When a woman has a history of severe and relapsing mental illness, but is stable on her current treatment, and is planning a pregnancy or is postpartum, what is the best course of action for her and her baby?
In my conventional training, I spent (and continue to spend) countless hours analyzing the available registry, cohort, retrospective, and prospective studies on the safety and efficacy of psychotropic medications in pregnancy and lactation. As one of approximately 300 reproductive psychiatrists in the world, I am privy to the defensive posture of clinicians who deign to help these women, often perceived by general psychiatrists to be too high liability to treat. I understand the feeling that psychiatric medications are held to a standard of obstetrical scrutiny that anti-emetics, antibiotics, steroids, and painkillers are not. I know that there are more than 25,000 cases of SSRIs in the perinatal literature and yet there still isn’t a clear signal of any reproducible, consistent teratogenicity or danger that is definitely not attributable to the underlying illness.
Miscarriage, preterm birth, and neonatal adaptation are all considerations, but are such common and multifactorial outcomes, that it will be some time before clear A-causes-B information surfaces. In many ways, the collective outcome of this data surprises me – we are applying medications (often prepared with unstudied preservatives, dyes, and metals) based on subjective diagnostic parameters, to women who bring other burdens to the table that are largely uncontrolled for in these studies (high glycemic diets, xenoestrogen/endocrine modulator exposure, baseline inflammation). We are rarely certain that the medication, if taken, has treated their symptoms to remission, and study after study fails to show a signal of serious danger on the order of alcohol, Accutane, or even Depakote.
These studies are compromised, fundamentally, by the fact that they are not, and will never be, randomized, double-blind-placebo controlled trials. Analyzing the methodology, reading beyond the abstract, and contextualizing findings for any given patient requires serious dedication of a practitioner’s intellectual resources. How do we personalize these recommendations? After all, studies are studies, and individuals are individuals. In my perspective, we assess for a better treatment path for the patient that addresses root cause hormonal and inflammatory contributors and applies interventions that are low risk and potentially high yield, preferably with some degree of evidence base. We start by looking at interventions that have benefits for mom, mood, and baby (diet, exercise, meditation, fatty acids, l-methylfolate, vitamin D, probiotics, etc).
This process is not for the impatient. It can take upwards of a year to truly rebalance a patient’s system, and to properly taper medication. It is no wonder that data suggests a high risk of relapse. Abrupt discontinuation of antidepressants (and mood stabilizers/benzos/stimulants) places a demand for reequilibration that often overwhelms a system’s ability to achieve that without support, or return to medication. The process of medication weaning is a complex and time-consuming one that, in my experience, requires cell membrane, amino acid, and micronutrient support in the setting of painstakingly slow taper of dosage. I always tell my patients that the ultimate goal is to gently usher the medication out the back door, not push it off the balcony.
When I meet a patient who is already pregnant on medication, wondering what is best for her and her fetus, it is not a black or white decision-making process. We have to consider the central nervous system stimulation of medication withdrawal, potential relapse (often hard to distinguish from the former), safety of supplements in pregnancy, and then the flipside, which is the known and unknown risks of medications, assuming that it is helping her. This web is brilliantly illuminated in this paper, which I would imagine leaves most readers feeling a sense of sky-is-falling nihilism about treating pregnant patients. Oberlander holds all of our assumptions about the interplay between medications, genes, and the epigenome under a microscope, revealing all of the pores and wrinkles we were hoping to obscure with a professional distance. The number of “if, then…” clauses becomes overwhelming.
An example: If the mother carries a short/short copy of the serotonin transporter gene (which we understand to confer “environmental sensitivity” or lack of resilience, and poor response to SSRIs), and she experienced childhood trauma herself, her serotonin trafficking may look very much like that of a woman with long alleles and SSRI exposure. He references an animal study which suggests normalization of the stress response after SSRI exposure in utero, alluding to the potential effects of SSRIs that span well beyond the serotonin modulation and may even be protective in some cases.
Then, once the serotonergic imprinting has occurred in utero, the effects are further modulated by postnatal exposures such as nurturing care and breastfeeding so that cortisol levels may be normalized even if there was alteration of serotonin signaling in pregnancy that messed with the hypothalamic pituitary axis. It appears that genetic variants “matter” only in settings of environmental stress, and maybe only if that stress represents a “mismatch” to the in utero level of stress. After all, epigenetics is a means of preparing the baby for the world it appears to be entering.
The summary of this article reads like a “well, maybe, uhh, we’re not sure” conclusion to the examination of just one proposed system of influence – serotonergic tone in utero as regulated by SRIs, genetic variants, and mood disorders. It renders the reductionist model of depression as a serotonin-deficit disease cured by a reuptake inhibitor, embarrassingly simplistic. In light of this, it is important to feel comfortable sitting with uncertainty, giving wellness and healing a cautious and humble best effort while respecting the vast swaths of knowledge that have yet to be achieved. I don’t waste my patient’s time with hand waving about biochemical imbalances as an explanation for their state (I have been known to gesticulate wildly when talking about gluten, though).
Adding to this complexity, we suspect, based on a study by the same author that maternal antenatal depression may increase methylation of the glucocorticoid receptor (shutting down its on switch), leading to elevated stress response in the child at three months. He discusses some 15% of childhood behavioral problems being attributed to antenatal stress/anxiety. This is a sign of a toxic, inflamed system, and it is no surprise that this maternal inflammation has a negative effect on the fetus.
What else can cause maternal inflammation? Here’s the short list:
- Processed foods/trans fats
- Lack of sleep
- Sugar and associated insulin resistance
- Obesity
- Environmental toxins/industrial chemicals
- Vaccines
- Chronic infection
I don’t know of many safety studies controlling for these individual variables, yet there are several that examine the deleterious effects on birth outcomes when a woman has evidence of inflammatory markers.
We are operating in a system of medication-driven treatment, and the only real time that medication risks are taken seriously is when a woman has seen that little plus sign on the stick in her bathroom. Then they are often violently tossed out the window, and deemed contraindicated for the coming 1+ years of gestation and lactation. We need to be thoughtfully examining how to best support a woman’s system from the time that she gets her first period (and even more so if that is before she is 13!), because engaging this line of rhetoric once she is pregnant is often too little to late, and a ones or zeros, meds or no meds approach does not do justice to the complexity of a system that is hard at work building another system.
Wonderful article! This really helped me gain a little more understanding of the complexity of the human brain and the problem of depression. Thank you, Kelly! You sound like a scientist and a doctor!
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Thank you for this excellent post.
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Interesting article, but some of the language is in keeping with BIG PHARMA ad ploys to justify their toxic psychiatric drugs and always blame the victims for any horrible “side effects.” I am not saying this was done deliberately, but any time I read the claim that useless, dangerous SSRI’s or any toxic psych drug protects, heals, improves the brain, I know I am reading total junk science since the opposite is true.
I find your articles unnecessarily difficult to read with such a focus on the most technical, medical, obtuse language available obfuscating the points you are trying to make.
I disagree about the question being to medicate or not because this article starts out with the false premise that a pregnant woman can be “severely mentally ill” and “stabilized.” Translation: the woman had some life problem or felt the blues over some issue or became anxious about a conflict and made the fatal error of seeing/believing bogus, dangerous BIG PHARMA ads and/or going to see a biopsychiatrist and got a life destroying bogus stigma to justify toxic psych drugs and THEY ARE ALL TOXIC AND USELESS!! Her bogus stigma will be used to falsely accuse her children of being “mentally ill” too based on fraudulent heritability, genetic claims about so called “mental illness.” Women should be steered away from the mainstream mental death profession because it is hazardous to their health, human, civil and democratic rights, which is also true for their children before, during and after pregnancy.
I disagree with your claim that it is difficult to judge whether bad events are due to the psych drugs or the victim’s so called mental illness, a typical evil ploy of psychiatry and BIG PHARMA to lie and deny that many of their lethal drugs cause miscarriage, birth defects and many other horrible effects for pregnant women and their children based on all too many events. Dr. David Healy describes many of these horrible drug effects in his books and articles including suicide, mania, akathasia, aggression, murder and many other dangerous “side effects” that can put the woman, her child and family at horrible risk. See poster child Andrea Yates under great psychiatric “care” and on a typical lethal drug cocktail when she killed her 5 children, but psychiatry gets off scott free and our corrupt government officials in bed with BIG PHARMA call for more screenings for “mental illness” for new mothers and toddlers to push more of these dangerous poisons to increase their campaign contributions and become richer at the horrific expense of their constituents.
Pregnant women should not be on SSRI’s and other psych drugs known to be in the top 25 drugs causing violence that most if not all school/public shooters were on. Books like THE EMPEROR’S NEW DRUGS: EXPLODING THE ANTIDEPRESSANT MYTH and many others expose SSRI’s are mostly useless and no better than placebo with dangerous, life threatening “side effects” that can’t be justified for anyone, never mind pregnant women. Given that these drugs have been banned for children and young adults due to suicide risk per the FDA, they most certainly should not be imbibed by babies in the womb.
Ideally, woman wouldn’t be conned by the mental death profession in bed with BIG PHARMA to go to biopsychiatrists to get life destroying bogus stigmas to push useless, lethal but very lucrative drugs that line the pockets of psychiatrists, BIG PHARMA and corrupt government hacks. But, if she has been so unfortunate, she like others can be slowly weaned off these poisons ideally before getting pregnant or even when she does get pregnant as the lesser of evils.
It’s very sad that our corrupt nation passed the MOTHER’S ACT to make more global billions for BIG PHARMA for the psychopathic power elite at the horrific expense of mothers and children. This horrible law was passed for the sole, soulless purpose of pushing more lethal SRRI’s and now the horrific atypical antipsychotics and others to push a lucrative toxic drug cocktail to drive the new mother over the edge with her new baby.
This nation like others perpetrating such criminal acts against its people has totally lost its moral compass!
I do appreciate your focus on natural, holistic and alternative methods and acknowledging that the epileptic drug, Depakote, fraudulently remarketed as a “mood stabilizer” by BIG PHARMA and psychiatry is deadly, but atypical antipsychotics are very deadly also and probably more so.
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Ob/gyn’s know all about “effexor babies.” If I’m not mistaken the babies go into pulmonary distress shortly after being born. I’m not sure if they also experience cardiac distress but for some reason it sticks in my mind. You would think that the ob/gyn’s would publicize this problem more but most doctors of any kind hardly ever blow the whistle on problems in medicine. It’s one of the big reasons that I only trust doctors who’ve proven to me that they know what they’re doing.
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Very good post. However, Dr. Brogan says “there still isn’t a clear signal of any reproducible, consistent teratogenicity or danger that is definitely not attributable to the underlying illness.”
Neonatal withdrawal syndrome is well documented. Like adult withdrawal syndrome, it is assumed to last only a few weeks. In neonates, this is when the baby stops continually crying and spasming.
However, in adults, withdrawal syndrome may last quite a bit longer than a few weeks, sometimes into a lengthy post-acute withdrawal syndrome (PAWS) phase, as with other drugs of dependency — see http://www.madinamerica.com/2013/03/alarming-report-on-antidepressant-side-effects/ .
The authors of the above-referenced paper, based on anecdotal patient reports, refer to a “postwithdrawal phase, consisting of tardive receptor supersensitivity disorders.”
We really don’t know what’s going on with neonatal withdrawal syndrome. The baby might stop crying and twitching, but may be suffering the newborn version of depersonalization (for example) for months or years, as adults do.
Let us hope that neonatal neuroplasticity compensates and accelerates recovery from the supersensitivity disorders, and does not devolve into, say, autism.
As for post-natal depression, studies show that mothers who feel isolated are more prone to this. Dr. Brogan, I urge you to add peer support groups for mothers-to-be and new mothers as an intervention to improve the health of mother and baby without resorting to treating with psychiatric drugs.
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“We need to be thoughtfully examining how to best support a woman’s system from the time that she gets her first period (and even more so if that is before she is 13!),”
I don’t follow. Why “even more so before she is 13?” What do the use in later life of antipsychotic medication and periods before the age of 13 have in common?
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check out the 2011 Archives Croen article on antidepressants during pregnancy increasing risk for autism and Adam Urato’s (OBGYN) on the risks of various problems with antidepressants in pregnancy.
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Just published:
Dan Med Bull. 2011 Sep;58(9):A4303.
Paediatric outcomes following intrauterine exposure to serotonin reuptake inhibitors: a systematic review.
Fenger-Grøn J, Thomsen M, Andersen KS, Nielsen RG.
Abstract and free full text at http://www.ncbi.nlm.nih.gov/pubmed/21893008
The use of serotonine reuptake inhibitors (SRIs) is increasing among Danish pregnant women. This systematic review addresses the potential adverse effects on the foetus and child of maternal SRI medication. The literature indicates a slightly increased risk of cardiovascular malformations and persistent pulmonary hypertension of the new-born, while evidence regarding the risk of preterm labour, low birth weight, low Apgar score, prolonged QT interval and miscarriage is less clear. An estimated 20-30% of infants will have neonatal symptoms following intrauterine SRI exposure. The symptoms may be caused by SRI withdrawal, toxicity or their overlap, but symptom aetiology basically remains controversial. The infants may exhibit neurological, gastrointestinal, autonomic, endocrine or respiratory symptoms. Although the symptoms are self-limited, the families may be seriously affected. In general, studies do not address this important aspect. Evidence concerning long-term effects is surprisingly sparse and many studies have important methodological limitations. However, present evidence does not convincingly indicate detrimental long-term effects. Until sufficient safety studies have been carried out, SRI must be used with caution in pregnancy and every treatment of the pregnant woman should be thoroughly considered.
Please allow me to say again: The assumption that neonatal withdrawal symptoms are “self-limited” is based on very limited evidence. The same assumption pertaining to adults is contradicted by hundreds of thousands of reports on the Web of withdrawal syndrome lasting many months or years.
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