Between Depression and a Hard Place
By Anna Blackmon Moore
As soon as I learned I was pregnant again, I shut myself into the bedroom of my two-year-old son, gazed at his train car blanket, his shoes on the floor that no longer fit, his stuffed penguin. I thought about my brain. Then I called my psychiatrist.
“This is a surprise,” she said coldly.
“I discussed the possibility with you at our last appointment, remember?” I said. I had actually discussed having another child with her at our last two meetings. Our appointments occurred only every three to six months and took half an hour; I used them for refills of anti-depressants. Five months before, I had started taking Lexapro, a switch from Prozac, which I had been on intermittently for nearly twenty years.
“I just wanted to ask about my medication,” I continued. “Should I go down to five milligrams? How safe is it?”
“Most women try to get off anti-depressants before they get pregnant, Anna,” she said. She had not mentioned this—not once, not in doctorese, not directly or indirectly or vaguely—in any of the appointments we’d had in the last four years, which is how long she’d been my doctor. During my first pregnancy, I decided on my own initiative to stop taking Prozac but then resumed it in the second trimester. I had not planned to do so, but anxiety, one of the many characteristics of my depression, became too debilitating.
“I’m only four weeks pregnant.”
“Well, I guess it’s too late now.”
Was she in a bad mood? Why was she talking to me this way? Why was I so incapable of asserting myself with doctors? Apparently, she wanted me to believe that I had already damaged my baby’s developing organs somehow, that there was no turning back. Too late now, she had said, since your baby is already ridden with birth defects.
“But they calculate conception by the first date of your last period,” I argued. “So the baby was really only conceived about two weeks ago.” She didn’t know this?
Women like me are hardly alone in their frustrations. Those of us who take anti-depressants and become pregnant are forced to make wrenching decisions about medication. Every piece of literature I have read on this issue, from studies in medical journals to user-friendly websites to sections of baby books, whether the drug in question is an SSRI like Prozac or a psychotropic like Lithium, summarizes the nature of our decision like this: Along with our doctors, we need to decide if benefits from our medications are greater than any potential risks they could bring to our baby’s health. If our benefits win, then we should take anti-depressants. If potential health risks to our baby win, we should not take our anti-depressants.
What a shit sandwich.
By the time I called my psychiatrist, I had already been served that sandwich. I was familiar with it; I had ingested the thing. I was preparing to ingest it again. But if my doctor was going to treat me with such impatience and disdain while I was going through a pregnancy, when women at any level of mental and physical health need as much support as possible, then, I thought, Fuck her. The following week I cancelled our appointment, recalling a poster that my best friend, sixteen years earlier, had taped on our kitchen cabinet when we were roommates in a tiny apartment after graduating from college. The heading was 20 Ways To Be a Strong Woman; below it were twenty bulleted commands. The only one I could remember was the last: “Walk out of any doctor’s office you want.” Instead of walking out, I just didn’t return.
* * *
When I learned I was pregnant with my first child, Ian, I was on Prozac. The average daily dose, the one I was prescribed, is twenty milligrams, but sometimes I’d skip a day (or two), sometimes I’d go down to ten, sometimes I’d wean from it altogether. Changing doses of medication without a doctor’s guidance is part of having a mental illness. For some people with severe depression or other severe mental illnesses, changing or stopping doses is a symptom of the illness itself.
I adjusted my dosage because I do not like being depressed. I would prefer not to have this condition. So self-adjusting is how I prove to no one at all (since I do not discuss my adjustments with anyone) that I do not need this drug. I still think I might not. Maybe I just need a good kick in the pants, a transformation of attitude, or time alone in a dark room where I can analyze my worthlessness and all its manifestations over and over again until I figure it out or until it goes away.
Pregnancy, however, made me think about my depression in ways that were less self-absorbed. My thoughts about how or whether I actually had this condition were no longer relevant or even important, I realized, because what if after I gave birth, I dropped into a serious depression? My mother had. She describes it like this: She had me, broke down, and then got into bed. She got out again “when it was spring.” Since I was born in the spring, this means that my mother was incapacitated and largely absent for the first year of my life.
For the rest of hers, she sought and received various forms of treatment at various times with varying levels of efficacy. She has always struggled with depression. As a result, my brother and I have struggled with it, too. (My alcoholic father shares plenty of responsibility here as well but requires too many additional words.) As a young adult, my brother’s mental illness institutionalized him for years; as a teenager, I was hospitalized for a suicidal gesture—I slit my wrist with a dull paring knife—and I was an in-patient in treatment programs for alcoholism and bulimia. I’ve been in and out of therapy since I was ten to “work through” the same “issues” that have influenced my feelings and thoughts for as long as I can remember. I’ve been on and off Elavil, Prozac, Paxil, Zoloft, Imipramine, Welbutrin, and Effexor. Despite my functional professional and social life—I’m a college instructor, a writer, a friend, a wife, a mother—I am always in some kind of emotional pain, or caught in a self-reflective ache, and in general I feel pretty bad about myself, who I am, how I behave, and how I think.
This state of being poses challenges for me and other depressed women when we become pregnant. Just a cursory glance through the various genres of pregnancy literature confirms that during pregnancy, a fetus needs a contented, functional mother. The mental health of the mother is even more important right after birth, because a depressed mother who neither smiles at nor interacts with her infants can easily be worse for them than most of the side effects they might experience as a result of anti-depressants.
And these side effects are a matter of mights. If pregnant women take Prozac or other selective serotonin reuptake inhibitors, or SSRIs, to regulate and adjust the activity of the neurotransmitter serotonin in their brains, their newborns might experience, according to the Mayo Clinic, “tremors, gastrointestinal problems, sleep disturbances and high-pitched cries.” These are withdrawal symptoms and go away within a few weeks of the baby’s birth. Knowledge of this dissipation, though, is hardly comforting to the almost eight percent of pregnant women who are prescribed these drugs during their pregnancies. No pregnant woman, depressed or not, could disregard visions of her newborn shaking uncontrollably or crying like a siren, especially if this suffering were caused by drugs she had passed into her baby’s system.
The possibilities of health risks grow mightier when we consider possible long-term effects on a child whose mother took SSRIs during pregnancy. According to my former psychiatrist, we do not know whether SSRI babies demonstrate a greater incidence of depression, attention disorders, mood disorders, or cognitive problems as children, teenagers, or adults. But I think we have to question the reliability of such implications, anyway: Since mental illnesses are often hereditary, children or teens could get them straight from the genes of their mother, whether she were medicated while pregnant or not. And if teenagers or even toddlers suffer from mood disorders, it would be impossible to prove definitively that fetal exposure to SSRIs was the cause.
What I do know is that my brother and I suffered from mood disorders—big ones—along with all kinds of other psychological and emotional problems; at the same time, while we were growing up, my mother’s depression was never consistently or properly treated. If it had been, I know my mother would not have been perfect, but it is fair to say that she would have been more engaged with her children, more attentive and supportive during our infancy, at least. Our family might have been stronger.
So we’re back to the shit sandwich. Treat it or don’t—which is worse, and which is better? Who knows?
Many doctors advise a weaning from anti-depressants before women become pregnant or early in the first trimester, when the baby’s organs are being formed. Both my GP and former psychiatrist advised me to stop taking them unless I was suicidal. I should “hold out” until the second trimester, they said, when the drugs would likely be safer for my baby. Their opinion is grounded not only in common sense, but also in the memory of the thalidomide catastrophe. From 1958 to 1961, pregnant women in the United Kingdom and Canada took thalidomide to ease first-trimester nausea, filling their prescriptions because the drug’s manufacturer and, subsequently, doctors espoused its safety. The manufacturers, in fact, had not tested the drug, and eight thousand babies were born with profound birth defects, from missing and deformed limbs to unsegmented intestines. According to Sandra Steingraber, in her excellent book Having Faith: An Ecologist’s Journey to Motherhood, what made thalidomide especially teratogenic—a cause of birth defects—was the fact that the drug interferes with the formation of blood vessels and protein production. Just as important was the timing of its ingestion: Pregnant women took it when their embryos were sixteen to twenty-one days old, during peak organ-formation.
As a result, the medical community now has clear directives on medications and pregnancy: Steer clear of as many as you can. The logic of this instruction is obvious. But as a person with a mental illness, I see perspectives and biases emerging on this issue that have little to do with thalidomide and untested drugs and lots to do with how we tend to blame mental illness on those who suffer from it. In a post to “Taking Anti-depressants During Pregnancy” on the Berkeley Parents Network website, an anonymous writer articulates perfectly what I was feeling: “There is a lot of discrimination against treating mental illness in pregnancy. Do you think a doctor would suggest someone with high blood pressure or diabetes just STOP [her] medicine while pregnant? Absolutely not.”
* * *
After the incident with my psychiatrist (who I saw primarily for medication), my therapist helped me by discussing the Lexapro issue with two doctors she has worked with in the past. As I sat in my usual spot on her couch, she informed me of my options: Go off Lexapro completely or stay on ten milligrams; five is non-therapeutic and, therefore, would not help me. Since I had already adjusted on my own to five milligrams a week before, I wasn’t sure where to go from there. I was stuck: If I kept taking such a low dose, I’d be exposing my fetus to the drug, and I wouldn’t be getting any benefit from it. It was ten milligrams or nothing.
“I guess,” I said, “it’s time for me to decide what to do.”
That night, I looked through various articles and websites on Lexapro and pregnancy. I found mostly information I already knew, since Lexapro is an SSRI and the research on these drugs lumps SSRIs together. Eventually, however, I found a public health alert put out by the U.S. Food and Drug Administration in 2006, which summarized the results of two studies published that year. The first, in the Journal of the American Medical Association, tracked a group of women who stopped taking anti-depressants while they were pregnant and a group of women who did not. The women who went off their meds were five times more likely to have a relapse of their depression.
The second study, published in the New England Journal of Medicine, found that fetuses exposed to SSRIs after twenty weeks had a six-times greater likelihood of developing persistent pulmonary hypertension. The disease is very serious and sometimes fatal, but “[the] risk has not so far been investigated by other researchers.” So it would seem that going off Lexapro in the first trimester actually carries less serious of a risk to the baby than my resuming the medicine later on. All right, but what about me? Whose risks finish first?
It was time to decide. But with whom? I live in a large town. We have other psychiatrists, but not many. Even if I lived in an urban area, getting in to see a psychiatrist can take months, especially as a new patient. There were other options—GPs and obstetricians are doctors, of course, but the ones I had seen discouraged medication in general and offered little support. So I made what I thought was the most informed decision I could about my health and the health of my family: I decided to discontinue the Lexapro, at least for the first trimester. For the next week, I took my five milligrams only every other day, and then I stopped it altogether. Maybe I could do it this time.
* * *
Now, in my ninth week of pregnancy, I sleep poorly, cry often, and feel deeply angry all the time. This anger has been characteristic of my depression all my life. I have to watch what I say and how I carry myself and how I react for fear of alienating my students, friends, and colleagues. I yell at the dog, snap at my husband, shout at my windshield. With my son, I am less patient. It’s cute when he explores the potential of his toothbrush and brushes the drain, but must he do it every single night? Must he always choose to read The Biggest Book Ever? If I do lose control, I feel disturbed, unhinged, and terribly guilty. The most difficult parts of my day are transitions, which require what feels like tremendous effort of body and mind: bed to bathroom, car to office, desk chair to kitchen, couch to bed. I feel more than ever like I am a failure.
Come on, woman, I hear in a deep authoritative voice of some distant patriarchal figure, pull yourself together. But I’ve been pulling since I was a teenager, and my depression has not seemed to budge for extended periods of time without the help of drugs. I have pulled myself into pieces. I work against a cavernous sense of negativity, and this in particular has never felt transitory. I cannot therapize it away, or overcome it, or counter it through cognitive exercises. As I get older, my depression feels more and more biological, more deeply folded into the fluid of my brain. Stopping medication when my hormones are in flux, when I’m sick, when I’m teaching a full load, when the stress of another baby grows by the day … this seems more and more like a bad idea, my husband says. And I agree.
So yesterday, I went to my unaccommodating GP and asked for Prozac. Prozac has been around a long time, so doctors and researchers have published hundreds of studies on it. Prozac and Zoloft are the safest of all SSRIs.
During my first pregnancy, I took twenty milligrams of Prozac per day in the second and third trimester. I also breastfed my son while I was on the same, consistent dose. When I was in the hospital, recovering from childbirth and learning to breastfeed, several nurses expressed concern. What were the possible effects of Prozac on the baby? Did I know? Had I consulted with my doctor? (Why they didn’t learn the answers themselves and then share the results with me, since I was consumed by worries of feeding my baby properly while fuzzy with painkillers and lack of sleep, I do not know. Perhaps they expected more from me.) I explained that I felt very safe in what I was doing because of what I was told by a lactation consultant in the hospital following his birth. The consultant explained that any side effects Ian might have—the same he might have from exposure to Prozac in the womb—would go away within a month. (Ian was a product of the good odds: He experienced no side effects and seems fine in every way, developmentally and temperamentally.)
According to the specialist I spoke with at the nonprofit Organization of Teratology Information Specialists (OTIS), to which I was referred by the FDA’s Office of Women’s Health, SSRIs are indeed the most studied of all the anti-depressants on the market.
The specialist started answering my questions by first explaining that the baseline of birth defects for every pregnant woman is three to four percent. This percentage goes up with factors like age, health problems, and the genetic history of the mother. Then she summarized what the studies say about mothers who take SSRIs during pregnancy. During the first trimester, women who took high doses (between sixty to eighty milligrams) of Prozac increased their risk of having a baby with a low birth weight by one percent. (These results were not found in newborns whose mothers took other SSRIs at similar doses.) The babies of mothers who take SSRIs in the third trimester have a ten to thirty percent rate of toxicity withdrawal—and the withdrawal is limited to the newborn period.
Okay, I thought. Okay. I felt suddenly relieved—not because I thought SSRIs might be totally safe, but because I understood the studies more clearly. I realized later that what I felt was not a rush of relief; what I felt was a rush of informed.
* * *
The studies I have read on anti-depressants and pregnancy are structured, more or less, like this: Over a period of years, scientists and doctors gather records on a group of infants with birth defects and a group of infants without birth defects. The doctors then conduct interviews with the mothers or review medical documents to learn about what drugs the mother took before and during their pregnancies. They then compare the interview results or the medical documents to the birth defects and look for correlations.
They have indeed found them. One study of 13,714 infants (9,622 with birth defects and 4,092 without) was published in the New England Journal of Medicine in July 2007. The correlations the authors found between the infants with birth defects and SSRI exposure were very low—low enough to conclude “maternal use of SSRIs during early pregnancy [is] not associated with significantly increased risks of congenital heart defects or of most other categories of birth defects. [We observed] associations between SSRI use and three types of birth defects, but the absolute risks were small, and these observations require confirmation by other studies.”
This study and others like it did not keep my GP, when I saw her on my Prozac mission, from suggesting that she would “prefer” I didn’t take the drug until week twelve or thirteen.
“But if you can’t make it,” she said, typing notes into her computer, “I’m okay with prescribing it now.” She then stopped typing and looked right at me. “As long as you know the risks.”
My doctor has my baby’s health in mind, I realize. But—way to be supportive.
“Perhaps I’ll just hold the bottle lovingly for the next few weeks,” I said. “Like a teddy bear.”
I understand, I went on, that as a general rule women should stay off everything in the first trimester. But isn’t there any evidence that a depressed mother can also be harmful to her fetus? Not really, she said, because that’s harder to quantify. What I understood her to mean was this: We see toddlers with emotional problems; we determine that all of their mothers were depressed or anxious during their pregnancies. But since so much happens between birth and toddlerhood to influence a child’s emotional state, it’s much more difficult for anyone to verify a concrete link between maternal depression and childhood mental health.
So I gaze longingly at my Prozac. In only a few weeks, it will be building in my system, doing whatever it does to make me feel better. And I can do it. I can make it. I am like a runner with burning pain in her legs, a few inches from the finish line, or a dieter warding off desires for a piece of chocolate cake.
These metaphors are absurd, unhelpful, and demeaning. I am trying, in acting like a strong woman, in making my decision while consuming a shit sandwich, to reject this language and this way of thinking. My difficult doctors were right: There’s a big difference between suicidal and too sad, too sleepy, too pissed. Yet the mother and her body and her mind—especially her mind—are the center of the family; they are its source, its foundation. Mothers need to be energetic, positive, patient, loving, and as present as possible. If I need drugs to embody these adjectives, then I need to take them. My children need me to take them. The medical community should direct and inform my taking of them as much as it is able to, but for now I have to keep my expectations of their knowledge and especially their support fairly low.
Women often have to endure. To tolerate. They also have to negotiate, evaluate, assert, reassert, assess, deliberate, and wonder. And cry. Because as I make the decision to take drugs, to go on Prozac as soon as the last day of week twelve has passed, I cry.
Bullet #21 on 20 Ways To Be a Strong Woman: “Make your decisions. Then weep.”
* * *
Author’s Note: My daughter, Adele, is now four months old. She’s a champion cooer, nurser, and puker, and she’s been doing beautifully since her birth. The rest of my pregnancy with her was very hard—I was chronically ill with colds and bronchitis, which affected my mood significantly. When I was about six months pregnant, I decided to go up on the Prozac—from twenty milligrams to thirty, and it helped get me through and be more present for my now three-year-old son.
In retrospect, I notice how doctors, when they discussed anti-depressants and my pregnancy with me, emphasized the safety of the baby in my body but forgot entirely about the needs of the one already here. Mothers need to be functional all the time, pregnant or not; along with their gestating babies, they and their families also need to thrive.
Anna Blackmon Moore is a writer and writing instructor in California. Her blog is dearadele.wordpress.com/.
Brain, Child (Winter 2009)
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