Tuesday, December 7, 2010

Taking Medication While Pregnant - A Psychiatrist's Thoughts

One of the most common questions I am asked in my psychiatry practice is, “Is it safe to keep taking my antidepressant/antianxiety medicine during pregnancy?” The answer to this involves looking at the risk of medicine use in pregnancy, the risk of depression/anxiety in pregnancy, and the benefit of the medicine. It’s also somewhat unique to each woman, based on her history of depression or anxiety.

My job is not to convince women to stay on medicine. That is a decision that is between the woman and her doctor (ideally with her partner’s input as well). However, the assumption is often made that medicines are always “bad” to continue in pregnancy, when the reality is that depression and anxiety can also be “bad.” If a woman decides to stop a medicine, I always hope that this is an informed decision (ie, she has talked with her doctor and learned about the risks and benefits), not one made out of fear. After she stops the medicine, she should still be seen by a mental health provider, even if only once a month, so that she has someone to check in with in case she starts having symptoms again. Many times this is a therapist or a psychiatrist. Hopefully, if symptoms are caught early, she can improve her depression or anxiety in therapy and avoid needing to restart the medicine (if that is her choice).

But, and this is a big BUT: this should be an informed decision, not a scared decision.

In my clinic I often see the following situation: a woman has 1, 2 or more depressive episodes in her life and is doing well on medication (and hopefully with therapy as well). She decides to start trying to get pregnant, and stops her medicine. Or, she waits until she is pregnant, and then stops as soon as the pink line turns up. She feels okay for the first few weeks or months of pregnancy, but the depression or anxiety gradually returns until it is worse than before. Now the woman feels like a failure because “pregnant women are supposed to be happy” and she is not.

Most of these women haven’t told their doctor who gave them the medicine that they stopped, and then they start seeing an OB or midwife, who only asks the woman “What medicines are you taking now?” rather than “What medicines were you taking before getting pregnant?” Because no one else knows that the woman has a history of depression or anxiety, or was on medicine in the recent past, it takes much longer for her to get help and feel better. Some women spend their entire pregnancies feeling terrible, and only after delivery does someone say, “I think you have postpartum depression.” The truth is that the “postpartum depression” started during pregnancy.

The problem with this scenario is that, even though the woman was doing really well before getting pregnant, once she stops the medicine she is at increased risk of becoming depressed or anxious again. A study done at Harvard in 2005 showed this very clearly: they followed 200 women with depression who were feeling good (not depressed) for at least 3 months before getting pregnant. Once the women were pregnant, the researchers watched to see who stopped or continued their medicine, and then who got depressed again. They found:

  • 68% of women who stopped their antidepressant medicine at the beginning of pregnancy became depressed again during pregnancy
  • 21% of women who continued their medicine also became depressed

Women are at much higher risk of becoming depressed again if they stopped their medicine. The bad news, however, is that even those women who continued their medicine were at high risk of depression.

So, what should women do?

  1. Talk to the doctor who prescribed your medicine, and let him or her know you are pregnant or trying to become pregnant. Ask about the risks of taking the medicine in pregnancy, and about what to do if you start feeling depressed or anxious again during pregnancy.
  2. Let your partner know that you are on medicine for depression or anxiety, if you think he will be supportive and helpful in making a decision about what to do.
  3. Get information about the medicine you are on and the risk of depression or anxiety in pregnancy. A great resource is California Teratogen Information Service: ctispregnancy.org/factsheets, or get more detailed information by calling for a free phone consult at 1-800-532-3749.
  4. Tell your prenatal care provider that you are/were taking a medicine for depression or anxiety.
  5. If you don’t feel comfortable asking the doctor who gave you the medicine, or if she or he does not know the answers to your questions, find someone who does. (See our provider directory at postpartumhealthalliance.org)
  6. If you stop the medicine, make sure that you are monitoring your mood, and ideally working with a therapist or doctor to prevent depression or anxiety from coming back.

Most importantly: Do not try to do this alone. Getting help does not mean you are a failure, it just means that someone else is in it with you.

Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, Suri R, Burt VK, Hendrick V, Reminick AM, Loughead A, Vitonis AF, Stowe ZN. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 295(5):499-507, 2006.

Katie Hirst, MD is the Education Coordinator for the Postpartum Health Alliance and the Director of the Maternal Mental Health Clinic at University of California, San Diego.

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