Depression during and after pregnancy: The ongoing debate about treatment

February 13, 2012

Within the last year, several studies have been published linking the use of anti-depressants during pregnancy to scary outcomes in babies. Probably the most disturbing was a study published last summer in the Archives of General Psychiatry linking anti-depressant use during pregnancy to an increased risk of autism spectrum disorders. Just last month, a study was published in the British Medical Journal linking usage of anti-depressants during pregnancy to persistent pulmonary hypertension. Yet at the same time, research studies also continue to be published that link the impact of untreated depression in mothers during pregnancy to different kinds of developmental delays in newborns, as well as linking untreated postpartum depression with an increased risk of behavioral problems in infants and toddlers. Talk about damned if you do, and damned if you don’t!

 

Now just add the layer of stigma that mental illness carries, in general, multiply that by 10 for new mothers, and you have a recipe for disaster! It’s no wonder most women don’t disclose how they are feeling to anyone, or ever make their way in for mental health treatment! Geez, Louise!

 

I want to offer some thoughts on what is sure to be an ongoing debate, but that may provide some ideas about the current research as well as some guidelines on how to make an informed decision if you are a pregnant or postpartum woman struggling with a mood or anxiety disorder or are in the role of working with this population to support women making decisions about treatment.

 

#1 Let go of “cause and effect” thinking
The problem with the scientific model is that it is limited by what can be objectively, and ethically measured (more on this in a minute), and follows a cause and effect model: A leads to B leads to C. However, in real life, things just don’t work this way. Outcomes are based on a confluence of multiple factors interacting, and we often do not know (at least completely) what factors created an outcome. Human development is a remarkable example of this – how a fetus develops in utero is an amazing combination of 2 people’s entire genetic history, plus how their genes interacted with their unique environments across their lifetimes so far, plus the environment in utero, etc. Somehow, miraculously, most infants are born relatively typical. However, there are a small percentage of infants that are born with medical complications or birth defects to the general population. Studies on birth defects have uncovered many helpful things that are now part of prenatal care and public health information, however, fully 70% of birth defects have no known cause. It is uncomfortable to live with this level of uncertainty and vulnerability, but the truth is, most of the time the correct answer to the question, “why did this happen?” is “I don’t know”.

 

#2 We know more about anti-depressants than any other class of drugs (and that’s a dangerous thing!)
OK, so that isn’t saying much, but due to the stigma surrounding “psychotropic” medications, a tremendous amount of research has been done on anti-depressant medications. Unfortunately, due to the limitations of this research (see more below) a ton of “associations” have been uncovered between anti-depressants and unwanted outcomes in babies but have not proved “causation” and so we have no coherent way to make sense of them or to appreciate the ways these associations may be better explained by other factors not included in the research hypothesis or model. Pregnant women with other chronic health conditions may receive treatment with other medications that cross the placenta or are secreted into breastmilk postpartum, and may have some impact on the fetus or baby (most likely relatively mild and transient) but are not met with the same kind of hysteria for what are clearly social and political reasons.

 

#3 Factor in the ethical limitations of drug research on pregnant women
The major limitation of all research looking at the impact of anti-depressants on pregnant and postpartum women is that the gold standard of research – randomized, controlled, double-blind (meaning the researchers and the participants have no idea which research group they have been randomly assigned to) studies are not ethical for pregnant women. In other words, we can’t ask a large sample of depressed, pregnant women to participate in a study where some are randomly given drugs and others are not to see what happens to them and their babies. So, research on anti-depressants rely on case reports of drug registries (where people call the drug company to inform them of something that went wrong on their medication), pharmacy databases, and women’s retrospective self-reports. Each of these has severe problems in that the drug registries have no way of knowing what other risk factors a person on their medication may have had (family history, other medications, smoking, etc), pharmacy databases have no way to prove whether or not a person took the prescribed medication (and recent research has shown that significant amount of people prescribed a medication, do not actually end up taking it), and self-reports are notoriously limited because our memories are imperfect at best.

 

#4 Babies experience “risk” through their interpersonal interactions with key caregivers (i.e. not just their mothers!)
Babies and toddlers do not “sense” their parent’s moods, per se. What they do experience in the context of caregiving interactions is whether or not their parent is meeting their needs – this includes emotional, and social needs. Babies cannot tell you what they need, so parents have to go through much trial and error on a daily basis to figure things out. This takes a lot of energy! If a parent is depressed or anxious, they may not have the energy to maintain the parent-infant “dance” and often these parents have distorted thoughts about themselves as parents (“I’m a bad mommy”) or about their babies (“My baby cries because she doesn’t like me”) that get in the way of them meeting their babies needs. The good news is that the research on infants and parents is that if parents can meet their infants needs about 30% of the time that is enough to support healthy social and emotional development. (The other 70% is the aformentioned trial and error!) So, just being depressed doesn’t necessarily expose your baby to anything! However, taking care of your needs is the only way to replenish yourself so you can continue to meet your babies needs which may include some form of mental health treatment. This goes for all caregivers in the baby’s life! The research tends to focus on mothers, but we know that the other adults in a baby’s life impact their development, and now that knowledge is being confirmed by newer research.

 

#5 Psychotherapy is an effective tool for managing most mild to moderate cases of depression and anxiety
Non-pharmacological treatment approaches have been shown to be just as effective for most cases of depression and anxiety. The most exciting research has been in the area of neurobiology which has shown structural changes in the brain as a result of psychotherapy. So, if a woman feels strongly that she does not want to take anti-depressants, there are other effective options for address the symptoms of mood and anxiety disorders. In certain severe cases, medication must be part of the treatment plan due to a lack of response to psychotherapy but even then, therapy seems to help move treatment along for a faster, more complete recovery. In addition, paying close attention to sleep, nutrition, and exercise have all been shown to be instrumental in both maintaining emotional wellness and recovering from a depressive episode. So, if psychotherapy is not your cup of tea, making healthy lifestyle changes can also be an option.

 

#6 What is best for you will be best for your family
The tried and true metaphor from the airplane safety lecture at the beginning of every flight is truly the best here – you have to put your oxygen mask on first, before attending to children in the event of an in flight emergency. I