Last week, I saw a new patient — let’s call her Mandy — who came to consult me after her obstetrician and her psychiatrist both told her she’d need to stop taking her antidepressants for the duration of her pregnancy. Mandy had been taking the medication for severe obsessive-compulsive disorder and was unsure how she would manage once she went off the drugs.
This is a familiar scenario to me. I’m a psychiatrist who focuses on pregnant women at an academic medical center, so I am asked multiple times a day — by patients, colleagues, friends, reporters, even random people at cocktail parties — about whether it’s safe for pregnant women to take psychiatric medications.
Almost never am I asked, however, about whether psychiatric illness itself is harmful to mothers and babies, and what the risks might be of stopping medication while pregnant. My colleagues in internal medicine report little difficulty in reassuring their patients with other chronic medical illnesses such as diabetes, epilepsy, and asthma that the benefits of taking these medications generally outweigh the risks in pregnancy, even though the amount of published literature ensuring the safety of drugs for these conditions is far less than that for antidepressants. So why the discrepancy?
Don’t get me wrong. I’m not saying that all psychiatric drugs during pregnancy are without risk. In an ideal world, we would avoid exposing a growing fetus to anything that could disrupt the uterine environment and that child’s developing brain and body.
Every woman and every pregnancy is different, and it’s always up to the individual to make her own decisions about what’s right for her and for her baby — but every woman also has the right to informed advice from her health care providers, and many women aren’t getting it.
There are risks to stopping medication during pregnancy, and those risks aren’t talked about enough. It’s yet another example of the stigma surrounding use of antidepressants and our society’s underlying inability to treat mental illness as a real disease.
Research shows that the mother’s mental health can impact a birth
Because it’s generally considered unethical to randomize healthy pregnant women to take a drug during pregnancy, we have no gold-standard randomized trials on the safety of using psychiatric drugs during pregnancy. Adults can consent to a study that might cause them harm, but a fetus cannot — so most research governing boards are reluctant to approve such studies.
We do, however, have an enormous body of increasingly sophisticated scientific literature pointing to the relative safety of most of these drugs, and that literature is beginning to tackle the risks of these drugs in conjunction with the risks of the reasons women are taking them.
Last year, there were more than 100 scientific articles published on the safety of antidepressants alone, not including all the other psychiatric medications such as mood stabilizers and antipsychotics, which are used commonly in bipolar disorder.
Nearly anything a mother encounters is a potential risk for a fetus, from the fish we now warn mothers against to the polluted air they breathe to cigarettes and marijuana and antibiotics — all of which are used by more women in pregnancy than are psychiatric drugs. What the doomsayers rarely consider, however, is that exposing a fetus to a psychiatric illness is itself is a potential risk and can lead to serious consequences for both mother and child.
Earlier this month, the New York Times Magazine ran a cover story about the alarmingly high rates of infant mortality and maternal death during birth in the black population, both several times higher than in the white population. One likely cause, researchers say, is toxic stress and racial discrimination.
The scientific literature is full of articles about the effects of stress and of depression and anxiety on pregnant women and their fetuses. These effects include higher rates of preterm birth, low birthweight, preeclampsia, and miscarriage as well as effects on child emotional and cognitive development.
The mechanisms by which these illnesses exert their effects are both indirect and direct. Indirectly, depressed women are more likely to smoke and use substances, more likely to be obese, and less likely to adhere to good prenatal care such as a healthy diet and regular appointments with an obstetrician or midwife.
Direct effects of mental illness include increased production of stress hormones, changes in immune activity, and decreases in the placenta’s ability to protect the fetus from stress. Some of the most intriguing current research finds that these effects play out differently depending on the sex of the fetus.
The effects of mental illnesses are known and quantifiable and call out for treatment during pregnancy. Yet so many mothers-to-be and the professionals who advise them on their care assume that women can and should go without treatment for their mental illnesses.
Treatment doesn’t always mean medication. In fact, every treatment decision for a pregnant woman with mental illness should be individual. Each decision should take into account the history of a woman’s illness, its severity, and her response to various treatment regimens. It should also take into account her preferences, her support system, and the degree to which she is able to access other evidence-based treatments such as psychotherapy, prenatal yoga, and artificial light therapy — all of which require specialized providers and are often not covered by insurance.
But for many women, these options are either inaccessible or not powerful enough. Why do we make those women feel that their suffering is not worth taking seriously? Doctors are very comfortable giving pregnant women medications for diabetes, seizures, and asthma, not because our evidence about the risks of those drugs is any better (in fact, the anti-seizure drugs are the very same drugs that women with bipolar disorder are often asked to stop for pregnancy) but because the medical community, and society at large, agrees that diabetic comas, seizures, and lack of oxygen are bad for babies. Neither doctors nor society at large seems to understand, or perhaps to care, that mental illness is also bad for babies.
Stigma around mental illness is a powerful force.
I frequently ask the medical students I teach to define the leading causes of maternal death in the first year after birth. They will accurately identify hemorrhage, preeclampsia, and blood or fluid clots as major killers. No one guesses suicide, and yet in many places, suicide is the leading cause.
While the US does not categorize postpartum suicides as pregnancy-related deaths, individual states have released studies showing suicide to be the leading cause of post-pregnancy death. And other countries, such as the UK, have placed suicide as the No. 1 cause of pregnancy-related death. A dead mother certainly isn’t good for a baby.
Suicide after pregnancy is usually linked to postpartum depression. Depression and anxiety during pregnancy are leading risk factors for postpartum depression, and most women who stop psychiatric medications for pregnancy will experience a relapse in their mental illness at some point during pregnancy or afterward.
One in three of those who relapse will become suicidal. But even when women are not suicidal after giving birth, depression isn’t good for babies. We have overwhelming evidence of the deleterious effects of postpartum depression on children’s cognition, development, and emotional functioning. So why, given what we know about the link between pre-birth depression and postpartum depression, isn’t treating mental illness in pregnancy not only accepted but a priority?
The answer is simple: It’s stigma about mental illness. We’ve made some progress — Brooke Shields, Gwyneth Paltrow, and other celebrity moms have shared their experience with postpartum depression with their fans — but for the most part, we still think of depression as a moral weakness rather than a medical illness. We’ll let moms pop Tylenol (whose risks we are just beginning to understand) liberally for headaches, but we expect them to “just live with” depression.
This is such a shortsighted view, both for the next generation and for the mothers themselves. Their suffering is often downplayed when we devote all our attention to the effects of medications on babies. Can’t we do better?
Dr. Lauren M. Osborne is an assistant professor of psychiatry and behavioral sciences and of gynecology and obstetrics at the Johns Hopkins University School of Medicine. She is an expert on the diagnosis and treatment of mood and anxiety disorders during pregnancy, the postpartum, the premenstrual period, and perimenopause. She conducts research on the biological mechanisms of perinatal mental illness, with a focus on the immune system, and her work is supported by the Brain and Behavior Foundation and the NIMH.