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.