Screening Pregnant Women for Depression

Peter Gøtzsche, MD
14
193

Editorial Note:
Denmark is now screening pregnant women for depression.
Here, Peter Gøtzsche imagines one of the conversations
that might take place
.

(First published in Danish, in Månedsskrift for Almen Praksis, April 2014)

“How’s the pregnancy going?”

“Fine, I don’t have any problems.”

“And you’re not worried about whether you can manage to look after the baby?”

“No, not at all. I am a housewife and have time to take care of it.”

“Are you aware that it’s possible to have depression without knowing it?”

“No, I didn’t know that, but I’m fine.”

“Yes, but … uhmmm … well … you see … if you are suffering from a depression, it would be good to find out.”

“But I’m perfectly fine.”

“I still think you should undergo this test for depression.”

“So what if it’s positive?”

“Then you may get a drug that will help you.”

“Well … I … There is nothing wrong with me, so why should I undergo this test?”

“The National Board of Health recommends it1.”

“Can’t you just unsubscribe from the Board of Health? Sorry, that was a joke!”

“No, we are obliged to follow the Board’s recommendations.”

“But a test like that is a screening test, is there a Cochrane review about it?”

“Yes, and it recommends that one shouldn’t screen healthy people for depression2.”

“Then why on earth does the Board of Health recommend screening pregnant women like me who are healthy?”

“I cannot understand this either, but the Board of Health has consulted experts in psychiatry who think it’s a good idea.”

“And how many of those who are healthy will get a wrong depression diagnosis with this screening test?”

“About one third3.”

“Holy smoke! How does the drug work?”

“It works like amphetamine. It’s also difficult for the patients to quit, just like for amphetamine and other narcotic drugs; half of the patients have difficulty stopping4,5.”

“And what do these experts say about the side effects of the drug? What is the most common side effect?”

“Sexual problems. They occur in half of the patients6. It can be lack of sex drive, impotence and lack of orgasm, even for the man if he receives the drug.”

“And how about suicide? Depressed people are at high risk of committing suicide, and I assume that this medication will prevent that from happening?”

“No, on the contrary, for someone as young as you, the drug increases the risk of suicide4,7. It can also cause birth defects8,9. The risk is small but it is clearly increased.”

“My goodness! Many thanks for all this information, doc. Count me out. You don’t need to give me that test. I don’t want to risk getting a wrong diagnosis of depression and get treated. My husband and I love sex. And I have no wish to get a narcotic on prescription, or to commit suicide, or to give birth to a deformed child.”

In my opinion, this contrived dialogue, with its fortunate outcome, requires three things: The doctor needs to be exceptionally well informed about the facts; the woman needs to ask relevant questions; and the doctor needs to reply adequately to them. The clinical reality is not like this very often. On the other hand, many doctors will not settle for a questionnaire but will ask clarifying questions and possibly use an additional instrument, which is recommended by the National Board of Health, e.g. the Major Depression Inventory (MDI), a self-assessment questionnaire that uses the diagnostic criteria directly from the ICD-101. Obviously, the use of such additional instruments will reduce the proportion of false positives, but they are also very uncertain. Screening healthy people will therefore inevitably lead to many false positive diagnoses, and many healthy people will be treated with antidepressants that harm them.

The risk of birth defects has been evaluated in several studies, and a large Danish cohort study of 500,000 children showed that the risk of heart septum defect is doubled9. This is not a trivial harm, as 1 % of those treated will get a septum defect. Cardiac birth defects are exactly what we would expect to see because serotonin plays a major role for the functioning of this organ. We have seen deadly valvular defects in adults who ate diet pills that increase serotonin levels, and these drugs have been withdrawn from the market4.

As far as I can see, screening pregnant women for depression is a very bad idea also because the beneficial effect of antidepressants is very modest. Under optimal conditions, where the woman have severe depression (which you do not need a questionnaire to find out), antidepressants benefit only every 10th patient10. This effect has even been considerably overestimated for a variety of reasons, where one of the most important ones is that we cannot blind studies effectively that compare an antidepressant with placebo because of the drug’s side effects4. As the assessment of the effect is pretty subjective, this fact causes so much bias in the effect evaluation4 that several psychiatrists quite legitimately have raised the question whether the newer antidepressants have any therapeutic effect4,11.

In any case, very few patients with depression benefit from the treatment. Many patients feel that the treatment helps them, which is often interpreted either as an effect of the pills, a placebo effect, or both. However, this is not what is important. What the patients feel is mainly the spontaneous remission of the depression4, and spontaneous recovery needs no medication.

* * * * *


 

Conflicts of interest: none.

References

1. Program for unipolar depression hos voksne. København: Sundhedsstyrelsen, 2007.

2. Gilbody S, House A, Sheldon T. Screening and case finding instruments for depression. Cochrane Database Syst Rev 2005;4:CD002792.

3. Lundh A. Er der evidens for screening for depression? Ugeskr Læger 2008;170:1479.

4. Gøtzsche PC. Deadly medicines and organised crime: How big pharma has corrupted health care. London: Radcliffe Publishing, 2013.

5. Fava GA, Bernardi M, Tomba E, et al. Effects of gradual discontinuation of selective serotonin reuptake inhibitors in panic disorder with agoraphobia. Int J Neuropsychopharmacol 2007;10:835-8.

6. Montejo A, Llorca G, Izquierdo J, et al. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. Spanish Working Group for the study of psychotropic-related sexual dysfunction. J Clin Psychiatry 2001;62(Suppl. 3):10–21.

7. Laughren TP. Overview for December 13 Meeting of Psychopharmacologic Drugs Advisory Committee (PDAC). 2006 Nov 16. http://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-01-FDA.pdf (læst 22. oktober 2012).

8. SSRI antidepressants and birth defects. Prescrire Int 2006;15:222-3.

9. Pedersen LH, Henriksen TB, Vestergaard M, Olsen J, Bech BH. Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: population based cohort study. BMJ 2009;339:b3569.

10. Arroll B, Elley CR, Fishman T, et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009;3:CD007954.

11. Healy D. Let them eat Prozac. New York: New York University Press, 2004.

14 COMMENTS

  1. The same thing is done to school children when the psychiatric industry goes trolling for customers.

    The child is sat down and asked introverting questions such as:

    Has there been a time when nothing seemed fun for you and you just weren’t interested in anything?
    Has there been a time when you felt you couldn’t do anything well or that your not as good-looking or as smart as other people?
    How often did your parents get annoyed or upset with you because of the way you were feeling or acting?
    Have you often felt very nervous when you’ve had to do things in front of people?
    Have you often worried a lot before you were going to play a sport or game or do some other activity?
    In the last four weeks, have you had trouble keeping your mind on schoolwork or other things?
    Have you ever thought about killing yourself??

    Based on how the child answered the mental health test he or she child is then sent off for “treatment” drugging.

    Does your child need to be drugged ? The following questions concern your child’s mood and behavior in the past month . Please click below and place a check mark or an ‘x’ in a box for each item.

    http://www.dbsalliance.org/pdfs/ChildManiaSurvey.pdf

    If your child passed that test we are not done yet, place a check mark or an ‘x’ in a box for each item below,

    Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities ?
    Has difficulty sustaining attention in tasks or play activities ?
    Does not seem to listen when spoken to directly ?
    Does not follow through on instructions and fails to finish schoolwork, chores ?
    Has difficulty organizing tasks and activities ?
    Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as homework ?
    Loses things necessary for tasks or activities?
    Is easily distracted by outside stimuli ?
    Is forgetful in daily activities ?

    Fidgets with hands or feet or squirms in seat ?
    Leaves seat in classroom or in other situations in which remaining seated is expected ?
    Runs about or climbs too much in situations in which it is inappropriate ?
    Has difficulty playing quietly ?
    Is ‘on the go’ or acts as if ‘driven by a motor’ ?
    Talks too much?

    Burts out answers before questions have been completed ?
    Has difficulty waiting his or her turn ?

    Interrupts or intrudes on others such as posting about child drugging on a thread about pregnant woman depression screening ?

    What I am saying is that if the child makes it out of the womb undrugged he/she still has a few hurtles to make it past if he or she wants a life free of psychiatry.

  2. I have always maintained that being depressed is a pretty normal and common occurrence after having a baby, at least in our disjointed Western society. Interestingly, I have recently learned that in “primitive” cultures, the new mother is generally surrounded by other mothers and tribal elders and various caretakers for some time after a birth, and they often have no other responsibilities than taking care of the baby for weeks afterward. In cultures where this is the case, I understand that “postpartum depression” is essentially nonexistent. In any case, there are a ton of very good reasons why a new mom might feel very depressed that have little or nothing to do with biological predispositions:

    http://www.naturalchild.org/robin_grille/post_natal_depression.html

    So much for “it’s all biological!”

    —- Steve

    • True. And because the mother’s body will make sacrifices to provide what the baby need in utero, it’s very important to screen pregnant women for deficiencies. B-12 and iron deficiencies produce a “retarded depression” that is a medical condition, not an endogenous depression.

    • It’s also because with birth all your hormones go crazy and you need some time and support until they get back to normal. Add the stress of the daily life, new responsibilities that keep you up at night and in some cases health worries if the child was premature or sick or you had a difficult labour and you’ll have a post-partum depression. It’s super normal and with support it goes away in the matter of weeks-a few months.

  3. This is even more worrying given the apparent correlation between SSRI use in pregnancy and autism.
    https://www.madinamerica.com/2014/04/exposure-ssris-pregnancy-triples-risk-autism-diagnosis/

    Meanwhile are pregnant women being informed that SSRIs may result their babies having autism at such screening? Are these babies of women on SSRIs effectively being born with a drug addiction and having to suffer SSRI withdrawal in their first months of life?

    What about breast feeding mums who are put on them for post-natal depression?

    Where are the studies proving that these drugs are safe for the unborn or breastfed infant?

    It seems drug companies and their advocates can attack studies such as those above by saying correlation does not prove causation, but surely it is up to them to prove safety and efficacy before a drug is used, rather than for studies to prove harm in a world where a random control study to prove harm would be impossible to conduct for ethical reasons.

    For me it also begs the question whether the increasing number of people are refusing to immunise their babies because of worries that immunisation may cause autism, should perhaps be asking whether the increasing incidence in autism is linked to increased anti-depressant use, and not the vaccines they currently blame.

      • …and when it’s autism or behavioural, the psychiatrists and drug companies have created for themselves a brand new tiny bundle of diagnoses who will be theirs for life.

        I too thought of thalidomide, but this new epidemic is far more subtle. Missing and deformed limbs can neither be denied nor “treated” with drugs – they are there for all to see and demand attention and explanation.
        Plus, while I am happy to stand corrected as I have no knowledge of autism and other developmental disorders, I think they tend to show up…well….developmentally and are not necessarily apparent at birth and so may not be seen as a birth defect as such and hence, again, do not demand immediate attention, or cause the outrage that thalidomide caused.
        This is just so much more subtle, insidious and potentially dangerous (not in any way to downplay the horrific effects of thalidomide on its victims) as it could take far longer to prove causation, and then, if history is any indicator, to get drug companies and psychiatry to accept any adverse findings and disseminate the information to patients and the public.

        They tend to be truth non-compliant….the rest of us would just become, or already are, drug non-compliant – I know which I’d prefer to be.

  4. That’s exactly it, subtle and insidious and difficult to pin down. There’s probably lots of long term damage already around, but try proving it. Not exactly autism, but not okay either.

    The other medicines are also very reluctant to diagnose psychiatric drug damage – drugs money can buy a lot of influence.