Not Just the Pregnancy Blues
Entry 2: When should a pregnant woman take antidepressants?
Photo by Thinkstock.
Until very recently, doctors didn’t think that pregnant women could get depressed—they believed that the elevated levels of estrogen during pregnancy protected women from psychological distress. When my mother, a psychiatrist, was pregnant with me 30 years ago and told her obstetrician that she was feeling depressed during her first trimester, he brushed it off. “He told me it should be the happiest time in my life,” she remembers. “I felt like punching him.”
There is no single explanation for why some women get depressed during their pregnancies while others don’t. While a history of depression is a risk factor for prenatal depression, there are also women who become depressed for the first time when they are pregnant, although we don’t know how many. In some ways it’s not surprising. Pregnant women are going through a barrage of physical, emotional, and hormonal changes during their nine gestational months, and many of these changes can be triggers for depression.
For some women, there is evidence of a link between elevated levels of progesterone during pregnancy and depression. Progesterone, the female hormone that increases drastically during pregnancy, can also increase the level of an enzyme that breaks down serotonin—a neurotransmitter that regulates mood. A study of just over 200 women from McGill University in 2001 showed that women who became depressed for the first time during their pregnancies had a higher level of a progesterone metabolite than other women in the study. Another smaller study of 19 pregnant women at University of Southern California also showed a relationship between higher levels of progesterone and diminished mood.
Numerous studies have pegged the rates of prenatal depression at more than 10 percent of women, and yet the myth persists that pregnancy protects you from melancholy. And it’s a dangerous one. The lack of public conversation about prenatal depression and the fallacy of the happy, glowing mother-to-be can block women from recognizing the problem and seeking help. This is particularly true for poorer women who have less access to regular prenatal care, much less sympathetic, enlightened doctors.
“Part of [the myth] is a wish that pregnancy would be protective,” says Dr. Elizabeth Fitelson, director of the Women’s Program at Columbia University. Fitelson thinks that the continued taboo of prenatal depression in part stems from our increasing devotion to all things natural in pregnancy. From the constantly growing list of foods to avoid to the overwhelming pressure to breastfeed, there’s an unavoidable cultural push toward being natural and pure in the prenatal and postnatal periods, and that includes a fear of antidepressants. “No one wants to take medications during pregnancy of any kind,” Fitelson says. “And no one wants to prescribe medication.”
Like the once stigmatized postpartum depression, prenatal depression is pretty much taboo. Where the former, thankfully, has benefited from an outpouring of, yes, good celebrity PR (starting with Brooke Shields’ book Down Came the Rain: My Journey Through Postpartum Depression and continuing in the pages of celeb weeklies today), the latter is still shrouded in shame. No famous actress with a baby bump wants to confess to that one.
Americans take antidepressants more than all but two kinds of prescription medications, and about 8 percent of pregnant women in the United States take antidepressants—so it’s not exactly a rare phenomenon. The effects of the most prescribed class of antidepressants, SSRIs (selective serotonin reuptake inhibitors), are among the most studied in pregnant women. According to Fitelson, there’s as much, if not more, research on SSRIs and pregnancy as there is on Tylenol and pregnancy. (PubMed, the collection of more than 21 million citations of biomedical literature from the National Institutes of Health, lists 824 citations for pregnancy and SSRIs and only 426 for pregnancy and Tylenol.)
The research is there, but doctors, particularly older doctors in nonurban areas, remain wary of prescribing antidepressants. This is partly because they’re not thoroughly informed about them and partly because their bias remains to protect the fetus first and the mother second. “An obstetrician’s job is to protect the pregnancy, to have the healthiest full-term baby,” Fitelson says. “There’s less appreciation that depression is a real illness.”
In their paper about prescribing antidepressants to pregnant women, Dr. Gideon Koren and registered nurse Adrienne Einarson tell the story of a pregnant woman they encountered who had moved to a very small town with just one family doctor. She had been taking citalopram (an SSRI also known as Celexa) for depression and had been prescribed the medication by a doctor in Halifax, Nova Scotia. Her new doctor:
… advised her that he would not renew the prescription because antidepressants were unsafe to take during pregnancy. She offered to call her physician in Halifax for confirmation, but the new physician still refused, and subsequently she had to make a trip to Halifax to see her previous family physician in order to get her medication.
Even for doctors who are well-educated on the risks and benefits of antidepressants, treatment is a complicated calculus. If you’re so depressed that you’re suicidal or in danger of harming yourself or your fetus, the answer is fairly clear: medicate. In my case, I was between OB-GYNs when I went off Prozac, and the psychiatric professionals advising me were not experts in treating pregnant women. By the time I went back on Prozac, I was seeing an understanding, trained obstetrician. I was not suicidal, but I was suffering to the point where I was nonfunctional, so it was easy for both my psychiatrist to prescribe the drug and for me to decide to take it. (Though my choice was not without guilt and self-recrimination.)
But for women who are moderately depressed, the research is conflicting and confusing. Determining the actual amount of risk involved in going on any kind of medication while pregnant—not just antidepressants—is impossible. Ethically scientists cannot do randomized studies (telling one group to take a medication and another group not to) on pregnant women. So studies on the effects of psychotropic medication on pregnant women are observational. Researchers are looking at women who are already taking antidepressants, and these women may differ from the general population.
Also, there might actually be risks: Some studies show a slight increase in heart defects, a rare lung disease, and withdrawal symptoms in infants whose mothers took certain SSRIs. Paxil in particular has been singled out as the riskiest of SSRIs for pregnant women. But as a paper published this year reviewing the current data on SSRIs in the journal Obstetrics and Gynecology International shows, for almost all of these studies, there are other studies that contradict the findings. The only risk that seems consistent among all of these drugs is for infants' withdrawal symptoms, which include jitteriness, irritability, respiratory problems, and in very rare cases, convulsions. However, the authors of the paper describe the majority of these symptoms as “mild and transient.” This paper, which is an analysis of more than 100 other studies on SSRIs and pregnancy done over the course of the past 20 years, concludes that “the general benefit of treatment seems to outweigh the potential small risk of untoward effects on the embryo, fetus, or neonate.”
Also, of course, doctors and patients have to include in the ledger the risk on the baby of untreated prenatal depression, which can be substantial: It is associated with a greater likelihood of low birth weight, miscarriage, preterm delivery, and increased incidence of hypertension and preeclampsia. (But to be fair, the studies about stress and pregnancy are just as confusing as the ones about medication and pregnancy. It is unclear how emotionally stressed a woman has to be for that stress to reach toxic levels. Since pregnancy is a finite period, at what point do you decide that a woman is depressed “enough” that talk therapy or other nonmedication treatments are not sufficient?)
The medical establishment is trying to create fixed standards to assess a pregnant woman’s level of depression, explains Dr. Catherine Monk, the associate director for research at the Women’s Program. “But it’s still hard,” she says. Some professionals use the Edinburgh Postnatal Depression Scale, which is a test used to measure postpartum depression, but it’s tough to say how widespread the use is. Sometimes, the way a depressed pregnant woman is treated comes down to money or lack thereof. Many women without insurance are lucky to even get diagnosed in the first place if they are not seeing an obstetrician regularly, or they are only seeing an overworked obstetrician for 15 minutes once a month. And even if they are diagnosed, a depressed, low-income woman would have a tough time managing the high expense of repeat visits to a psychiatrist, psychologist, or social worker, making it much more difficult to get a prescription for psychotropic meds.
This is not just a hypothetical issue: The incidence of prenatal depression is much, much higher among poor women. This study of low-income women in Atlanta pegged the rates of depression during the second trimester of pregnancy between 39 and 47 percent.
Take Brittany, a 26-year-old Texan who was in her third trimester of pregnancy with her first child when we spoke in June. (She had emailed Dr. Shoshana Bennett, one of the experts I consulted, for help.) A few months before she got pregnant, her husband lost his job, and they both lost their health insurance. When she found out she was expecting, Brittany decided to go off Prozac cold turkey. Even though she had a history of clinical depression, she couldn’t afford the refills, and “because I didn’t have adequate information,” she says, “I bought into the stigma” against medication during pregnancy. She saw the ads for shyster lawyers touting settlements for birth defects caused by SSRIs and got scared.
She also got extremely depressed. So depressed, she had to quit her nannying job because she was concerned that she couldn’t adequately care for her charges. She couldn’t go to a mental health professional because it was too expensive, and her obstetrician was zero help in giving her a referral. The doctor just handed her some public health materials and told her to try to find a shrink. Brittany ended up going to the family pastor for a free version of talk therapy, and while he was very compassionate, he wasn’t much help with medical advice.
Brittany finally went back on Prozac only after doing her own research and discovering Bennett’s book Pregnant on Prozac, which is one excellent resource for women who are suffering from prenatal depression and not getting the support they need from medical practitioners. (Pregnancy Blues, by Dr. Shaila Kulkarni Misri, is another.) She found a new obstetrician, one who took her depression seriously and wrote her a prescription, and her husband found a new job—albeit one that pays significantly less than his old one. “It’s still a lot of stress, but we’re making it,” Brittany says.
The absolute risk of taking SSRIs while you are pregnant may never be perfectly measurable. But what’s important is that more women are aware of prenatal depression as a real possibility and that more obstetricians are actively screening women for depression during their pregnancies. The American College of Obstetricians and Gynecologists says that screening pregnant women for depression should be “strongly considered,” but they do not make a firm recommendation for universal screening, and they do not make a recommendation for how often screening should be done.
That’s not to say that the picture of care for depressed pregnant women is entirely bleak. Jill Cordes, who remained on antidepressants during two pregnancies after an awful time trying to get off them, wrote about the experience at Parents.com: “I have an excellent OB and psychiatrist, both of whom agree: going through my pregnancy depressed and dark is far more dangerous than sticking to what works.” That attitude is the right one. Doctors and midwives should listen to their patients and be open to the idea that they may need some kind of treatment for depression. Whether a woman would be better served by antidepressants, acupuncture, talk therapy, or any other nonmedication treatment is deeply idiosyncratic—and there shouldn’t be an immediate prejudice against any option. No one should have to suffer through nine months of misery when she doesn't have to.
Now I want to hear from you: I have created a survey for both women who have experienced depression during their pregnancies and their loved ones. Take the survey here, and all responses are anonymous. Next week, I will write up what I’ve learned from you. Also, if you’d like to tell me more about your story, please email me at firstname.lastname@example.org. All of those emails will also be kept anonymous unless you explicitly give Slate permission to publish your essay about your experience with prenatal depression.