Postpartum Progress

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 ...

Can Estrogen Be Used to Treat PPD?

Here's a link to a very helpful post on the efficacy of estrogen in treating postpartum mood disorders.  It's written by Dr. Ruta Nonacs of Massachusetts General Hospital and Harvard Medical School.

Center for Women's Mental Health: Cognitive Therapy Vs. Medication In the Treatment of Depression

Here's a link to a very helpful post at the Center for Women's Mental Health Blog about cognitive therapy vs. medication in the treatment of depression.  This is a great argument for the use of therapy, which I believe in strongly, and should be a relief to those of you who would rather not take medication.  A trained therapist can really help you to work through all of the bad feelings you experience when going through a postpartum mood disorder.  It makes a big impact when you have someone help you understand where your thinking has gone awry and help you get back on the right path.   

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.

Upcoming Event in Asheville Features My Psychiatrist!

The Mountain Area Health Education Center in Asheville, NC is hosting an evening for prescribing clinicians called "Postpartum Mood Disorders: A Systemic Approach to Biopsychosocial Treatment" on Thursday, August 16, from 5:30 to 8pm and an all-day conference on Friday, August 17, from 8:30am to 4:45pm..  The key speaker will be Dr. Jeffrey Newport, associate director of the Emory Women's Mental Health Program here in Atlanta and also my psychiatrist!!!!  I have firsthand knowledge that Dr. Newport rocks.  Dr. Judy McKay, a psychiatrist specializing in perinatal mood disorders from Columbia, SC, will also present.  Continuting education credits will be available, and the program is aimed at physicians, nurse practitioners, psychiatrists and physicians' assistants.  The fee to attend on the 16th is $65.00 and includes dinner, and the fee for the 17th is $99.  To register, go to www.mahec.net. 

San Diego Mother Gets Five Years Probation

Here's a link to an article from the San Diego Union-Tribune about a mother with postpartum depression who attempted infanticide but was (thankfully!) unsuccessful.  These types of stories are tough to read, but they help reinforce the importance of treatment.

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. 

Insurance Companies Add to Suffering of Women with Postpartum Mood Disorders

Susan Paynter, columnist at the Seattle Post-Intelligencer, wrote a great column on Monday about the problem with insurance companies refusing to pay for certain antidepressant medications prescribed to treat postpartum mood disorders.  To read the entire column, click here.  Paynter uses the example of a new mother named Jessica Lane whose insurance company Group Health required her to try several other drugs before agreeing to pay for the one she was prescribed and knew would work after using samples from her psychiatrist.  As you know, it takes a couple of weeks to find out if a medication works, so on the outside chance none of these other drugs work, a patient would have to continue to suffer for at least two more months if not longer just to save the insurance company money, which is absolutely awful.

Here is an excerpt:

"Meanwhile, what happens to my family?" Lane asked. "I could spend the next year of my life experimenting with different side effects just so they don't have to pay for the one (drug) that already works for me. That's not only absurd, it's cruel."

Group Health's director of clinical pharmacy services is Jim Carlson, who reasons that it's not a matter of Group Health second-guessing Lane's physician.

"I wouldn't call it second-guessing because the patient can still get the medication."

That is, if the patient pays for it herself.

"In general, most of the drugs used for depression have been shown to be equally effective and tolerated equally well in large populations of patients," he said.

That leaves the only thing left to define, and that is the cost effectiveness of care. It makes sense, Carlson said, to sequence the use of medications in order of cost.

In some rare cases, Carlson said, drug A may not work or be tolerated. Say drug F is on the high end of the cost spectrum. "We don't try to micromanage a physician's prescriptions or use of anti-depressants," he said. "But, if there are several (drugs) that are comparable in cost, then let's try the other three or four first."

A patient doesn't have to go from A to B to C. She can try C, then D and then B.

But can't that take an awful lot of potentially troubling time?

"Indeed," Carlson said. "But there is no real evidence to support that leap (from drug A to the more expensive drug F) based on literature. No way to predict it will be best."

How about the fact that it already IS working, Lane asks?

I don't know what Group Health's research shows, but I know that I had to try many different drugs and they all had very different effects on me -- I've taken Celexa, Serzone, Effexor, Luvox and Cymbalta.  I certainly hope that what I was being prescribed by my psychiatrist wasn't being dictated by some cost-effectiveness schedule of my insurance company.  I didn't to deserve to continue to suffer, nor did my child, simply to save money.  Paynter sums this up so well that I'll leave the last word to her:

Still, we need fewer hoops and more help for moms who may lack the coverage and the navigational skills that Lane does have. "It's as if the insurance company is telling the woman and her doctor that they know best," she said.

"This is the very attitude that leads women to feel weak and ridiculous for even considering they might need help. When I got off the phone (after calling the insurer for an explanation), I just sat on the floor and cried. It seems like it's cheaper for them if I'm nuts or if harm comes to my children. What about women who don't have the resources and the wherewithal to fight this?"

Headlines or not, what happens to them, and to their kids, should matter to us all.

Researchers Had Ties to Pharmaceutial Companies in Antidepressant Study

The Journal of the American Medical Association (JAMA) has announced it was misled by researchers who failed to reveal financial ties to drug companies in a study showing that pregnant women who stop taking antidepressants risk slipping back into depression.  From the Associated Press:

Most of the 13 authors [of the study] have financial ties to drug companies including antidepressant makers, but only two of the them revealed their ties when the study was published in February.

Antidepressant use during pregnancy is controversial and some studies have suggested that the drugs could pose risks to the fetus.

"For readers to be able to make informed judgments about potential biases in this study, they should have been made aware of all of these associations and potential conflicts of interest," Dr. Adam Urato of Tufts University-New England Medical Center, wrote in a letter to JAMA editors ...

The authors of the depression study defended their research in a separate letter to the editor published Wednesday. Lead author Dr. Lee Cohen, of Massachusetts General Hospital, who is on the speaker's bureau for eight drug companies, disputed that such ties could influence the findings.

The business ties were not disclosed because "we did not view those associations as relevant" partly because the research was funded by the government, not industry.

This announcement doesn't mean the study was flawed, of course, but it does make you feel nervous about the outcome, doesn't it?  I don't want ANYTHING, a subconscious bias or something more nefarious, influencing the results of a study on the effects of antidepressant use during pregnancy.  We're talking about the safety of ourselves and our children here, and we need to feel confident about the results of these studies when we make decisions about how to be treated.

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.  I've taken many medications, including Effexor, Celexa, Seroquel, Risperdal, Wellbutrin, Luvox, Cymbalta, etc.  Throughout all of them, I was on the road to recovery.  Some just worked better than others at treating my symptoms. 

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. 

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

Prescription Assistance for Psychiatric Medications

Someone recently pointed me to the Partnership for Prescription Assistance program.  I've seen the commercials on TV, of course, but for some reason it never hit me that this would be an excellent program for those people who have little or no insurance and cannot afford the psychiatric medications they need to help recover from a postpartum mood disorder.  In the six months since the program began, more than 1 million qualified people have been able to get no cost or low cost prescriptions.  I went on the website myself, and saw that Eli Lilly, the maker of Cymbalta and Prozac, participates in the program.  So does GlaxoSmithKline, the maker of Wellbutrin, Wyeth, the maker of Effexor, and Pfizer, the maker of Zoloft, as well as other pharmaceutical companies.  Qualifications vary by program so I can't tell you whether you'd individually qualify -- you'll have to go to the site and fill out the necessary forms or you can call 1-888-4PPA-NOW. 

Thanks to Helena Bradford for the heads up!

Upcoming Satellite Broadcast on Treating Psychiatric Disorders During Pregnancy

On Wednesday, May 17th, Massachusetts General Hospital's Department of Psychiatry will present a satellite broadcast on psychotropic drug use during pregnancy.  The purpose of the broadcast is to discuss the treatment of psychiatric disorders during pregnancy.  The program is described as follows:

Though the last decade has brought considerable interest in women's mental health, systematic data informing the clinical decisions regarding psychotropic drug use for women who wish to become pregnant or who are pregnant are lacking. The course of psychiatric disorder during pregnancy has yet to be sufficiently delineated and growing evidence suggests that pregnancy is not necessarily a time of emotional well-being for patients and the prevalence of psychiatric illness in women during their childbearing years is significant. Safe ways to use psychotropic agents including antidepressants, mood stabilizers, antipsychotics and benzodiazepines need to be developed. [They will also discuss] why delineating the relative risks of untreated psychiatric illness during pregnancy versus the risks of prenatal use of psychotropics is necessary if women and their doctors are to make informed decisions about using these agents during pregnancy.

Participants can listen to the broadcast via telephone, or watch it via webcast or satellite.  The event is aimed at physicians, pharmacists and nurses, and participants can receive continuing education credits.  To register, use this link. 

This is certainly topical for me, as I was treated for depression during my pregnancy to help avoid suffering PPD right now as I raise my brand new baby girl.  I would imagine those women who experienced a postpartum mood disorder with their first child will be particularly interested in the results of the discussion as they consider whether to have another one.

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

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.