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I read a comment once about depression as a “minor” side effect of taking oral contraceptives: depression is a minor side effect that merely ruins the entire quality of a woman’s life.  While pretty much everyone feels sad once in a while, depression is not the same as situational sadness.  Here is some basic information on depression from the National Alliance on Mental Illness (NAMI):

Major depression is a mood state that goes well beyond temporarily feeling sad or blue. It is a serious medical illness that affects one’s thoughts, feelings, behavior, mood and physical health….Without treatment, the frequency and severity of these symptoms tend to increase over time….[symptoms include] depressed mood (sadness), poor concentration, insomnia, fatigue, appetite disturbances, excessive guilt and thoughts of suicide. Left untreated, depression can lead to serious impairment in daily functioning and even suicide, which is the 10th leading cause of death in the U.S.

Fortunately depression is treatable, and one main component of treatment is often taking selective serotonin reuptake inhibitors (SSRIs), which include commonly prescribed antidepressants such as Zoloft and Prozac.  Treatment for depression not only impacts quality of life, but life itself.

Imagine my surprise, then, to read New York Times writer Roni Caryn Rabin‘s comparison of giving up prescribed antidepressants to giving up smoking.  And imagine how much more surprising it was when she compared giving up antidepressants to giving up brie.  Yes, brie, as in a single type of gourmet cheese.

brie

I’m sure that anyone who has ever confessed to loving brie more than life was being hyperbolic.

The piece goes on to quote Barbara Mintzes, an associate professor at the University of British Columbia School of Population and Public Health:

If antidepressants made such a big difference, and women on them were eating better, sleeping better and taking better care of themselves, then one would expect to see better birth outcomes among the women who took medication than among similar women who did not.  What’s striking is that there’s no research evidence showing that, [but on the contrary] when you look for it, all you find are harms.

Who is harmed by the continued use of antidepressants, you might ask?  After all, if they were harming the woman, wouldn’t she have stopped taking them on her own?  Wouldn’t it be likely that she would have stopped taking them before she became pregnant?

Well, it turns out that the “harms” of taking antidepressants accrue only to the fetus–maybe.

Among the possible harm that the article lists are autism, attention deficit hyperactivity disorder (ADHD), lower language competence at age 3, preterm birth, birth defects, a lung disorder, REM sleep disruption, and lower birthweight and Apgar scores.

The problem is, most studies were of low scientific quality.  In some of the studies, when further controls were used, many of the negative outcomes were associated with having a mother with depression, whether or not she took antidepressants.

The article does not distinguish between different SSRIs–although these drugs all impact seratonin, they have different chemical formations.  The only concession to this that the article makes is to note that Paxil in particular is associated with birth defects, but information about Paxil strongly recommends against using it in pregnancy, and the FDA changed Paxil’s labeling and pregnancy category in 2005.

Many women actually do give up antidepressants in pregnancy.  For instance, one study of over 100,000 women in the UK found that “Only 10% of women treated before pregnancy still received antidepressants at the start of the third trimester. In contrast, 35% of nonpregnant women were still treated after a similar time period.”  The study does not indicate whether women who continued using antidepressants had different outcomes.

Rabin’s piece does quote Dr. Roy Perlis, an associate professor of psychiatry at Harvard Medical School and author of a study that found a connection between fetal antidepressant exposure and ADHD. Depite this research, he says,

The downside of these studies is that it ends up scaring women away from treatment…the severity of the depression or anxiety can make it very hard for [women] to take care of a child, and is such that their life is at risk if they’re not treated.

The article then closes with an implication that Dr. Adam Urato, a maternal-fetal medicine specialist at Tufts Medical Center, thinks women should stop using antidepressants in pregnancy in favor of non-drug options such as counseling, exercise, and bright light therapy.  I am in favor of all of these things as first line treatments, but if they are not sufficient, what should a pregnant woman do?

The response from pregnant women and young mothers who read this piece doesn’t indicate that Rabin’s information was helpful.  Isn’t it bad enough to be depressed without being shamed for seeking treatment?

Alexis, the mother of a 7-week-old, says

Well I guess I’m a horrible person and mother…Now I feel guilty about the drug that I was prescribed following a suicide attempt 2 years ago, a drug that literally saved my life.

Rachel, currently pregnant, writes

OMG, I am totally freaking out! I have been taking Prozac for symptoms of anxiety for the last few years. When I became pregnant, my ob/gyn, my current therapist, a past therapist whom I consulted, and my prescribing doctor all assured me, in no uncertain terms, that it would be better for my baby if I stuck to this regimen than if I were to discontinue it. Now I am about to start my second trimester, and I read here, also in no uncertain terms, that all my doctors were wrong! Now what am I supposed to do?! Help!!!

On a brighter note, unlike many articles that generate sympathy primarily for the fetus at the expense of the woman, many commenters here point out the deficits in Rabin’s presentation and her argument.  A number of them  are physicians or nurses, and many are also outraged at the comparison of antidepressant use to smoking and eating cheese.

Here’s Nicole:

As an obstetrician I am mortified that this article starts off by comparing quitting smoking and not drinking alcohol to weaning off SSRIs, and it blames the mother for staying on them while barely mentioning that it can’t happen without providers like me who do the prescribing.

And Alabama Doc:

First, medication for a serious brain disorder is nothing whatsoever analogous to buying cheese…There is muddling of several separate issues here, with the assumption that the women and their doctors are using an ineffective medication just for… what, a lifestyle preference? Yes, we have evidence that non-medication treatment can be highly effective for mild to moderate depression and that there may be no clear benefit of SSRIs for mild depression. For severe depression, however, medication appears to have significant benefit. Notice how all the discussion of risks/ benefits centered around the infant and really nothing was said about the mother? Is the mother’s life so unimportant?

and Caroline Cylkowski, Nurse Practitioner:

Shame on NYtimes for publishing an article completely based on pseudoscience. The author cites the opinions of one MFM doctor and one public health researcher as the basis for her argument. What is scary is that pregnant mothers, who already worry that everything they do might harm their future child, will read this this and discontinue their antidepressants. Antidepressants are not optional medications. The disease they treat has debilitating and sometimes life-threatening consequences.

In contrast to Rabin’s piece, sources from medical institutions take a very different tone.  For instance, Massachusetts General Hospital points out

Many women may consider stopping medication abruptly after learning they are pregnant, but for many women this may carry substantial risks.  Decisions regarding the initiation or maintenance of treatment during pregnancy must reflect an understanding of the risks associated with fetal exposure to a particular medication but must also take into consideration the risks associated with untreated psychiatric illness in the mother. Psychiatric illness in the mother is not a benign event and may cause significant morbidity for both the mother and her child; thus, discontinuing or withholding medication during pregnancy is not always the safest option.

The MGH site goes on to point out that each medication is different and some carry more risks than others.  They identify several antidepressants that appear to have no association with birth defects and point out that symptoms of neonatal withdrawal from antidepressants are generally mild and disappear within a few days.

What is perhaps most disheartening about Rabin’s piece is the addition of women’s legitimate medical treatment to the Pregnancy Outcome Blame Game.  Major causes of birth defects include environmental contamination and domestic abuse.  Major causes of preterm birth are racism and lack of prenatal care.  But these require broader social intervention to mitigate.  How much easier to blame individual women for poor birth outcomes, especially when they are too depressed to defend themselves.

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