Baby Blues, Postpartum Depression & Psychosis: Countering the Danger of Antidepressants

Robert Berezin, MD
22
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I have a complicated response to the article Panel Calls for Depression Screenings During and After Pregnancy, by Pam Belluck, in the January 26th New York Times, which calls for depression screening before and after pregnancy. On the face of it this sounds like a great idea – a public health measure to prevent or deal with problematic postpartum responses – baby blues, postpartum depression, and postpartum psychosis.

This public health measure is absolutely well meaning. Good enough maternal love ought to be the highest value in our society. It provides the foundation for the well-being of our children. If this meant that mothers would be helped to deal with realities of a new baby and given sufficient loving support and real psychotherapy, when needed, it would be fantastic.

But unfortunately, in the real world, as we know it, this simply means giving antidepressants to mothers during and after pregnancy. In the article there is some discussion about ‘talk’ therapy, but unfortunately, the real meaning is ‘drugs.’ The article addresses that in the past there weren’t enough mental health treatments available, but now there are. We cannot be naïve about what that means. “The standard treatment for so-called depression is antidepressants” (I give an alternative understanding in “Smashing the Neurotransmitter Myth.”) When I talk to primary care doctors they tell me that they hand out antidepressants all the time. When there are referrals to a psychiatrist, they are to pharmacological psychiatrists. This is the prevailing belief system.

Here’s an example of how prevalent and absurd is the dispensing of antidepressants. Over the past several years I have had several patients die of cancer. Each had had psychiatric consultations when they were dying. One patient had the most painful, intractable bone pain, I’ve ever seen. She was on every drug known to man. When a psychiatrist was called in, I assumed it was to help her with the issues of her dying. The psychiatrist diagnosed her as depressed and ordered an antidepressant. She wasn’t depressed. She was dying a painful death and was amazingly heroic about it. He truly believed it would take away some of her emotional suffering. Most psychiatrists and the public really think antidepressants are some kind of joy juice. Fortunately I was able to stop this travesty. She died three days later.

With a second patient, I had permission to monitor all the complicated multisystem complications. One day, the psychiatrist who was supposed to talk to him about his condition asked me if he had Restless Leg Syndrome. By the way; he didn’t talk and deal with death and dying, he only prescribed. I was made suspicious, of course, by the Restless Leg Syndrome question. Yes, he had been put on an antidepressant and was having akathisia. I got them to stop it. And then they snuck in another one which generated the same akathisia. He wasn’t so-called “depressed.” He was dying. He needed his full faculties. He needed his family to be with him, and they were.

These are two over-the-top examples of the false belief that antidepressants can bring magical relief even in such dire circumstances — never mind more routine ones. Put aside the various debates about ‘depression.’ The belief is simply that a happy pill will make you feel better. This absurdity is totally accepted and is perpetrated all the time, not just by psychiatry; it is believed by the general public.

For starters, the Edinburg Postnatal Depression Scale is embarrassing. A doctorly relationship ought to be one where the doctor knows his patient. A real evaluation of risk before delivery and after delivery is not very hard. There certainly is no place for some silly multiple choice test. It means the patient ought to be understood and known as the person she is. This should be a matter of course. Unfortunately this usually doesn’t take place in the impersonal time-limited meetings that gynecologists, pediatricians and primary care doctors are restricted by. The relationship aspect of medicine is the heart of medicine. Other professionals – nurses, assistants, social workers should have a real relationship with the patient. They should routinely be alert to evaluating the possibility of postpartum depression, just as much as other complications of pregnancy. Since 15% of mothers may have some form of postpartum events, of course attention must be paid.

Postpartum reactions are generated by massive hormonal shifts, in combination with psychological issues such as perfectionism, fear of responsibility of a new baby, fear of one’s abilities, etc. All these things take place in a state of permanent jet lag. A new baby is the most exciting event on earth, but caring for the baby is a major life adaptation. Baby blues – crying and irritability –  is very common. To deal with it, one needs loving support and others on hand to share in the care. It’s quite normal. A larger reaction than this can generate more intense guilt and shame, and even thoughts of hurting the baby or oneself. In this case one needs a sympathetic therapist to talk with, to deal with what has been stirred up, and to get through this hormonally tumultuous period. To have others on hand to temporarily share in the responsibilities is very helpful. It takes a village.

There is no such thing as a ‘biological’ depression that predicts a postpartum reaction. More importantly, the effects of antidepressants on the newborn hasn’t been adequately studied. The studies that exist have been suppressed. There are risks of cardiac malformations, other birth defects, preterm birth, preeclampsia, and other newborn complications. Studies are beginning to show possible correlations of maternal antidepressant use and the massive increase of autism in our population. Women who have been taking antidepressants before pregnancy are in a difficult position. Withdrawing from them can generate a drug-induced rebound of symptoms and all kinds of neurological symptoms. Nonetheless, they must be in a position of informed knowledge to make difficult decisions about the effects on their newborns. This situation has been created by the irresponsibility of the APA and the  pharmaceutical companies.

In addition, antidepressants do not diminish suicidal behavior, they magnify it. There are very good reasons for the black box warning. Putting mothers on antidepressants after delivery increases rather than decreases the suicide potential. Our psychiatric care needs to be a human process that respectfully honors the realities that mothers are going through.

Postpartum psychosis is a different matter. The hormones and turmoil of a pregnancy may trigger a psychosis in patients who are manic-depressive or schizoaffective, no matter what theories one carries about etiology. This may be a first episode or a subsequent episode. In the early 1900’s over 50% of females in hospitals had postpartum psychoses. (At the same time in males, 50% were psychotic due to syphilis.) Treatment requires intensive psychotherapy with special care for the baby with a primary caretaker, when the mother is unable to manage. Resumption of care is so important as soon as she is able. She is the mother and needs to be respected as such. The recovery of the maternal connection is so central to the well being of the baby. Sometimes, short-term anti-psychotics may be useful for postpartum psychosis. I will add as well that antidepressants can generate a manic episode or a psychosis in susceptible mothers. They should never be given under any circumstances. Even though the APA actually acknowledges this, it happens all the time.

In short, the public health measure called for in this article is extremely important. But it must be done in a humane, safe, and caring way. It isn’t really that difficult. Doctors (including psychiatrists), nurses and social workers can be educated to provide a responsive caring environment. They need to work with the mother and the family in the best interests of the child. The greatest impediment to this great idea is the destructive prevalence of, and delusions about antidepressants.

 

 

 

22 COMMENTS

  1. It should always be remembered that Irving Kirsch’s and Joanna Moncrieff’s work has shown that that antidepressants are only 10-15% better at reducing distress than sugar pills, and that clinically, for mild to moderately depressed people, they have no observable effect. Furthermore, even for severe depression, the effect is small, and the side effects often severe.

    If the public knew the truth about how ineffective antidepressants are relative to placebos, and about their risk profile relative to other interventions, far fewer people would choose to take them. It is a measure of how gullible and ignorant the American public is, and of the extreme propagandistic power that corporate overlords wield over the public and over their psychiatrist and general MD minions, that America, a country with 4% of the world’s populations, ravenously consumes over 50% of global antidepressants taken every year, with no sign of change in sight. (from Grace Jackson).

  2. As always, Dr. B, I appreciate your perspective that heart and a sense of humanity easily trumps dangerous brain-altering chemicals when it comes to healing. It does seem like common sense, but at the same time, I feel we are a bit relationship challenged these days, in general. I’ve noticed a vastly decreasing capacity in society to deal with changes and challenges, especially in others. Sad but true, I think.

    I believe that, as a society, we have overall lost our sense of neutrality, reason, balance, and fairness, and even in the most sacred areas of life–such as being born and then passing on–it seems there is no longer perspective on these events, and so we are left with overwhelming fear.

    You write here about birth and death, our most mystical and emotional transitions in life, and all the changes and shifting that occur with these profound events. Within the span of our lives, we experience many metaphorical deaths and rebirths, as we shed our skin into new layers of personal evolution. These are all stressful and exhilarating, causing natural chemical changes, hormone shifts, emotional and spiritual challenges, and a big dose of embracing the unknown. Family and community support would be, I believe, our most desirable remedy for this level of stress, and from that, the unknown can be filled with excitement, rather than dread.

    With unconditionally loving support, we take comfort in our challenging and inevitable transitions, and can look forward to the next stage of our journey, including the ‘after-life, if that is what we choose to believe. When we are comforted rather than frightened and worried, we have a clear path to our own innate wisdom, and this guides us to healing the imbalances that can occur with such transitions. This is transformational, which is needed to embrace fully the next passage, given how we are led by our own nature grow through these transitions.

    Just a few thoughts generated by your passionate article. It actually causes me a bit of grief to realize and think about how far off the mark we’ve gotten when it comes to truly unconditionally supportive relationships.

    I very much appreciate that your intention is to create this level of authentic heart-based and stigma-free connection in your psychotherapy practice. We need more examples of this, so that instead of popping pills for stress because we feel neither natural nor relationship support, we can be comforted by the power of unconditional compassion, understanding, and loving support, which I feel we all crave, and which it seems fewer and fewer people are experiencing in life.

    Thank you.

  3. I work in a health care setting and I am bombarded continually with information of how much control drug companies have. PHQ9’s in every patient clinic exam room (these are exam rooms where you go for medical issues), Zoloft money saving cards in Dr.’s offices, endless pamphlets (created by the healthcare company) with the new increase in the ever popular “pregnancy and post pregnancy depression” category, etc. There is even an emerging redoubled effort to “prevent” teen suicide by “recommending” every kid over 12 take an annual PHQ9 and creating social events to give kids and families “tools” to handle the topic. The answer for all of it is medication first with some supplemental program such as CBT. You have to understand that the insurance companies also play a role in this. Then there are the support group (there is nothing like focusing on what’s wrong to make one feel better!) and the hospital sanctioned NAMI meetings.
    It is all disturbing enough but when you hear a Dr. tell a family that their loved one is depressed, while lying in ICU and dying from a health condition, and that he isn’t capable of making a decision regarding ending treatment and dying… there are no ways to understand this type of ignorance. The medical professionals discredit valid choices regarding healthcare by throwing “mental health” diagnosis at them as if it will prevent their inevitable death. A death only drug out by the health care industry.
    I appreciate your perspective and concerns and wish there was a way to counter the misinformation. The truth concerning alternative approaches and side effects are almost non existent it seems. Everyone is offered the same approach that has failed for decades: pills.

    • “Then there are the support group (there is nothing like focusing on what’s wrong to make one feel better!)”

      I agree, that is a big problem that I don’t hear people call out enough, thanks for saying this, squash.

      I went through a period where I did several groups, both private and through social services, and every time we were starting to feel lighter and get a bit of good cheer going, the negative focus would come back like a lightening bolt, and often by the facilitator, but that could also happen due to chronically cynical clients.

      In fact, my journey down the rabbit hole started with a social service group therapy ‘complex’ as part of a day treatment center. This is where my head got turned around from overbearing chronic stigma and relentlessly negative focus. I found these groups to be so toxic, I got a lot better when I stopped going because first of all, I went back to feeling ok about myself, which was impossible in there, we were spoken to and treated like children, unequivocally; and also I also stopped ruminating about my past.

      Anyway, don’t mean to go off topic here, but when I saw this phrase, it brought this all back. Treacherous, disabling environment, no doubt. Thank goodness this agency no longer exists.

      • Rest of your post is excellent, too, btw. It’s just all so disheartening, that’s the very least negative thing I can say! This is where I’m really challenged to feel loving, thinking about this ‘mental health system journey.’ Nothing loving about it.

        I should put my money where my mouth is here, and stop thinking about it, and perhaps stop talking about it, altogether, at this point. I’ve yakked on and on about it for years, and very publicly. Only so much people can hear all at once.

        It’s a bottomless pit of disheartening, can’t reconcile it, other than to recognize it as my journey to have taken in order to find myself. Still, I don’t know how to think about that experience and not feel angry, and I’m so tired of feeling angry, it festers. Can’t be healthy to keep triggering it like this, so I guess it’s time to let go and move on. It’s been rather a habit, from lack of positive closure. I’m sure I should give up on that one, it seems impossible.

        Sorry to ramble, it’s late and this discussion got me thinking…

  4. Dr Berezin,

    I appreciate your ethics. You mention Schizoaffective dis order – this was my final ‘diagnosis’ (many years ago).

    I was fairly browned off earlier today so I used the recommendations of Buddhist monk Thich Nhat Hanh on how to create some contentment – and this worked very well.

    I think If I wanted a chemical solution I might try some cannabis or consume some alcohol, as these are likely to be less harmful than a neuroleptic.

  5. As a birth professional, I applaud this. In the hormonal swings that pregnancy and postpartum bring, support and good nutrition are what is needed. Prescribing antidepressants further the mom’s alienation and create a sense of her body being a lemon and a feeling of inadequacy in caring for herself or her baby without chemical help. Awesome postpartum therapists, support, rest, and nutrition are much better qualified for the job of building women up and empowering them

    • I agree, defaming a mother with a scientifically invalid “life long, incurable, genetic mental illness,” and claiming her brain is defective forever, just after giving birth is, in reality, quite evil. And what is even more evil is forcing her to take a class of drugs that increases the likelihood of her committing suicide, becoming violent, becoming manic, etc. Not to mention, a class of drugs that may harm the breast feeding baby.

      I wish I could believe “This public health measure is absolutely well meaning.” But, my experience leads me to believe it’s more about making money for the medical and pharmaceutical industries, than helping new mothers. It’s about preying on women, during a challenging time in their lives. I absolutely agree advise on good nutrition, exercise, a good support system, and rest will benefit new mothers more than antidepressants. And I am very disappointed in my government for claiming it’s wise to push these toxic drugs onto new mothers and their breast feeding babies.

  6. In the early 1960s, after have three babies in two years ( I have a daughter and twin sons), I went through post partum depression, but no one identified it as such, and many years later I was diagnosed with hyperparathyroidism which causes depression and fatigue and most certainly contributed to my condition. I don’t remember hearing the term post-partum depression until the mid-1970s when women in the feminist movement began to discuss it. During that time, post-partum thyroiditis was identified as one cause of depression and psychosis in new mothers, but this diagnosis seems to have disappeared and “hormonal changes” are now merely a catch phrase for what could be causative and potentially curative. Although psychiatry acknowledges evidence of “hormonal changes,” as long as the problem is considered psychiatric and there is no actual medical/endocrine research devoted to finding a cure, women will continue to suffer and be given pejorative psychiatric labels. Alternative treatments like vitamins and nutrition as well as psychotherapy and social support for new mothers may all help, but, unlike the search for spurious genetic causes of so-called mental illness, there are very likely physiological causes of post-partum depression and psychosis which to my knowledge are not being explored, perhaps, in part, due to their identification as psychiatric illnesses as well as the continuing dismissive attitude toward medical problems that are unique to women.

  7. “I was made suspicious, of course, by the Restless Leg Syndrome question. Yes, he had been put on an antidepressant and was having akathisia.” By the way, I’m glad you confessed to at least one of the etiologies of Restless Leg Syndrome. I remember at one of my daughter’s birthday slumber parties, one of the little girls was upset, and needed a break from the other girls. So I took her into a different room, sat, and listened to her for a little while. She complained about her mother drugging her up and the fact she had Restless Leg Syndrome. She hated being stigmatized, and was terrified the other girls would find out. I did confront her mother later, about her daughter’s concerns, although I do not know if she was taken off the antidepressant. Her mom was quite an insecure and jealous woman, unfortunately. But thanks for pointing out this adverse effect of the antidepressants.