Postpartum Progress

Told It's a 5-Month Wait to See A Psychiatrist? Tips on What to Do Next to Get Help for Postpartum Depression

After I wrote last week about my opinion that women with postpartum depression should try to seek out a specialist for treatment, I heard from a family physician in a major metropolitan city who told me that her patients now need to wait 5 months to get in to see any psychiatrist, not just a specialist.

My perspective comes from being a family physician in [major city].  Right now, in the health system I am in, we are booking into late April and May for a first appointment with a general psychiatrist.  It does take "special clout" to get someone in sooner in my system ... and that's just to see a regular psychiatrist.  As a physician I am someone with that special clout, and it still takes me multiple phone calls, begging, etc., to get a patient in any sooner.  On top of this, my health system just cut psychiatric and counseling services by 30% because it wasn't a money maker, and because leadership determined we were doing more than our fair share here in [major city].  Patients are coming in from other health systems because our wait lists are shorter than average.

If someone has an unrestricted insurance plan (and that's a big "if") or can pay out of pocket (bigger "if") or is willing to drive to the inner city county hospital (many of my patients are not), they may be able to go outside the system and be seen sooner.

I understand that you would want a loved one to get the best care.  But from my perspective I have trouble getting my patients any care at all in a timely fashion.

I appreciated hearing from this doctor about her experience.  Among other things, this email made me think about how awful it is for a mom with postpartum depression or anxiety who has finally gotten the courage to reach out for help only to be told "Sorry.  You'll have to wait."  For months!  I decided I'd ask some healthcare providers I know to provide Postpartum Progress readers with tips on what to do if you want to see a psychiatrist but can't get an appointment.

 

Jennifer Payne, MD, PhD, co-founder of the Women's Mood Disorders Center at Johns Hopkins, suggests:

First, remember if you are having suicidal thoughts or thoughts of harming your baby, go to the ER. They will help you.  Otherwise, you can seek immediate help from your primary care physician or OB-GYN. They can start medications while you're waiting to see a psychiatrist [should you need them].  Also, call a therapist. They can often see you sooner and if they are concerned may have more direct access to a psychiatrist. Check to see if there are any postpartum depression groups at local hospitals or birthing centers for support. And finally, don't give up.  Keep calling around and ask to be on a call list for cancellations.

Ann Dunnewold, PhD, author of Even June Cleaver Would Forget the Juice Box, says that if you need medication and can't get in to see a psychiatrist, you should talk to your physician:

When a woman already has a good relationship with a physician (such as an OB/GYN, internist, family practitioner or even nurse practitioner), reaching out to that person can be a much quicker route to treatment.  And while psychiatrists may disagree, I've seen that when a woman has a good relationship with her regular care provider, that provider often more readily considers the whole person (i.e. lifestyle issues, other underlying illnesses, etc.)  Many of these care providers also are more comfortable prescribing medication if the mom is seeing a psychologist for therapy who is willing to be part of the treatment team and give feedback.

Diana Lynn Barnes, PsyD, LMFT, and author of The Journey to Parenthood: Myths, Reality & What Really Matters, suggests working with your therapist to try and get an earlier appointment with a psychiatrist:

I find a 5-month wait for a woman with depression unconscionable.  I know for myself that I have developed a close, collegial relationship with a few psychiatrists in my community whom I know specialize in women's reproductive mental health so that when I refer clients I can pretty well know that they will be seen within a few days.  And I leave room in my schedule so that I can see a new patient within 24 hours.

Erika Krull, MS, LMHP, author of the Family Mental Health blog on PsychCentral suggests spending time with other moms for support and considering therapy:

Find a small moms group of some kind -- MOPS, church group, library toddler time with some moms, a little weekly play group, quilting group, PPD support group, whatever.  Something with regularity and other moms so that relationships can develop and there is some level of obligation that gets you going even if you don't feel like going.  That social support is key.  When I didn't know what was wrong with me I happened to already have a habit of attending a young moms church group.  Unbeknownst to me, that was what kept me going until I put the pieces together and got a diagnosis.

Also, getting started with a mental health counselor might be quicker and certainly can help the mom start finding ways to cope with her symptoms.  Just having that listening ear with a professional filter can also help give some direction, keep an eye on worsening symptoms, etc.  Meds work best with therapy, but in some milder cases therapy alone may be enough.

Pec Indman, EdD, MFT, co-author of Beyond the Blues and board member of Postpartum Support International, says it's not unusual for women to be told they'll have to wait a long time to get in to see a psychiatrist, especially those moms without private insurance or those who have medicare/medicaid for only a few months postpartum.  Her suggestion:

Any healthcare provider (OB, family practice, etc) can call the University of Illinois at Chicago Perinatal Depression Project's Toll-Free Consultation Line for Providers at 1-800-573-6121.  It may not be as good as getting the patient in now to see a psychiatrist, but it's better than nothing.  Most OBs, family practice and internal medicine docs treat a lot of anxiety and depression.  They need more information, though, to rule out mania and information about medication during pregnancy and nursing.  That can be provided through consultation with specialists. 

In the meantime, Karen Kleiman, LSW, MSW, author of This Isn't What I Expected: Overcoming Postpartum Depression, suggests making sure you don't have an underlying physical illness that, if treated, would relieve the depression, thereby eliminating your need to see a psychiatrist at all:

Get a physical and rule out some of the conditions that can mimic depression and anxiety symptoms.  Check for thyroid problems, anemia and general blood count.

I thought I'd join in and give you a tip of my own:  If you are having a problem getting timely treatment, or you have issues with insurance or being able to afford treatment, you should consider checking to see whether you are eligible for any clinical trials.  If you find one in your area in which you are willing to paricipate, your treatment and related medical appointments may be free of charge and you'll probably be able to get started right away.  (Yesterday, as it happens, I posted of list of current clinical trials going on around the country!)

And finally, from the family physician who e-mailed me, an exhortation that medical schools need to do better to train all physicians on the identification and treatment of perinatal mood and anxiety disorders:

Training programs in the primary care specialties can and should cover these issues properly.  If these programs could be convinced to do a good job with this (and I think they could be), this would go a lot further toward helping more women, no matter where they live, no matter what insurance, no matter if they have empowerment, no matter if they have clout.

Which meds can be used in pregnancy, in breastfeeding, etc., should not be special knowledge.  It should be normal knowledge.  With 15% of moms getting PPD this is not a special disease.  It's a normal disease.  I want it to be a normal part of training for normal docs that a normal patient can access in a normal way.  Then the specialists will be available to focus on the truly difficult cases.

Is Postpartum Depression A Disease or A Coping Strategy? Or Neither?

Today I got a direct message on Twitter from someone telling me the following:

Postpartum Depression is not a disease.  It's a coping strategy.

Ok ... thanks for the info ... 

I don't know the therapist who sent me the message.  I don't want to malign her thinking.  Perhaps she's got a point, perhaps she doesn't.  I have no medical training, so how would I know?

What her tweet did bring up in my mind is all of the discussion about whether postpartum depression is real or not, whether it's genetic or not, whether we can help it or not.  These discussions tire me. I've seen this illness in myself and I've seen it in other people and I KNOW it's real, regardless of the reason why it's there.  Do I understand exactly what causes postpartum depression?  Nope.  Does anyone else?  Nope.  Not yet, anyway.

We can get stuck there, arguing over whether it's really an illness or what precise thing brings it about.  We can choose to dig in, locked in that dispute forever, quarreling back and forth and accusing each other of being wrong.  (It's genetic.  No, it's a hormone problem.  No, it's dietary.  No, it's caused by neurotransmitters.  No, it's due to the modern materialistic society of the West.  No, it's due to childhood trauma ...)  Meanwhile, women will continue to suffer and will still need help.  At that moment.  They can't wait for the cause to be found.

Thankfully there are a small handful of ways women can be helped, enough of which work effectively enough to get us through the crisis.  And there are scientists who are still looking into the causes of depression in general, refusing to get bogged down in the bickering.

Psych Central just reported on the work of scientists at Northwestern University who believe they have found that depression is not related to stress, and that the reason antidepressants don't work for everyone is that they are targeting the wrong thing.

"In the second part of the study, Redei found strong indications that depression actually begins further up in the chain of events in the brain. The biochemical events that ultimately result in depression actually start in the development and functioning of neurons.

'The medications have been focusing on the effect, not the cause,' she said. 'That’s why it takes so long for them to work and why they aren’t effective for so many people.'

What does this mean?  I have no idea.  I'm grateful they're working so hard to figure this all out.  I look forward to the day when we will know the cause of postpartum depression for sure.  And that day surely will come. 

In the meantime, we've got to go with what we've got now, choosing to reach out for help, weighing the risks of various treatments, working with professionals, and getting better.  If you want an emotionally healthy family now, you don't have the luxury of waiting for the exact right answer.

Miami Herald Covers Issue of Antidepressants During Pregnancy

Kudos to reporter Sherry Rauh and the Miami Herald for doing a nicely balanced article on depression during pregnancy and the treatment options.  There are risks either way, and it is important to work with your ob/gyn to make the best decision for YOU.

Did Research Find Taking Antidepressants In Pregnancy Really Causes 500% Increase In Heart Defects?

Terrifying headlines loomed last week about pregnancy and antidepressants.  Did you see them?

Antidepressants Linked to Heart Defects in Newborns - Yahoo! Health

Taking Antidepressants in Early Pregnancy Linked to Child Heart Defects - Medical News Today

If you were reading Twitter on the day this news came out, you might have seen this:

500%!

If you did see any of these headlines, and if you happen to be pregnant and on an antidepressant, then you were probably standing on a ledge somewhere with a loved one trying to talk you down.  This is very scary stuff.  So let's take a look at the study that led to those headlines and see what all this really means to you.

What started it all?  The British Medical Journal published the results of research conducted by Danish researchers that found a slight increased risk of a septal heart defect for the babies of women who take an antidepressant during the first trimester.

Notice the risk is for a very specific birth defect of the heart.  Not "antidepressants are linked to heart defects" as many headlines read.  Notice the increase risk is small, and there's no clear causation like the headlines infer.  How much is the risk?

Of all women who give birth, .05% will have a child with a septal heart defect.  Of all women who give birth who take a selective serotonin reuptake inhibitor -- a class of antidepressants commonly known as SSRIs -- during the first trimester, .09% will have a child with a septal heart defect.

The researchers also broke the data down further by taking a look at the increase in risk for specific SSRI antidepressants.  They found no increase at all in risk for septal heart defects for women taking fluoxetine (Prozac) or paroxetine (Paxil).  The risk went up one-half of a percentage point for those taking citalopram (Celexa), and one percentage point for those taking sertraline (Zoloft). 

Is there an increase in risk of septal heart defect with certain medications?  Yes.  Do the researchers know why?  No.

"Pederson and colleagues also could not exclude the possibility that something about depression itself, rather than the treatments, accounted for the increase in heart defects."

Is this a study we should pay attention to?  Yes, but it's not definitive.  A sidebar of the original Medical News Today story entitled "Action Steps" indicated that one purpose of their article was to "explain that this study was a retrospective analysis of medical records, a relatively weak form of evidence."  I didn't see that reported in most places.

Additionally, it appears that the researchers did not control for things like whether the mom took prenatal vitamins or used alcohol, among other compounding factors.  Lauren Hale at Sharing the Journey wrote last week that they also didn't actually know whether the women in the study took their medication as prescribed, or whether they took it at all ... only that their prescriptions were filled.

"Pederson and colleagues noted that variations in compliance or errors in records could have affected the findings.  They also acknowledged that previous studies of individual drugs have not consistently identified birth-defect risks associated with SSRIs."

One of my missions here at Postpartum Progress is to make sure women get all the information they need and to remediate sensationalist or misguided reporting related to perinatal mood and anxiety disorders that sometimes takes place, while also publicizing the balanced, informed reporting that we are grateful to see. 

One of the experts I spoke with about this new research said "Unfortunately, statistics are always translated to make the results look as scary as possible, especially in pregnancy.  It is called negative framing."  In other words, saying there is a five-fold increase in the risk of a birth defect gets much more attention than saying that 99% of women will have a health baby.

In a commentary just published in the Journal of Clinical Psychiatry, Adrienne Einarson writes:

"A recent Google search (June 23, 2009) using the keywords 'antidepressants, pregnancy' revealed 1,420,000 results, many describing how 'dangerous/harmful' antidepressants are to take in pregnancy, with many sites warning women not to take antidepressants if they are pregnant.  Studies that do not find evidence for harm more often than not are ignored by the media, such as in the recent Vogue article that focused only on studies that reported adverse effects." 

I recall the titillating headline on the front cover of that Vogue issue read something like "The Shocking Truth About Antidepressants & Pregnancy".   Then there was the completely unbalanced article about postpartum depression screening from Time magazine.  Such biased representations are unfair, and are often made by the same outlets and individuals who trumpet the importance of informed consent in healthcare.  I suppose they mean informed consent only if the information supports their point of view.  If you want to make sure new moms and moms-to-be have the right information, then why not give it to them straight and let them decide?

Thankfully, some responsible news outlets treated the study as it should have been treated.  WebMD reported that "women who take antidepressants during pregnancy have a small increased risk for a specific heart defect ... The new study shows the overall risk for congenital heart problems associated with SSRIs to be quite low." (Other balanced and well-reported pieces include this one from the New York Times, and a related piece from the same paper on the Well blog with comments from readers.)

Even the Danish researchers agree with that statement as quoted in the WebMD story:

"The bottom line is the risk associated with SSRI use appears to be very small, and this has to be balanced against the very real risk associated with having untreated depression during pregnancy," study researcher Lars H. Pederson of Aarhus University tells WebMD.

This is rarely pointed out.  There are risks NO MATTER WHICH DECISION YOU MAKE.  Those who are vehemently against anyone taking antidepressants during pregnancy often leave out the fact that there are many risks to the children of women who suffer depression and choose to go untreated during pregnancy. 

One finding of the study which does raise new concern, across everyone reporting, is that of women taking two or more antidepressants during the first trimester.  Of the 400,000 cases that were part of the study, according to Medical News Today, 2,315 (.05%) of unexposed babies had septal heart defects, 12 (.09%) of SSRI exposed babies had septal heart defects, and 4 (2.1%) of babies exposed to more than one type of SSRI in the first trimester had septal heart defects. 

Christina Chambers sums up the new research succinctly in an editorial about the Danish research also appearing in the British Medical Journal:

"How does Pedersen and colleagues' study contribute to clinicians' and patients' decisions about the use of SSRIs in pregnancy, and how should this be weighed against the risks of non-treatment?  The answer remains as before -- if an increased risk for major congenital malformations does exist, this study and others suggest that the absolute risk for the individual pregnant woman is very low.  Furthermore, each of the more commonly used drugs in this class has been implicated in at least one study, so it is difficult to conclude that one SSRI is 'safer' than another ... Clinicians and patients need to balance the small risks associated with SSRIs against those associated with undertreatment or no treatment."

The answer remains as before.  Talk to your doctor and work together to make the choice that is right for you.

Can A New Test Predict Which Antidepressant Will Work for You?

One of the chief problems for anyone who chooses to take medication to treat her perintal mood or anxiety disorder is figuring out whether a medication will even work for you.  Psych Central reports on a new test that may be able to predict how you'll respond to certain antidepressants.  There's more on this here and here.

Are SNRIs Effective in Treating Depression?

Psych Central reports on the effectiveness of a new class of antidepressants called SNRIs (serotonin and norepinephrine reuptake inhibitors).   

ACOG & APA Issue Guidelines For Treatment of Depression During Pregnancy

The American College of Obstetricians and Gynecologists, in partnership with the American Psychiatric Association, has just issued specific direction and guidelines on the use of antidepressants during pregnancy.  They must be congratulated for their clear understanding of the nuances of treatment for depression during pregnancy, and for acknowledging that there is no one right answer to this situation as some would have you believe. 

"This is a report intended to reach out to psychiatrists as well as obstetrician-gynecologists," said Dr. Kimberly Yonkers [the report's author, who is from both the Department of Psychiatry and the Department of OB/GYN at Yale University]. "We developed algorithms which I think reflect the fact that there are multiple issues to consider and [that] there should be no knee-jerk response in managing a woman who is depressed and pregnant or contemplating pregnancy. Psychiatric history and a woman's preference are among the important features that should be taken into consideration."

In a nutshell, ACOG and the APA recommend that those with mild depression who are pregnant may be better served trying psychotherapy and seeing if that will relieve their symptoms.  Women with severe depression or those who have a history of depression or psychosis, however, should remain on their medication during pregnancy.  And of course, all pregnant women or those who are thinking about becoming pregnant should discuss their specific situation with their doctors.  Here are just a couple of the common scenarios the report offers along with recommendations to doctors and patients as to how to proceed:

Pregnant Women Currently on Medication for Depression

• After a consultation between their psychiatrist and obstetrician/gynecologist (to discuss risks), psychiatrically stable women who prefer to stay on medication may be able to do so.
• For those who want to discontinue medication and are not experiencing symptoms, tapering and discontinuation may be attempted. However, women with a history of recurrent depression are at a high risk for relapse.
• Those with recurrent depression or symptoms despite their medication may benefit from psychotherapy to replace or augment medication.
• Women with severe depression should remain on medication. If a patient refuses, alternative treatment and monitoring should be in place, preferably before discontinuation.

Pregnant Women Not Currently on Medication for Depression

• For those who want to avoid antidepressant medication, psychotherapy may be beneficial.
• For those who prefer taking medication, risks and benefits of treatment choices should be evaluated and discussed.

If you have access to the September issue of the journal Obstetrics & Gynecology, you can read the entire report here.  It will also appear in the September/October issue of General Hospital Psychiatry. 

Surprisingly, this report has been covered fairly well thus far by the mainstream media.  ABCNews.com did a good piece that included quotes from Dr. Lucy Puryear and Dr. Ruta Nonacs.   Nice job by ABC with a story on Good Morning America as well.  And here is coverage from Medscape and Medical News Today.  The Wall Street Journal Health Blog chose to go with a story angle about ECT for some odd reason.  Will keep you posted if I see more on this ...

For more from Postpartum Progress on depression during pregnancy, also called antepartum depression, click here.

Psych Central: Antidepressant Use Up, Therapy Use Down

What he said.

" ... while a psychiatrist might well understand the complexities and difficulties in treating depression, many family physicians and general practitioners do not. They might make a recommendation for psychotherapy in passing, but have little time to ensure the patient follows-up on the recommendation. A psychiatrist, on the other hand, better understands the value of psychotherapy and might make it a requirement of being prescribed an antidepressant through them."

You can always count on Grohol to get it right.

 

You Don't NEED Antidepressants, Do You?

I happened upon this great post from a blogger at Scienceblogs.com who wrote about the stigma around taking antidepressant medication, a stigma that doesn't exist for most other medications. 

"Great Caesar's Ghost!" as my grandmother would exclaim ... I hear the same stuff this blogger hears all the time and it drives me CRAZY!!! ... wait ... where's my antidepressant? ... ;-)

As Mark Chu-Carroll explains in part of his piece:

"Out of the dozens of people who've heard about my stomach problem, and know about the drugs I take for it, how many have lectured me about how I shouldn't take those nasty drugs? Zero. No one has ever even made a comment about how I shouldn't be taking medications for something that's just uncomfortable. Even knowing that some of the stuff I take for it is addictive, no one, not one single person has ever told me that I didn't need my medication. No one would even consider it.

But depression? It's a very different story."

I'm sure many of you who have taken meds as part of your treatment for a perinatal mood or anxiety disorder have come up against this.  It's okay to take antibiotics or statins or insulin or whatever else you're prescribed for other ailments, but whoa baby, NOT THE ANTIDEPRESSAAAAAAANTS!!!!!!! AAAAAAAAAAAAHHHHH!!!!! (meant to simulate screaming sound) 

After he concludes his post, you'll find a long and involved and amazing discussion -- comment after comment from people who have had the same experience, or people who understand how real depression is and that for some it requires treatment with medication, as well as from people who disagree with the use of psychiatric medication but do so with intelligence and kindness, not raving and misstatement of fact.

Antidepressants are not the end all, be all.  They aren't perfect.  They're not always necessary.  They don't work for everybody.  They can even be dangerous to some, as can most other medications.  But they're also the only thing that works for some.  The thing that saves many women's lives.  It's not an EITHER/OR situation. 

I refuse to be stigmatized about my treatment choices.  I refuse to be stigmatized about having a mental illness. 

I refuse to be stigmatized.

 

For more stories from Postpartum Progress on antidepressants and postpartum depression, click here.

Psychiatrist Received Pharm Payments While Researching Antidepressants in Pregnant Women

The Wall Street Journal reported Wednesday that Emory University psychiatrist Zachary Stowe had an improperly reported relationship with pharmaceutical company GlaxoSmithKline, which they said " ... made payments to Stowe at the same time he was conducting federal research about the use of antidepressants, such as Glaxo's Paxil, in pregnant women."

Apparently Stowe made approximately $250,000 from his relationship with Glaxo.  The paper reports that Stowe has been reprimanded and told he must eliminate all conflicts related to current federal grants. "In a statement, the school said Stowe had informed it of 'previously unreported activities and has disclosed his failure to abide by Emory policies.'" 

This is very disappointing.  It calls into question his research, regardless of whether it was or was not affected by this relationship.  Is it possible to separate church and state and have federally-funded research that completely bars any additional funding from pharmaceutical companies?  What is the issue with the cost of research or the amount that researchers are getting paid that makes them seek additional funding from sources that could compromise their work?  Can't we ensure that people are paid well enough in their jobs that they don't need to seek this kind of questionable funding elsewhere?  Ugh.

No matter how many he times he may say that this didn't affect his research results, it won't help because this damages his credibility, at least in the public arena.  No matter how much good work he may have done.  That is why this is so awful.

For more on this, check out the Carlat Psychiatry Blog here.

Mayo Clinic Weighs In on Antidepressants During Pregnancy

Here's a section from the highly-respected Mayo Clinic on the issue of antidepressants and safety during pregnancy.  (Note: there are two pages, so don't miss the second page.)  It is a well-balanced piece that discusses the pros and cons.  Here's their conclusion, which is exactly what I've tried to put forth here at Postpartum Progress:

"If you have depression and are pregnant or thinking about getting pregnant, consult your doctor.  Sometimes mild depression can be managed with support groups, counseling or other therapies.  If your depression is severe or you have a recent history of depression, the risk of relapse may be greater than the risks associated with antidepressants.

It's not an easy decision.  As researchers continue to learn more about antidepressants, the risks and benefits of taking the drugs during pregnancy must be weighed carefully on a case-by-case basis.  Work with your doctor to make an informed choice that gives you -- and your baby -- the best chance for long-term health."

Update (Nov. 2009):  For more on this, find out what the American College of Obstetricians and Gynecologists' recommendations are on the depression during pregnancy and the use of antidepressants.

News Roundup on Antidepressants, Online Treatment & More

There are lots of interesting articles, tidbits and posts online by the cast of characters I like to read, and I want to share some of them with you here:

Therese Borchard at Beyond Blue: Do Antidepressants Dull Emotions?

Therese Borchard at Beyond Blue:  How Would the Dalai Lama Treat A Mood Disorder?

Lauren Hale at Sharing the Journey:  Adrienne Einarson Responds to Vogue's "Pregnant Pause" Article

John Grohol at Psych Central:  No Significant Relationship Between Violent Crime & Mental Illness

John Grohol at Psych Central:  Online Treatment for Depression

OB-GYNs Attitudes on Screening for PPD, Sex & PPD, & Other New Research

I missed out on telling you about a lot of study results and articles that have come out in the last several weeks while I was getting ready for the Mother's Day Rally for Moms' Mental Health.  So here goes ...

An editorial from the May 2009 issue of the American Journal of Psychiatry entitled "Assessing Risk & Benefit: To Treat or Not to Treat Major Depression During Pregnancy with Antidepressant Medication."  Here's the article's conclusion:

"Thus, all things considered, on the basis of the findings from the methodologically sound and rigorous study of Wisner et al. and the evidence available from long-term studies, this author thinks that the risk of untreated major depression outweighs the risk of effects of SSRI treatment on neonatal outcomes."

A study presented at this year's annual meeting of the Society for Maternal-Fetal Medicine that finds the majority of obstetric providers are not documenting the Edinburgh Postnatal Depression Scale in their postpartum assessment, yet they feel responsible for and confident in screening for postpartum depression.

An article on breastfeeding and postpartum depression from Advance for Physicians Assistants.

And get ready for the big one ... women with postpartum depression who are treated with antidepressants often see their sexual problems resolve as well, per a new study in the Journal of Clinical Psychiatry.

Hale Responds to Vogue Piece on Antidepressants in Pregnancy

Each year in May, women's magazines pull out all the stops to write about moms, moms, moms.  The best moms in the world, the best mom gifts, what moms need to know, mom tips, mom, mommy, mama, momma, mommie dearest, mom-mommy-mommy all the time.  Something to draw moms in and sell lots of copies.

Vogue's entry into this field this month is a story on the dangers of using antidepressants during pregnancy.  They use the words "SHOCKING TRUTH" on the cover in reference to this story, to titillate and sell more covers of course. 

Lauren Hale did her own investigation into the claims made in the article and into the wide variety of research that currently exists, and wrote a response to the article.  Check it out here. 

Study Looks At Pre-Term Births Among Women Using Antidepressants

As I'm not a clinician, I sometimes have a hard time understanding the medical-school-speak used in the research results published in journals.  It's important for us all to know what the research finds, but sometimes I just find myself confused and not sure what they're trying to tell me.

Which is why I'm glad Karen Kleiman just wrote about the study "Major Depression & Antidepressant Treatment: Impact on Pregnancy and Neonatal Outcomes" published this month in the American Journal of Psychiatry. 

She explains on her Postpartum Stress Center blog:

"... As expected, women with no depression or antidepressant medication had a low rate, (6 percent) of preterm births. But women exposed to SSRI treatment had a 23 percent rate and those with depression and no treatment had similar risks, 21 percent, for preterm birth.

According to Kathy Wisner, MD (lead author of the study and renowned PPD expert):

'Given the similarity in outcomes for continuous SSRI treatment and continuous depression, one possibility is that the underlying depressive disorder is a factor in preterm birth among women taking SSRIs.'

The take-home point (and dilemma) is this:

Though clearly this is more evidence that the use of SSRIs during pregnancy is associated with an increase risk of preterm birth, the risk of an untreated depression during pregnancy poses a similar risk. Suggesting that perhaps factors other than the SSRI treatment (such as the depression itself?) are linked with the preterm birth."

I will tell you that with my first child was born two weeks early and I was on no medication.  I will also tell you that with my second birth my daughter was born 4 weeks early, and I happened to be on an antidepressant to prevent PPD since I'd had it with my son.  But I also happened to have a kidney stone when I was 8 months pregnant (I inherited them from my father), and just a few days after coming home from the hospital after going through that unholy horror my daughter was born.  So do I attribute her early birth to the medication, to the enormous stress caused by the kidney stone, or both?  Or to something else entirely.  I have no clue.

How To Decide Whether To Take Meds for Depression or Anxiety During Pregnancy

So you have a history of depression (or anxiety or bipolar disorder) and you're trying to decide whether to have a child or not.  OR you've gotten pregnant and now have depression (or anxiety or bipolar disorder) during your pregnancy, maybe even for the first time in your life.  OR you are pregnant and you're feeling fine but you've had antepartum or postpartum depression (or anxiety) with a previous child and you want to prevent it from happening again. 

Let's say you happen to know (from reading Postpartum Progress!) that research shows that the rate of relapse for women with depression who are taken off their medication while pregnant is 50 to 75%.  You also already know that babies whose moms suffer untreated depression while pregnant are negatively affected, including having a higher risk of being born pre-term and with low birthweight.  On the other hand, you're worried about the risks of taking medications while you are pregnant.  You've read about conflicting studies and you're not sure what they mean.  You're starting to realize there is no 100% safe choice either way.  So what the hell should you do?!

Most of us feel like we're damned if we do take medication to treat or prevent depression or anxiety and we're damned if we don't take medication to treat or prevent our depression or anxiety. 

You can freak out about it and make yourself sick over it.  I've been there.  It is no doubt a scary decision to make and one that I've had to make myself.  But I'd like to suggest a different approach ... a Warrior Mom approach, if you will.

As a Warrior Mom, you're going to talk it over carefully with your psychiatrist and your OB/GYN and come up with a plan that makes the most sense for you as an individual.  Your plan may include therapy, support groups, medication, nutrition, and/or exercise ... there are lots of options.  What you need is a healthcare professional who has knowledge and experience, who is measured and balanced, and who can have an intelligent discussion with you about your unique history and situation. 

If you have a doctor who hands out antidepressants like candy and doesn't talk to you about the risks, get another doctor.  If you have a doctor who refuses to allow anyone to take medication during pregnancy and doesn't understand the risks to you and your baby of untreated mental illness during pregnancy, get another doctor.  If the healthcare professional you're going to is an extremist on either end, they're not fully informed and that's not fair to you.  At minimum, you can have your doctor consult with another who has more expertise on these issues.  Then you can make a decision.

The next step is to remind yourself that this will be only ONE of a million decisions you will make about your children that may (or may not!) deeply affect them.  We make choices every day that can change our children's lives, in big ways and small, for better or worse.  Do we breastfeed or don't we?  Do we send them to daycare or do we stay at home with them?  How much television?  Public school or private?  City, suburbs or country?  Do we sign them up for this sport or that one, this art class or that one, or do we sign them up for nothing at all?  Do we let them spend the night or not?  What's the right curfew?  Do we stand our ground or give them a break?  Give them birth control or tell them to abstain?  Do we let them go on that trip, borrow the car, wear that outfit or get that nose ring?  There are no 100% safe answers to any of these questions.  What you decide, based on your circumstances, may be very different than what I decide.

We can't run off and hide, much as we might like.  As parents, or parents-to-be, we have to decide.  So we do the best we can each day.  All you can do is try and make the best decision for yourself and your family on each of these issues, including the important issue of how to tackle mental illness and pregnancy. 

For more on this, read this great article from Brain Child magazine called "Between Depression And a Hard Place" by Anna Blackmon Moore on how she made the decision whether to take an SSRI during pregnancy, the resources she used, and the varying feedback she got from different doctors. 

And this piece from Heather Armstrong at the very famous blog Dooce about her decision.  And this post from me about my decision.

Also, these pieces, one from the New England Journal of Medicine called "Use of Selective Serotonin Reuptake Inhibitors [SSRIs or antidepressants] In Pregnancy & The Risk of Birth Defects" and this helpful piece from Dr. David Schatz at CTIS.  And this from the Mayo Clinic.

Also, you can check out the following books:  Pregnant on Prozac by Shoshanna Bennett, Pregnancy Blues by Shaila Misri and What Am I Thinking? by Karen Kleiman.  I haven't had the chance to read Shoshanna's or Shaila's books yet, but I know they cover this topic in detail.  I have read Karen's, and as with all her other books, it's very helpful.

Dooce on Taking Antidepressants While Pregnant

Very famous blogger Dooce (Heather Armstrong) is pregnant again apparently, and in this post she talks about her decision to remain on her antidepressant while pregnant.  If you don't know her, she has already experienced postpartum depression, and after consultation with her doctor has decided to continue on Prozac.  As you probably know if you're a long-time reader, I made that same decision with my second child, which I talked about here.  It wasn't an easy one to make, but I'm comfortable with the choice I made, as is Dooce.  I appreciate her bravery in discussing this openly.  

Depression and The Medication vs. No Medication Camps

This is an EXCELLENT, EXCELLENT piece from Therese Borchard at BeliefNet about taking medication for mental illness and all those arguing against it.  I think this is a MUST read.  She writes about James Gordon, author of "Unstuck," who talks about how drugs aren't necessary to treat depression in an interview with Newsweek.

"I have no doubt Gordon's techniques work for those struggling with mild and moderate depression. My doctor confirmed that. Alternative therapies are wonderful for folks with uncomplicated mood disorders. Maybe I wouldn't need meds if I was in that camp.

But I'm not. What I have is serious, and even Gordon didn't sound all that convincing when Newsweek's Anne Underwood asked him, 'And for severe depression?'

His response: 'That's harder to work with. That's where we need studies.'"

Thanks Therese.  Right on girl.  I hate how judgmental people are about medication.  What I know is that it worked for me.  Let me repeat:  It. Worked. For. Me.    I know lots of people for whom it works.  There are others who don't need it.  That's fine.  Stop judging, world.  Just stop it.

P.S.  Here's Dr. John Grohol from Psych Central's response to Therese's piece

Psych Central: WSJ Covers Problems Between Generic & Brand Name Drugs

This is a very interesting story from Dr. John Grohol over at Psych Central about the difference between some generic drugs and their associated brand-name versions as it was discussed in the Wall Street Journal.  I had no idea!!! 

The Wall Street Journal yesterday wrote an entry yesterday about how they differ — Inexact Copies: How Generics Differ From Brand Names. The spotlight is shining on generics because of their low cost and increasing reports about how being switched to a generic form of a medication can lead to negative side effects not experienced on the brand-name drug.

You might want to check out the link ...

New Guidelines On Use of Psychiatric Meds During Pregnancy

From Medscape:

The American College of Obstetricians and Gynecologists (ACOG) has issued updated guidelines for the treatment of certain psychiatric illnesses during pregnancy and breast-feeding. The April 2008 Practice Bulletin updates the previous November 2007 bulletin and is based on current evidence of risks and benefits of treatment of psychiatric illnesses during pregnancy. The guidelines are designed to aid clinicians in providing appropriate care.

"The bulletin acknowledges that there's good evidence that untreated or inadequately treated mental illness is unhealthy, which is probably one of the first times it's ever been pointed out so definitively," Zachary N. Stowe, MD, from Emory University in Atlanta, Georgia, who contributed to the development of these guidelines, told Medscape Psychiatry.

The study is published in the April issue of Obstetrics & Gynecology.

Scaremongering, Risk & Postpartum Depression

I wanted to share this quote from an email sent to me by a woman in the UK who suffers from depression.  It is so well put, and represents how a lot of us feel when it comes to taking medication:

[I was pleased with the] intelligent discussion on your Blog about the risk-benefit of antidepressants, amidst the relentless tide of scaremongering from "big pharma sponsored" psychiatrists warning people that they will inevitably relapse into bad mental health if we discontinue our medication and the scaremongering from "litigation sponsored" lawyers frightening us to death about inevitable child defects. There is nothing inevitable in life & people manage risks as well as they can.

Agreed.

Study Highlights Disconnect Between Perceptions of Women and Doctors on Postpartum Depression

A fascinating piece of research has just come out from the Society for Women's Health Research that highlights that vast differences of opinion between women and physicians on the use of medication to treat depression during and after pregnancy, as well as women's lack of understanding of the risk factors for postpartum depression:

Only 10 percent of women think it is safe for women to take medication for depression while they are pregnant, compared to 68 percent of doctors, according to a new survey of women and physicians released today by the Society for Women’s Health Research. Even after pregnancy, in the postpartum period, only half of women think it is safe for women to take medication for depression, compared to 97 percent of doctors.

“This survey shows a tremendous disconnect between doctors’ beliefs about managing depression and the perceptions held by women,” said Sherry Marts, Ph.D., vice president of scientific affairs for the Society, a Washington, D.C., based advocacy organization. “The health care community needs to do a better job communicating with women about depression. We need to carefully explain the full range of treatment options for mood disorders and the pros and cons of taking medications during pregnancy and after pregnancy so that women can make better informed choices.”

African American women and women 18-34 in the survey were even more likely than others to say that it is not safe to take depression medications during pregnancy or the postpartum period.

“Many pregnant and postpartum women falsely think that depressive symptoms, and even clinical depression, are part of the normal experiences of being pregnant and delivering a baby,” said Kimberly Yonkers, M.D., an associate professor of psychiatry and obstetrics and gynecology at the Yale University School of Medicine in New Haven, Conn. “Moreover, they often assume that these symptoms will spontaneously go away when that is not always the case. There are a range of treatments available to women and we need to get the message out and encourage depressed women to access care for their emotional symptoms.”

The survey also revealed that women underestimate, compared to doctors, their risk for depression at specific life stages where they undergo a hormonal transition. The gap is largest for perimenopause and menopause. Only 47.5 percent of women thought perimenopause is a time of heightened risk for depression, compared to 83.2 percent of doctors. Even fewer women, 39.5 percent said menopause presents unique depression risks, while 77.8 percent of doctors noted this time of risk. Women’s recognition of depression risk at puberty and in postpartum was better.

“Women’s bodies undergo changes in hormone levels during key life cycle transitions from puberty to menopause,” said Marts. “Most women navigate these transitions with minimal mood disturbances, but some women experience mood disorders such as depression or bipolar disorder. We need more research to understand the underlying mechanisms in the brain where mood disorders are triggered by hormone changes. Women need to be aware of this issue and talk to their health care providers about their individual risk factors, warning signs and treatment options if needed.”

When asked about the major symptoms of depression, women focused on emotional symptoms and most neglected to mention the physical symptoms that can accompany depression, such as trouble sleeping, fatigue, changes in appetite or pain. Only 38.2 percent of women noted at least one physical symptom that can be a sign of depression, compared to 86.4 percent of doctors.

Regarding risk factors for postpartum depression, less than one percent of women mentioned family history, previous depression problems or genetics as a risk factor, compared to more than half (53.8 percent) of doctors.

The survey of 1,000 U.S. women 18 and older was conducted through a national telephone omnibus survey, Oct. 4-14, 2007, and the results are weighted to be representative of the total population. The survey of doctors took place Oct. 11-17, 2007, via the Internet. Both surveys were conducted by International Communications Research (ICR) of Media, Pa. The margin of error for the full women’s survey is plus or minus 3.1 percent. It is 4.4 percent for the survey of doctors, which included family practitioners, general practitioners and internal medicine specialists. Support for the survey was provided to the Society by Novartis through an educational grant.

The Painful Decision of Medicating While Pregnant

I've had a couple of people reach out to me lately for my advice about having another baby after they've experienced a postpartum mood disorder with a previous child.  I combed back through Postpartum Progress and realized I didn't write very much about my pregnancy with my second beautiful child, and what I was thinking at the time.  Perhaps I was avoiding writing down how I really felt as I awaited her birth. 

Since I knew I was highly likely to experience postpartum OCD again, this time I made sure I had a team around me that I knew would watch me like a hawk.  I saw my fabulous psychiatrist at Emory every month (Hi Dr. Newport!), took my meds, talked to my therapist and made my family and friends put on their eagle eyes and their super-sensitive ears to monitor me.  I truly felt comfortable that I was doing all I could do to have a better experience the second time around. The absolute hardest part about all of it, though, was the meds.  I can still feel twinges of guilt about taking medication while pregnant even to this day.  And I'm sure there are plenty of judgmental people out there (like one Mr. Tom Cruise) who would love to tell me what an awful mother I was and am for doing that.

I thought long and hard about it.  I prayed about it.  I, of all people, know the latest research because it's my job to inform you about it here at Postpartum Progress.  Truly, the risk in general is small, though there are some antidepressants that are more dangerous in utero than others.  Yet a risk is a risk.  For mothers, even a teensy, less than 1% small risk is really a HUMONGOUS, MAMMOTH-SIZED, JUMBO JET GIGANTO-RISK.  The risk that my son or daughter might get pink-eye from one of their friends is enough to give me a headache.  My children are like delicate, precious packages of plutonium love as far as I'm concerned.  The LAST THING I would ever want to be responsible for is putting them at risk.  Yet there I was.

I talked about this with my therapist a lot.  I cried about it.  But she told me about how the flight attendants on planes warn you that, in case of cabin decompression or oxygen loss or however they put it, you should put the oxygen mask on yourself first before you put one on your child.  If you're out of commission, you can't help the ones you love.  So I decided I wanted to help myself so I could help my family.  I know there was risk to taking the medication, and I know there was risk to my child if I hadn't taken it.  Either way there was unavoidable risk.  So I bit the bullet.  Or the Cymbalta, as it were.  I ended up being fine and so did my daughter.  That makes me happy.  And for those of you who decide not to take meds, find other successful ways to cope, and end up being fine, that makes me happy too.

Just so you know, lots of women take medications while pregnant and are not judged at all.  It's just that society has decided that, while it's okay for women who have chronic physical illnesses or diseases to remain medicated, mental illness is "optional" so we really don't have to take that antidepressant stuff if we don't want to, right?  It's okay if you need something to stop your brain tumor from growing, but if you're just trying to stop your brain from acting out of control, well that's different.

Is it?

Two New Studies Suggest Antidepressant Use Poses Minute Danger To Babies

One of the biggest issues for all of the women who need to be treated for postpartum mood disorders is that of medication:  Why do I have to take it?  How long will I have to take it?  Will it hurt my baby if taken during pregnancy?  Will it hurt my baby if taken while I'm breastfeeding?  What is the tradeoff between taking the medication and getting better but possibly harming my child (due to potential birth defects), and not taking medication and not getting better and still possibly harming my child (due to potential learning disabilities and behavioral problems, etc.)? 

It's all SO MURKY, and so difficult, and I find that whatever choice women make, it NEVER feels like a win/win situation.  Something seems to lose out either way.  Below is an article about the results of two new studies that found that antidepressant use poses very little risk to babies.  I have put the entire article here verbatim for you to see for yourself (the highlights, however, are mine). 

Does this mean we should all run out and chow down on some Zoloft???  Of course not!  Taking medication is still and issue for each individual and her doctor to discuss and decide on together.  For mothers, even a .0000000001% risk is a lot.  But at least the results of these studies are encouraging ... 

Wednesday, June 27, from HealthDay News:  Pregnant women who use antidepressants known as selective serotonin reuptake inhibitors (SSRIs) are not increasing the risk of most birth defects for their newborns, new research suggests.

Drugs within this class -- which include Celexa, Paxil, Prozac and Zoloft -- may increase the risk for certain defects, but, even then, the absolute risk is extremely small, concluded two studies published in the June 28 issue of the New England Journal of Medicine.

"It's a fairly reassuring message for women who need antidepressants and are pregnant or who plan on becoming pregnant," said Carol Louik, lead author of the first paper and an assistant professor of epidemiology at Boston University's Slone Epidemiology Center. "We saw no large risks, and the fewer elevated risks that we did see would only lead to very small absolute risks."

"This is a valuable contribution," added Dr. Jon Shaw, director of child and adolescent psychiatry at the University of Miami's Miller School of Medicine. "It substantiates the need to always be prudent in prescribing antidepressants."

The issue of maternal use of antidepressants, particularly those known as selective serotonin reuptake inhibitors (SSRIs) is a charged one.

Last November, the American College of Obstetricians and Gynecologists recommended that women avoid the SSRI Paxil if they are pregnant or planning on becoming pregnant, due to a potential heightened risk of birth defects.

The guidelines come a year after the U.S. Food and Drug Administration (FDA) issued a warning about possible birth defects associated with Paxil when the drug is taken during the first trimester of pregnancy.

The initial FDA warning came in September of 2005. In December of the same year, the FDA instructed Paxil's maker, GlaxoSmithKline, to reclassify the drug from a Category C to D (a stronger warning) for pregnant women. Category D means studies in pregnant women have demonstrated a risk to the fetus.

Other reports had indicated that SSRIs may cause newborns to have withdrawal symptoms.

To complicate matters further, yet another study found that pregnant women who discontinued their antidepressant medication were five times more likely to relapse into depression than women who continued with the medication.

Women of reproductive age have the highest prevalence of major depressive disorders, with experts estimating that about one in 10 will experience a bout of major or minor depression sometime during pregnancy or the postpartum period.

The first study, conducted by Louik's team of Boston researchers, looked at almost 10,000 infants with birth defects and close to 6,000 infants without birth defects. The researchers wanted to see if there was an association between defects that had been previously linked to SSRIs and the use of these drugs by mothers during their first trimester of pregnancy.

Overall, SSRI use was not associated with significantly increased risks of craniosynostosis (when connections between skull bones close prematurely), omphalocele (when intestines or other abdominal organs protrude from the navel) or heart defects.

There were, however, associations between maternal use of Zoloft (sertraline) and omphalocele and septal defects (defects in the walls that separate the chambers of the heart) and between Paxil and defects that interfere with blood flow to the lungs.

But even if a certain drug increased rates by a factor of four, the risk of having a child affected by the problem would still be less than 1 percent, the researchers said.

The study was funded by grants from the U.S. National Institute of Child Health and Human Development and the U.S. National Heart, Lung, and Blood Institute, as well as drug companies Aventis, Sanofi Pasteur and GlaxoSmithKline (maker of Paxil).

A second study, this time conducted by scientists at the U.S. Centers for Disease Control and Prevention (CDC), Atlanta, found that the use of SSRIs during the first trimester of pregnancy was not associated with any increased risks of most categories of birth defects, including congenital heart defects.

The researchers looked at four SSRIs: fluoxetine (Prozac), sertraline (Zoloft), Paxil and citalopram (Celexa).

There were some associations between maternal SSRI use and anencephaly (a brain defect), craniosynostosis and omphalocele, but, again, the absolute risk was very small. These defects had not previously been associated with SSRI use during pregnancy, the study authors noted.

Louik said she did not anticipate any labeling changes based on these studies, but that she did anticipate more research.

"These studies make a large contribution to the field, but they're not the final word by any means," she said.

Reluctance to take Meds: What If It Was Diabetes or High Blood Pressure Instead?

I get so many comments and questions from women who want to know how to get over postpartum depression without taking medication.  I'm NOT judging them or questioning their reluctance one bit, because truthfully I didn't want to take medication either.  But all these concerns have led me to wonder what our reluctance really is.  As I said in an email to one of these women earlier today, if I was diagnosed with diabetes I wouldn't think twice about taking medication prescribed to me.  If I was told by my doctor that I had high cholesterol or high blood pressure, I'd take the medication prescribed to me.  Sure, I'd need to change my lifestyle as well to address the underlying problems causing the high blood pressure or cholesterol -- I'd exercise more, I'd eat better, I'd develop better coping mechanisms for stress -- but I'd also take the medication to address the current crisis until my other activities kicked in and my blood levels were safe enough that I could discontinue the meds.   

Isn't it the SAME THING with postpartum mood disorders?  Aren't meds ok to help resolve the immediate crisis, while at the same time we can use exercise and/or talk therapy and support gropups and whatever else works to resolve any contributing underlying factors and to recover and get back to our old selves?  And when we do recover, we can reduce them until it's okay to stop taking them altogether. 

It seems to me that psychiatric medication, where appropriate and prescribed by an experienced professional, is simply addressing a physical medical crisis.  Our bodies don't differentiate between psychiatric illnesses and other physical illnesses.  Only society does.  It's society, and the damn insurance companies, that make us feel like psychiatric illnesses are some how different and highly questionable.   Who the hell is some insurance person to tell me how many damn doctor visits I'm allowed to have to get better from postpartum depression?  Are you kidding?  ... sorry ... it just incenses me that we're given hard limits on what treatment we can have to get better as if (wink, wink) we're probably not really sick in the first place, now are we??

Anyway, I'm sure there are people who have recovered from postpartum mood disorders without taking medication.  And I say more power to them, seriously.  Potentially, through continued research into various hormones and brain chemicals and genes and levels of various things in our blood we may get to a point where there is a more direct treatment for these illnesses which may or may not involve medication.  Until then, I can only tell you that I, myself, would not have recovered without the medication I took.  As Oprah says, that's one thing I know for sure.

P.S.  On the same topic, click here to go over to The Perinatal Project blog to read about some recommended changes in the way mental illnesses are covered by insurance.

Nationally-Recognized Author/Social Worker Karen Kleiman Sounds Off

Karen Kleiman has written an excellent response to the ignorant Ms. Shore on her Postpartum Stress Center blog:

Katherine Stone (and her wonderful Postpartum Progress Blog) has called our attention to the words of Tricia Shore , a writer who, when she isn't stirring up trouble, is a comedian (someone should tell her this isn't funny) who has declared her comments on PPD for all to see. On behalf of women with postpartum depression, I feel compelled to clarify a few things:

It's a shame that so many ill-equipped and opinionated writers have such an expansive audience to whom they can further spread their misconceptions. In the past, when someone found a forum to preach misinformation, it could be dismissed as an isolated aberration or an individual’s distorted interpretation or simply unbridled discourse at a cocktail party.

But today, as we continue to seek or be bombarded by Internet-available information we may or may not want or ask for, sometimes something seeps through cracks. We are then forced to spend what little available time we have wondering why someone actually spent the energy and bandwidth to put forth a particular message. The reason we have to respond is because there is now, more than ever, greater access to these unsupervised communications and more lives potentially impacted.

So I reluctantly confess that I spent superfluous time reflecting on the piece written by Tricia Shore that Katherine so responsibly brought to our attention.

In what might, at first glance, be a not-so-popular posture, I must admit that I agree with her opening opinion which raises a concern of my own: Has our media-soaked attention to a devastating illness, somehow diminished its worthiness in the medical and mental health community? Is there so much hype surrounding postpartum depression that in addition to promoting much needed awareness to this underdiagnosed illness, it might actually dilute the impact and sabotage our own efforts?

I hope not.

Those of us who treat this illness know only too well how excruciatingly painful and potentially deadly it is. Quite frankly, we should not be the least bit influenced by the misguided insights of a bystander who claims to have a worthwhile opinion. But for the sake of those who have been disturbed by this very well-written commentary, and on behalf of women who struggle with postpartum depression, let me do my best to respond to some of her specific points with a few of my own opinions:

--Postpartum depression does not make strong women appear weak. It makes strong women sick.

--Claiming that Brooke is "prostituting", Oprah is "enabling" and Mary Jo is "victimized" is inflammatory and simply unmerited.

--"Little pills that supposedly cure depression" can save lives and improve the quality of life. This is not a belief, it is evidence-based information that may or may not be significant to Ms. Shore or anyone she loves.

--Breastfeeding may indeed facilitate a pre-pregnant hormonal state. Breastfeeding may also be contraindicated if a woman is sick and unable to adequately care for herself and/or her baby. Breastfeeding can be associated with increased fatigue, depletion of personal resources and guilt that renders a mother virtually frozen with ambivalence. Pressuring a woman to breastfeed when she is in the throes of a major depressive episode and feeling suicidal can have catastrophic consequences.

--If a woman is fortunate enough to be surrounded by family and friends to "help hormones return to normal", she is likely to feel less isolated, less agitated and far more comforted. The presence of her loving family and friends cannot, however, prevent nor treat a major depressive episode.

--She makes a good point regarding the thyroid and it's worth repeating by one of the "supposed experts" who understands and treats women with postpartum depression: Before a definitive diagnosis of postpartum depression is made, depression caused by medical conditions such as thyroid dysfunction or anemia must always be ruled out.

--It’s okay for her to be skeptical about our mental health industry. She should be. We all should be. Women who are sick should be especially skeptical about misdiagnoses, mistreatment and misinformation. No one should be prescribed medication if they do not need it. And no one should question the use of medication by someone who does.

--"I even wanted to be a social worker… my plans have changed about becoming a social worker…"

This point, Ms. Shore, is very good news for all of us.

Sheer perfection!

Genetic Test Can Predict Impact of Antidepressant Side Effects

Wendy Davis sent me a VERY interesting article called "The Right Drug?" from the Mayo Clinic website, which first appeared in the Minneapolis Star-Tribune in November 2004. Psychiatrists at the Mayo Clinic have found that they can use genetic tests to predict which people will have side effects from certain antidepressants.  This could be huge!  Here is much of the article verbatim:

"Psychiatrists at the Mayo Clinic have come up with a new way to help people avoid some of the nasty side effects of antidepressants and other drugs.

They're using genetic tests to predict which patients are likely to get headaches, nausea or other problems from medications such as Prozac and Paxil. And they're changing their treatment accordingly.

The tests are among the first in a new wave of genetic tools that, experts say, will transform the way doctors make decisions about treating their patients.

'At this point in time, the test really can't tell you what drug will work,' said Dr. David Mrazek, Mayo's chief of psychiatry, who has led the charge for genetic testing. But 'it will identify drugs that don't work.' And that, he says, can help reduce side effects and failure rates.

In effect, the DNA tests look for faulty genes that can interfere with someone's ability to process drugs normally. Doctors can use the information to adjust dosing levels or steer people away from drugs that may harm them or can't help them ...

At Mayo, Mrazek and his colleagues have focused on genes for a family of enzymes known as cytochrome P450. Those enzymes control how the body processes dozens of medications, including some antidepressants, heart drugs and cancer drugs. If those genes don't work right, the body's ability to metabolize drugs -- to use them and dispose of them -- goes haywire.

For some patients, this translates into years of frustration, searching for a drug that works and won't make them sick.

By the time one woman came to see him, Mrazek recalled, she had spent about 10 years seeking help for her depression. She claimed that every antidepressant she tried caused excruciating headaches or other problems. Her doctors would roll their eyes and scold her for not taking her medication.

When she had the DNA test, Mrazek said, he discovered that she was a classic 'poor metabolizer.' Because of faulty genes, she couldn't produce a key enzyme, known as 2D6, which helps break down certain drugs in the body. Without the enzyme, the antidepressants built up in her bloodstream like a toxic overdose, triggering the side effects.

He switched her to a different drug that didn't need that enzyme to function. And her relief was palpable. 'This is the reaction I have over and over again -- We're not crazy. We're not hypochondriacs,' Mrazek said. 'They feel like they've been sort of mishandled by doctors who haven't listened to them.'

Many depressed people simply stop taking their drugs because of side effects, experts say.

So for patients, this kind of test could be a dream come true, according to Sue Abderholden, executive director of the National Alliance for the Mentally Ill, Minnesota chapter. 'If we could reduce the side effects -- boy, that would be huge.'

At the other extreme, some patients don't benefit at all from certain antidepressants, at least at standard doses. In those cases, Mrazek says, they may have too many copies of a certain gene, which results in a surplus of enzymes working overtime to clear the medicine out of their bodies. They may need a bigger dose than normal, or a different drug.

This kind of test won't prevent all side effects, he notes. For example, antidepressants have been linked to an increase in suicidal thoughts, and he said genes may have little or nothing to do with that. But genetic differences are clearly to blame for other types of side effects, such as impotence or loss of sex drive.

Generally, most people tolerate these drugs well, he adds. Only about one in 10 people may have a genetic variation that causes a problem, though the rates vary by race, geographic origin and the type of drug involved.

The DNA test Mrazek uses is a simple blood test and needs to be done only once in a lifetime. But some worry about the costs. At the Mayo Clinic, it's about $650 to test just two key genes.

That's one problem psychiatrists at the Veterans Medical Center in Minneapolis are wrestling with as they prepare to start offering the tests. 'Depression is such a common thing. If you start doing this indiscriminately, it's a lot of cost,' said Dr. Adityanjee, a VA psychiatrist who is part of a committee studying the DNA testing. For now, he said, they'll probably limit it to certain patients, such as those who have had problems with medications in the past. 'It's too early at this point in time for this to be part of, let's say, gold-standard treatment,' said Adityanjee, who uses only one name.

But as costs drop and more tests become available, he predicts, 'It will become part of our day-to-day treatment" ...

Mayo is also offering the test commercially, to doctors and clinics around the world.

Eventually, Mrazek hopes to fine-tune the tests to be able to predict which drugs will work best for each patient. 'We're not there now,' he said. But he's optimistic: 'I think it will happen in the next five, 10 years.'"

Carolyn Brink, who experienced postpartum depression and eventually became a patient of Mrazek, found the right medication thanks to Mrazek's cytochrome p450 test.  Her new book "Mommies Cry, Too" chronicles her experience.  You can learn more about it here.  I have a copy (thanks Carolyn!) but haven't had the chance to sit down and read it yet. 

The Art of Psychiatric Medication

One of the most frustrating things about getting treated for a postpartum mood disorder is the fact that you can't take one single magic pill and get better the next day.  When I first went to see my psychiatrist, I had the expectation that he would give me something that would begin working immediately.  I was pretty surprised to find out that prescribing psychiatric medication is both a science and an art.  ("You mean to tell me I have to wait two weeks to see if something will even work????!!!!!!" )

Each of us has a different brain, and thus different medications work for different people.  If I took a medication and it didn't work, or worked but had unpleasant side effects, I became concvinced that I'd simply never get better.  Of course, when you're depressed, it's easy to become convinced that you'll never get better.  Now I know that is simply not true.  You WILL get better.  You simply have to find the strength within yourself to accept that treatment is a process and expecting to get better in a week is unrealistic.  What you can expect is to get less sick over time until you get back to who you were before you got sick.  For some people that takes a couple of months, for some people longer.  However long it takes you has nothing to do with the kind of person you are -- it's just biochemistry.  My psychiatrist gave me seven different medications, partially because he didn't know what he was doing and partially because some of them didn't work for me.  When I finally found a trained doctor, we developed a plan that worked, including one antidepressant and weekly therapy.

The most important thing you can do is to take charge of your health and march into your doctor armed with all of the information that physician might need to fine tune your medication.  If you're not eating, tell the truth.  If you fall asleep well, but wake a lot in the middle of the night, tell them that.  If you can't fall asleep to begin with, tell them that.  If you're having intrusive thoughts, or they've gotten worse, lay it on them.  If you feel jittery, or alternatively you feel sluggish, let them know.  If you feel like you want nothing to do with your husband or your children, don't be embarassed to say it.  Nothing you can say is going to shock them or me -- I know exactly what you're going through because I've been through it myself.  I remember I used to drive right through stop signs (with my baby in the car!) -- it's like I was in some kind of dream world and I had delayed reaction time to everything.  I made sure to mention it.  Every detail is important and you can't hold back.   In this way, you help both yourself and your doctor, no matter what treatment path you decide to take. 

You will find the right treatment for you, and you will get better. 

Effects of Medication on Infants at Delivery

The following study provides helpful information about the use of antidepressant medication during pregnancy and its effects on infants after delivery.  I find the results of this study comforting -- not that I think any ill effects on babies are a good thing -- since the possible withdrawal symptoms are so short-lived and don't have any long-term effect.

MONDAY, Feb. 6 (HealthDay News) -- Pregnant women who take selective serotonin reuptake inhibitor (SSRI) antidepressants such as Celexa, Paxil, Prozac and Zoloft could boost the risk of withdrawal symptoms for their newborns, a new study suggests.  However, the Israeli researchers add that these symptoms are usually gone within 48 hours and appear to pose no long-term threat to the infant's health.

Another expert noted that stopping antidepressant therapy during pregnancy poses its own risk to the health of a mother and her child.  "At present, probably the effect of not treating the women's clinical depression is a much bigger issue for mothers and their infants," said Dr. Tim Oberlander, an associate professor of pediatrics at the University of British Columbia and a developmental pediatrician at Children's & Women's Health Centre of British Columbia, Vancouver, Canada.

In the study, published in the February issue of the Archives of Pediatrics & Adolescent Medicine, a team at the Schneider Children's Medical Center of Israel studied the health of 120 newborns. Sixty of these babies' mothers took an SSRI to treat depression during their pregnancy, while the other 60 mothers did not.

The researchers assessed each infant's behavior two hours after birth and again at regular intervals to see if they displayed withdrawal symptoms.

Among the 60 infants exposed to SSRIs in the womb, 18 displayed what experts call "neonatal abstinence syndrome." In a minority of cases, this syndrome "may be severe enough to cause seizures," said senior researcher Dr. Gil Klinger, a neonatologist at the hospital. Of the 18 cases noted, eight were severe. The most common symptoms were tremors, gastrointestinal problems, an abnormal increase in muscle tone, sleep disturbances and high-pitched cries.

However, Klinger added that "signs of neonatal abstinence subside usually within a few days," he added, noting that none of the babies required treatment.

Based on the findings, Klinger advises that "infants born to mothers treated with SSRIs must be observed for a minimum period of 48 hours or longer if signs of a neonatal abstinence syndrome are evident."

Both mothers and their doctors should become aware of the possible effects of SSRIs on newborns, Klinger said. However, he said the findings don't mean women shouldn't take the drugs to ease depressive symptoms.  "It must be made clear that depression during pregnancy entails risk to the mother and her fetus, thus we are not suggesting cessation of medication," Klinger said ...

Oberlander agreed that women who need them should not stop taking their SSRIs during pregnancy.  "These findings are consistent with what others have found," he said ...

In his own research, Oberlander found that a mom's emotional state seems to be the biggest predictor of her child's long-term behavior. "It's the mother's mood that seems to have the greatest long-term effect, not prenatal exposure to SSRIs."

Tags: depression antidepressants pregnancy effects on infants

Paxil Linked to Birth Defects

This appeared in USA Today today:

The Food and Drug Administration is warning that a study has suggested that the antidepressant Paxil might be associated with birth defects. Paxil's manufacturer, GlaxoSmithKline, said it would include the results of the study in the drug's list of of precautions.  A retrospective study found increased numbers of babies born with birth defects to women who were taking Paxil during the first trimester of pregnancy when compared with women on other antidepressants, according to the FDA and the company.  This included an increase in heart defects, according to a letter from GlaxoSmithKline to health care professionals. 

This is important information, but of course I don't want to freak out those women who may be on this medication and pregnant.  If you are, just call your OB and discuss your options.  Note, it doesn't say this definitely causes birth defects, but is associated with a higher risk.

Tags: postpartum depression Paxil medication

The Importance of Medication: A Study on Women's Views

Helena Bradford, chairwoman of the Ruth Rhoden Craven Foundation for Postpartum Depression Awareness, sent me the following information on the results of a study entitled "Women's Views of Antidepressants in the Treatment of Postnatal Depression."

An abstract of the study, which was conducted at the Faculty of Health and Sciences at Staffordshire University in Britain, stated that:

Little research has been carried out on the treatment of postnatal depression [which we call postpartum depression here in the U.S.] and clinicians must currently rely on general recommendations for the use of antidepressants.  Antidepressant medication as the main treatment for depression in general practice has been shown to be effective when used as prescribed.  However, research has shown that depressed patients consistently receive either no medication or consistently low doses of medication.  This study investigated women's experiences of taking antidepressant medication for postnatal depression.  Thirty-five women with a clinical diagnosis of postnatal depression who had been prescribed antidepressant medication completed a questionnaire detailing their experiences of taking medication ... Of the 35 women who were prescribed medication, four chose not to take it because they were breastfeeding.  Twenty of the women described finding medication helpful.  Although only four women directly reported not taking antidepressants as prescribed, the comments made by a further nine women suggest that compliance may have been poor.  This study suggests a need to improve information about medication for postnatal depression.  If this information is not provided, women are likely to continue to self-manage medication at a dosage that may be clinically ineffective.

Helena says that her experience has been that most physicians unfamiliar with treating postpartum depression fall into the same trap as described in the last sentence of the report, undertreating the illness.  "My prayer," she said, "is that better information surrounding the safety of SSRI's used during pregnancy and lactation will be forthcoming -- and quickly."  I second that.