her baby and then read your article…………

Adrienne Einarson, Coordinator, The International Reproductive Psychiatry group

Thoughts on exploring a “Pregnant Pause”

An article in May’s issue of Vogue entitled “Pregnant Pause” by Alexis Jetter attempts to provide insight into the very confusing world of the pharmacological treatment of depression or mental illness during pregnancy. Ms. Jetter seems to have done her homework. She brings up some very valid points, includes supportive research, referring to specific studies all framed within a heart-tugging story of a boy born with a heart defect as a result of his Mom taking Paxil during her pregnancy. Yet Ms. Jetter forgets to tell both sides of the story. Here’s my take on the article.

In no way am I belittling this Mom’s experience by rebutting some of Ms. Jetter’s claims. As a Mom of a special needs child, I know first-hand how difficult life becomes as you work with and around your child’s needs. I also understand the enveloping guilt which rages inside you every time you see your child suffer or struggle and wonder “Did I do that? Was it my fault?”

You see, I didn’t take my pre-natal vitamins during my second pregnancy. At first it was because of the wretched morning sickness. Then I just didn’t want to take them. I even pondered what would happen if I didn’t take them, thinking it would be a neat little “experiment” to find out.

When my daughter was born with Pierre Robin Sequence which included a complete and bilateral cleft of her hard and soft palate, I felt a guilt that cannot begin to be described by any words known to mankind. It took me nearly two years to admit this to anyone. I lied at the hospital when I was asked if I had taken my prenatal vitamins. Why? Because I knew from my mom’s quick research about PRS that lack of folic acid in the maternal diet increases the risk for this particular condition. The last thing I needed was for the doctors to also blame me for my monumentally bad judgment. Looking back, I’m pretty sure this erratic behavior was directly related to my untreated issues with Postpartum OCD/Depression after the birth of our first daughter.

To this day as my daughter struggles with speech, socialization, and a myriad of other challenges, I still blame myself somewhat. Intellectually I know her problems are not my fault. I have accepted this on that level. But a small part of me will always wonder if she would have these problems if I had just taken my vitamins. So I get it. I get the guilt, I get the hind-sight. I get the anger and outrage. And I definitely get the need for education and informed consent.

What I don’t get is the desire to limit treatment options for other people. Instead of limiting, let’s encourage the development and shared knowledge of non-pharmacological therapies for mild cases of depression during pregnancy such as altering your diet, increasing exercise, natural supplements, psychotherapy, to name a few. Instead of judging, let’s allow women to make their own decisions regarding their mental health treatment. (you can read more on my thoughts regarding the ante-partum medication conundrum here)

Just as with those who are passionate for home-birth and those who are passionate for breastfeeding, there is a caution to be heeded here. We cannot convince a woman who is determined to have a caesarean section to have home-birth just as we cannot convince a woman who is convinced that a pill will solve her problems to try other therapies. All we can do is provide the education, statistics, and support. Then we need to step out of the way and let the woman make the decision with her medical professional team.

We can only fix ourselves, not those around us.

Now, onto the meat of the article, if you will.

After we meet Gina Fromm and hear of her difficult experience as a result of taking Paxil during her pregnancy, we are introduced to Dr. Anick Berard, PhD and Professor of Pharmacy at the University of Montreal. He discusses his study on Paxil, concluding that “..now other people have done the studies, too. And I’m much more comfortable saying that Paxil is a bad drug to take during pregnancy.”

Really, Dr. Berard?

I found a more recent study undertaken by none other than Dr. Anick Berard which concludes that unless the dose of Paxil is above 25mg during the first trimester, Paxil usage is not associated with an increase in congenital cardiac malformations when compared with non-SSRI usage. (Typical therapeutic dosage for Paxil can range anywhere from 10mg to 40mg.) When researching it’s not difficult to find studies to contradict one another but when you find them from the same researcher it’s a bit odd.

Next we meet Carol Louik, Sc.D, author of one of the two studies released in June of 2007 extolling the small risk SSRI’s posed to the human fetus. Turns out Carol’s study was partially funded by GlaxoSmithKline, Sanofi Aventis, and another Pharmaceutical Company. However, at the same time Carol’s study was published in the New England Journal of Medicine, another study was also published. This study was coordinated by the CDC out of Atlanta and did not have any financial disclosures to the Pharmaceutical Companies. Sura Alwan, MSc, and Jennita Reefhuis, RN, were first and senior authors respectively. Their study concluded the absolute risk of exposure vs. non-exposure not to be much different than the standard baseline risk for defects in any healthy pregnancy.

But the Alwan/Reffhuis study results are not present in the Vogue article.

Then we’re tossed this golden nugget – “….SSRI usage dramatically increases the chances that a baby may be miscarried, born prematurely or too small, suffer erratic heartbeats, and have trouble breathing.” The author further states that “Taken together the NEW research caught many experts by surprise.” Yet most of the research articles I located by the researchers quoted were from 2006 or earlier. This is hardly NEW research. In fact, the NEW research contradicts many of the studies referenced in the Vogue Article.

For instance, we’re informed through a quote from Dr. Adam Urato, M.D. That “these antidepressants are portrayed almost like prenatal vitamins that will level out their mood and lead to a healthier baby. But antidepressants have not been shown to decrease rates of miscarriage or birth defects or low birth weight. On the contrary, they’ve been shown to increase those problems.” Then directly after this quote, Ms. Jetters states pregnant women are routinely excluded from clinical tests of new drugs. But she fails to ask a very important question.

Why?

A solid answer can be found in the February 2009 Carlat Psychiatry Report, an unbiased report regarding all things psychiatry related, including medication. According to an article entitled “Psychotropics and Pregnancy: An Update,” the Carlat Psychiatry Report states “the gold standard study will never occur. It will never be ethically permissible to enroll pregnant women into a randomized, placebo controlled trial designed to determine if a drug causes birth defects. For this reason, we are left with less than ideal methods of determining risk.”

To seemingly substantiate Dr. Urato’s quote regarding miscarriage, birth defects, or low birth weight, a study performed by Developmental Pediatrician Tim Oberlander, M.D. At the University of British Columbia is briefly examined. This study concluded after tracking the birth outcomes of 120,000 women that infants exposed to SSRI’s prenatally were born too small and have trouble breathing. Oberlander’s quoted conclusion for the article? “It’s not the mother’s mood,” Oberlander says. “It’s the medication.”

Yet Oberlander’s study is negated by Einarson’s study, “Evaluation of the Risk of Congenital Cardiovascular Defects Associated With Use of Paroxetine During Pregnancy” Einarson also writes a letter to the American Journal of Psychiatry, (located in Vol. 64, No. 7, July 2007) which states the conclusions made by Oberlander and others is not supported by the data presented. Einarson points out that low birth weight was not stated as an investigated outcome and that only average weight of newborns and proportion falling lower than the 10th percentile (ie, small for gestational age but NOT low birth weight. Low birth weight is technically defined as >2500g2.

Einarson’s study combined both prospective and retrospective methodology to examine a large number of women specifically on Paxil. Their conclusion? “Paroxetine does not appear to be associated with an increased risk of cardiovascular defects following use in early pregnancy, as the incidence in more than 3,000 infants was well within the population incidence of approximately 1%.”

Just in case you’re wondering, no, their study was not funded by GlaxoSmithKline. The Carlat Psychiatry Report is quick to point out that seven of the nine authors received no funding from GSK or any other drug company but two have received funding for drug research from other drug companies but not GSK.

The Carlat Report also address what one should do with conflicting information regarding medicating during pregnancy. The best one can do from a “medico-legal perspective is to avoid paroxetine. But the data does suggest that paroxetine – and perhaps by extension, all SSRI’s – may be safer than what has been suggested by other smaller studies.”

Going back to the issue of pre-term delivery as well as low birth weight and their relation to mood or medication, a recent study released by Dr. Katherine Wisner examines this very topic. The study looked at 238 women with no, partial, or continuous exposure to either SSRI treatment or depression and compared infant outcomes. Dr. Wisner’s study found that exposure to SSRI’s did not increase birth defects or affect infant birth weight but the importance of this study lies within the finding that the pre-term delivery rates were the same with depression exclusive of SSRI treatment, leading the researchers to state that it is “possible that underlying depressive disorder is a factor in pre-term birth among women taking SSRI’s.” Dr. Wisner also encourages further research into this topic even though her study was just released this year. You can read more about this study by clicking here.

Rita Suri, M.D. from UCLA also studied this very situation, publishing her research in August 2007 in the American Journal of Psychiatry. Not surprisingly, Suri’s study is quoted in the Vogue article. Her results found that infants born to women taking SSRI’s were three times more likely to be born prematurely (although most were only 1 week early) She also found that the higher the antidepressant dose, the higher the risk of early delivery. However, her results did not show that untreated mild depression had an effect on prematurity. I’d like to add a personal digression here. My second daughter was born at 36 weeks. While not officially diagnosed, I would say that I suffered from untreated depression during that pregnancy. Sure it’s not an official research study but it’s very hard to discount personal experience especially when it agrees with current research.

At this point in the article, we’re introduced to one of the more well-known disorders associated with paroxetine usage, Persistent Pulmonary Hypertension of the newborn. Tina Chambers, Ph.d, a birth-defects researcher from University of California at San Diego is the chosen expert for this topic. She states that this condition normally strikes only one or two infants in 1,000. But Chambers found that rates jumped between six and twelve per 1,000 for mothers who take SSRI’s. In contrast, a recent prospective study by Susan Andrade, ScD, concluded no relationship between SSRI usage and PPHN but did admit that given limitations of the study and small number of confirmed cases, further study in this area may be warranted. In Andrade’s study, 1104 mothers were followed with only 5 confirmed cases of PPHN reported.

Alexis McLaughlin’s story about her daughter’s struggle with PPHN is striking, especially for me, because I’ve seen my daughter struggle for breath immediately after birth. Her quote, “It’s difficult because you need good mental health and a healthy baby,” is very reminiscent. You do indeed need good mental health and a healthy baby. When I was pregnant with Charlotte, we told people we didn’t care about gender, all we cared about was health. But if that doesn’t happen? You do your best to get through it because there is nothing you can do to go back and change what was done in the past. We can only move forward, changing what we can, and if we can’t change it, we change the way we think about it. Even with a normal pregnancy given no SSRI exposure or depressive exposure, a mother faces a 3% risk of giving birth to a child with a birth defect of some kind.

We are then moved into the science behind the affect of an anti-depressant on the human fetus. It’s hypothesized that serotonin is responsible for sending “crucial developmental signals to the fetal heart, lung, and brain….[and that]…SSRI’s, which prevent the body’s natural absorption of serotonin, could be tampering with essential cell growth.” A study by Francine Cote concludes that maternal serotonin is indeed involved in fetal development, precedes the appearance of sertogenic neurons, and is critical for development. The latter hypothesis regarding the interference of SSRI with essential cell growth has been and I’m sure will be studied for quite some time.

Shortly after this, the article winds down by warning of the “small coterie of influential doctors who…underplay the dangers of antidepressants,” again, a quote from Dr. Adam Urato. I do agree whole-heartedly with the latter part of his quote: “We want and need expert opinion that’s free from industry influence and from the appearance of bias,” Urato says. “It’s just outrageous that doctors have to work with that.”

Any of the several women I’ve come across who work with the Perinatal Population will be some of the first to admit that yes, there are risks to taking medications while pregnant or nursing. We even inform women we support to not only weigh the benefits against the risks by researching their options but let the professionals determine if the situation is severe enough to warrant medication.

Dr. Katherine Wisner examined this Risk-Benefit relationship in a study back in 2000. In this study, Dr. Wisner encourages physician and patient communication through the use of informed consent, provided the patient meets the legal definition of competent. She also recommends a family member or friend of the patient be present to help alleviate any anxiety and to ask questions the patient may not think of asking regarding any medication decision.

Many of the recommendations Dr. Wisner sets forth should be commonly used by a competent physician. Unfortunately there are physicians who do not follow informed consent and instead pay attention to the perks offered by Pharmaceutical Companies. However; these perks are slowly disappearing as the medical community awakens to the ethical dangers they pose as a result of increased consumer advocacy for fair and informed treatment when it comes to mental illness. If you should find yourself with a physician who prescribes SSRI’s like m&m’s or refuses to listen to your situation, it is time to find a new doctor for your care. A good doctor will listen, research, and collaborate with you.

I want to close with a quote directly from the Vogue article by Gina Fromm, Mother to Mark Fromm, the little boy with the heart defect as a result of his mother’s usage of Paxil. I couldn’t say it any better than this.

“It is easier to take a pill,” Gina says. “But over the long run, that’s not the best solution. It certainly hasn’t been for my life.”

I agree Gina, I agree whole-heartedly.

In my opinion, society today has gotten in the habit of quick fixes instead of sustaining solutions. I personally think it’s time we change that. But let’s do so in a logical, evidence based, and bias-free manner. Otherwise we’ll all just end up stuck right where we are screaming at each other so loud we can no longer hear ourselves think.