Susan didn’t thinkshe could have children. She’d been diagnosed with an infertility disease that made conception unlikely. So discovering that she was pregnant was “beyond a surprise,” says the 28-year-old, who asked that her name be changed to protect her privacy. A nurse at a local hospital, Susan wanted to do everything right for her […]
Susan didn’t thinkshe could have children. She’d been diagnosed with an infertility disease that made conception unlikely. So discovering that she was pregnant was “beyond a surprise,” says the 28-year-old, who asked that her name be changed to protect her privacy.
A nurse at a local hospital, Susan wanted to do everything right for her baby. She ate healthily and took prenatal vitamins. And she decided to stop taking the medication that controlled the depression and anxiety she’d battled since her teens. She didn’t want to expose the baby to medicine. Plus, she recalls, “I had always assumed if I were to get pregnant, I’d be so happy about it, there was no way I could get depressed.”
Within weeks of stopping her meds, Susan – usually outgoing and upbeat – became withdrawn. Colleagues commented that she looked worn out, that she wasn’t acting like herself. She lost weight. She frequently called her
parents in tears, unsure she could make it through the day. She began to doubt everything about herself: her ability to perform her job, to be a good partner, to be a good mother.
One day at work, she found herself sobbing inexplicably in the hallway, and realized she had to take action. With the help of a psychiatrist, she learned about the risks and benefits of using antidepressants during pregnancy and decided to resume the medication. Yet Susan struggled with the decision. “Even after I started taking the medication again, I felt bad about it. I felt guilty and ashamed,” she says. Now 25 weeks into her pregnancy and feeling much better, she knows she made the right choice: “It would have been so much more of a risk to my child to stay at that level of depression.”
According to the American Pregnancy Association, up to 20 percent of women suffer from depression during pregnancy. But despite the prevalence of the problem, such struggles often aren’t talked about. “There is an ideological image of how a mother should be. Mothers should adjust to pregnancy without any problems,” says Dr. Vani Ray, a psychiatrist with Aurora Health Care.
The question of how best to treat a pregnant woman with depression or anxiety can be a tough one. “There is always the dilemma: Should you expose the baby to depression or should you expose the baby to the medication?” says Ray. Some medicines are known to have negative effects on a developing fetus, while others appear to have very minimal risks. On the other hand, “the risk of untreated [mental] illness can be very severe – on the woman, on the pregnancy, on the development of the fetus, on long-term parenting,” notes Dr. Veena Prabhakar, a psychiatrist with Wheaton Franciscan Behavioral Health. In the end, the answers involve a delicate balancing act of risks and benefits.
A Difficult Diagnosis
It was once widely believed that pregnancy protected against mental illnesses such as depression. But now researchers know that’s not true. “These disorders don’t just go away during pregnancy,” says Prabhakar. Women are twice as likely as men to suffer from depression, and the lifetime risk for major depression in women is highest during their childbearing years. Studies show roughly 9 to 13 percent of women develop major depression while pregnant. About 22 percent of women develop major depression in the first year after giving birth. Likewise, anxiety disorders such as panic disorder, obsessive-compulsive disorder and post-traumatic stress disorder can all persist, be exacerbated, or appear for the first time during pregnancy.
And these problems can often go unnoticed by doctors – as much as three-quarters of the time, estimates Dr. John Waeltz, an obstetrician/gynecologist with Wheaton Franciscan Medical Group in Glendale. “It’s a difficult diagnosis because a lot of the symptoms are attributed to pregnancy,” he explains. Complaints of fatigue, sleeping too much or too little, appetite disturbances or diminished libido can easily be chalked up to the pregnancy itself.
In cases where depression is diagnosed, concerns about medication can often overshadow the effects of the disease. “A lot of times the focus is so much on medication that the importance of depression affecting the baby gets lost,” notes Ray. In fact, untreated mental illness can have a tremendous impact on both the baby and the mother. Among the risks associated with depression and anxiety during pregnancy are premature birth and low birthweight; developmental, behavioral and sleep problems in babies; and a greater chance of postpartum depression for women. Some studies have shown increased rates of cortisol in babies born to depressed or anxious mothers, which may lead to poor stress adaptation later in life. Researchers at Harvard Medical School recently suggested that a mother’s stress during pregnancy can have lasting effects on her child’s health, including higher incidences of allergies and asthma.
Untreated mental illness also raises the likelihood that a mother won’t take good care of herself, to the detriment of her own health and her baby’s, notes Waeltz. She may not get proper nutrition, exercise, or attend regular doctor’s appointments, and she may abuse drugs, tobacco or alcohol in an effort to self-medicate. In the case of severe depression, lack of treatment puts the mother at higher risk of suicide. Depressed mothers who don’t take care of themselves during pregnancy often feel guilty for it after birth and doubt their parenting ability, says Ray, which leads to more emotional strain and difficulty bonding with the baby. Postpartum depression can lead to negative parenting behaviors, such as ignoring or yelling at the child, and a reduction in positive behaviors, such as singing or reading to the baby, notes Prabhakar. Both have serious consequences for a child’s cognitive and emotional development.
Weighing the Risks
Deciding which treatment is best can be tricky. “It’s not an uncomplicated situation that you’re trying to figure out,” notes Dr. Carlyle Chan, professor of psychiatry and behavioral medicine at the Medical College of Wisconsin. A woman’s mental health history, her socioeconomic stressors and support system, her plans for nursing and her own feelings about medication all come into play.
For Prabhakar, a woman’s history – especially if it includes prior hospitalizations for depression or a tendency to self-neglect – is most important. “If a woman has had a history of recurrent depressive episodes, and moderate to severe depression, chances are she would probably benefit from staying on medication during pregnancy,” says Prabhakar.
For a woman with milder depression who doesn’t like the idea of medication, psychotherapy, cognitive-behavioral or interpersonal therapies can all be helpful. Light therapy and the use of omega-3 fatty acids have also shown some promise for alleviating depression.
Although few medications have proven indisputably safe to take during pregnancy, some antidepressants are better than others. Research to date shows that selective serotonin reuptake inhibitors (SSRIs) such as Prozac (fluoxetine) and Zoloft (sertraline) have a low risk of birth defects – roughly equivalent to that of the general population, Prabhakar says. The exception among SSRIs, Paxil (paroxetine), has been associated with fetal heart defects.
However, SSRI exposure during the second half of pregnancy has been associated with a potentially greater risk of persistent pulmonary hypertension in newborns. (According to the Mayo Clinic, the disorder is rare, and the ultimate risk for women taking SSRIs during pregnancy is still “extremely low.”) The use of SSRIs during the third trimester may also lead to increased jitteriness, irritability or other symptoms in a baby after birth, but these tend to go away after a few days. Depending on their condition, some women may want to talk to their doctors about minimizing use of the medication during the first or third trimesters, when the risks of exposure may be the greatest. For others, it’s better not to interrupt the treatment.
Many doctors consider Zoloft the safest option for expectant mothers. Still, Ray and others caution against switching a woman from a medication she has been stable on and which has low risks for the baby for what amounts to a negligible difference in potential side effects. Not all health care practitioners are equally familiar or comfortable with antidepressants, Ray notes, sowomen should make sure their doctor is well-informed. For her part, Susan switched obstetricians after her doctor was unwilling to advise her on the subject of medication.
Women who contemplate stopping their antidepressants during pregnancy should be aware they stand about a 70 percent chance of relapse, Prabhakar says. Depending on the situation, such a risk may be far greater than that of medication exposure.
Still, many women simply are not comfortable with taking medicine during pregnancy. “A lot of women say, ‘No. I don’t want my babies exposed to any medications … I don’t care how high the risk is that I’m going to relapse; I don’t care how high the risk is of postpartum depression,” says Prabhakar. “If they feel strongly about that, you have to work with them.” In such situations, a doctor continues to evaluate the patient throughout her pregnancy to make sure she is coping well with alternative therapies.
Above all, professional help is crucial for a woman struggling with mental health issues. “The take-home message is that it’s important to seek an evaluation and get some recommendations regarding treatment,” says Chan.
Beyond depression and anxiety, there are a host of psychiatric illnesses that affect women, notes Prabhakar. In the case of conditions such as schizophrenia and bipolar disorder, treatment during pregnancy is an even more complicated issue because many of the medications used to treat those diseases are known to be harmful to a fetus. The same is true of certain anxiety medications, such as benzodiazepines.
Ultimately, education is key not just for expectant mothers, but for the general public, to create an environment in which women battling mental illness can get the care they need. “Let’s not pathologize these mothers,” says Ray. “They are going through a difficult time. What will help them is support, not condemnation.” n
Caroline Goyette is a frequent contributor toMilwaukee Magazine.
A roundup of the latest health wisdom
Tips for overweight kids. The American Medical Association recently recommended a multistage approach for physicians to treat childhood obesity. Key suggestions: TV viewing and “other screen time” should be limited to two hours or less per day; children should not drink more than one serving of sweetened beverages per day (regular-calorie soda, fruit juice, energy drinks, etc.); kids should get at least one hour of physical activity almost every day; fast food should be restricted to one day per week at most; and families should eat meals together as often as possible at regularly scheduled times.
This is your brain on tea. Regular consumption of black or oolong tea may reduce the risk of cognitive impairment and decline, found a new study of 2,500 Chinese people ages 55 and older. Over time, those who seldom or never drank black or oolong tea were more likely to experience impaired and declining mental functioning, according to the report in the American Journal of Clinical Nutrition. Green tea consumption had more limited protective qualities, while coffee appeared to offer none.
The risks of seizure medication. An FDA panel says that all anti-epileptic drugs increase the risk of suicidal thoughts and behavior. Anti-seizure medications include Neurontin, Lamictal, Lyrica, Topamax and Tegretol and are used to treat depression, anxiety, bipolar disorder, migraine and chronic pain, as well as epilepsy. While the panel agreed that doctors and patients should be made aware of its findings, in most cases benefits outweigh the risks.
A lifeline for anorexics? It’s very difficult to treat and has the highest mortality rate of all psychiatric disorders. But there may be new hope for those with anorexia: Preliminary study findings suggest a drug used to treat bipolar disorder and schizophrenia may help women with severe cases. Published in the American Journal of Psychiatry, the study found that olanzapine (Zyprexa) resulted in greater weight gain and reduced obsessive-compulsive thoughts when compared to a placebo.
News for knees. A torn anterior cruciate ligament (ACL), like that of Tiger Woods, requires reconstructive surgery using either a ligament from a cadaver or from the patient himself. Using a cadaver ligament usually means less postoperative pain and a faster return to work. But a new study found that cadaver ligaments used in physically active patients under 40 fail 24 percent of the time. Study results were presented at the American Orthopaedic Society for Sports Medicine 2008 Annual Meeting. Earlier research had found a failure rate of cadaver ligaments was just 2.4 percent in patients older than 40.
– Scott R. Weinberger