In the era of Google, there is a massive amount of information available about antidepressants. Even for a medical professional, it can be daunting to know what’s real and what’s not. Considering this decision can impact the lifelong health of a baby though, it’s important to be informed.
As a psychiatrist, I hear a lot of opinions, rumors and beliefs about psychiatric medications. I would like to point out that I have no financial incentive to promote medications. There are no pharmaceutical companies paying me, period. I don’t get reimbursed more by an insurance company if I code my visits as medication management. And my practice is a mix of therapy and medication, so if none of my patients were on medication, it really wouldn’t matter to me. I work hard to be unbiased with prescribing medications. I try to focus on using research and evidence to guide my clinical decisions so that I’m not persuaded by my own bias, culture or religion in developing treatment plans for my patients. The answers to the questions below are just me sharing my knowledge with the internet. There is so much information out there, that it can be confusing to know what’s real versus what’s made up.
According to The Agency for Healthcare Research and Quality, the most widely prescribed psychotropic medication, or psychiatric medication, in 2017 was sertraline, commonly known by the brand name Zoloft. In general, antidepressants are the most commonly prescribed class of psychotropic medication, so it’s no surprise that they get a lot of limelight. Public attention is always accompanied by truths and lies, though, as well as a plethora of opinions. Below, I answer the most frequent questions I hear from my patients about antidepressants.
No. No one craves an antidepressant. There is no “antidepressant use disorder” diagnosis in existence either. Similar to blood pressure medications, someone can rely on the medication for the rest of their life, but that doesn’t constitute being addicted to them. It means they have a malfunction in an organ that is treated by taking a medication.
It shouldn’t. The goal of antidepressants is to get people feeling back to normal. When someone is in a depressive episode or struggling with worsening anxiety, an antidepressant is one way to help them get back to feeling normal faster. Antidepressants are supposed to treat symptoms of an illness, so that the symptoms go away. They’re supposed to make someone feel like their old self again, which is most often what they do when they work. Some people have emotional side effects to antidepressants though - they may feel emotionally blunted, or may have difficulty crying or feeling more extreme joy. This is an unwanted side effect, and should be brought to the prescriber’s attention so the medication can either be adjusted or a different medication can be trialed.
No. Big fat NO. Starting an antidepressant is, in no way, a life-long commitment. It’s simply a trial. If someone has side effects to the medication, doesn’t like the way it makes them feel, or later decides they want to come off of it, that is okay. It is often recommended to be on an antidepressant long term if someone has had two or more depressive episodes before, or has struggled with more chronic, severe anxiety. This is because the likelihood of their symptoms recurring are very high, and the risk of the illness is outweighed by the risks of the medication. Antidepressants always work best (in preventing relapses) if they are taken for about a year from the time symptoms go away, and if they are taken in conjunction with psychotherapy. If someone’s goal is to get off of antidepressants successfully, then I would argue therapy is a must.
No. I can’t tell you how many patients have told me that they have been told this. It makes me angry, honestly. It is shaming a woman, and for what reason? We have a lot of good, quality research supporting the idea that antidepressants do not increase infertility rates. There were some older studies suggesting that antidepressants do increase infertility, but as we have advanced our education more about the interface between mental illness and fertility, we’ve learned that those with mental illness, regardless of being on an antidepressant, are at increased risk of infertility. So it is better supported that infertility has more to do with the depression and anxiety illnesses themselves, rather than the medication used to treat them.
No. Similar to infertility, miscarriage used to be thought of as a possible effect of antidepressants rather than of mental illness itself. More substantial, robust research has provided solid evidence that antidepressants do not increase the risk of miscarriage. The association between mental illness and miscarriage is the real culprit.
In short, no. Research shows that the dose of the antidepressant during pregnancy does not increase risks to the baby. There is some evolving research that may indicate that the dose of antidepressants could increase the risk or severity of neonatal adaptation syndrome; however, most research shows it does not. Untreated mental illness during pregnancy has a lot of risks to the fetus though. Research supports that the more severe and the longer the duration the mental illness is during pregnancy, the higher the risk is to the developing fetus. Active mental illness increases medical complications of the pregnancy and poor birth outcomes, and increases the risk of long-term physical and mental illness in the baby. So it is safer to fully treat the illness into remission with necessary doses, rather than expose the baby to both the medication risks and the illness risks. The risks of the illness far outweighs the risks of most antidepressants. Additionally, a woman’s metabolism of the majority of antidepressants greatly changes throughout pregnancy, which necessitates higher doses to maintain the same level of medication in the body.
Ideally, we don’t want people on antidepressants. Our brain is an organ though, and sometimes it needs medication to help it function properly. Bringing back in the analogy of high blood pressure: we can use lifestyle changes to improve symptoms and decrease risk, but sometimes lifestyle changes are not enough or the illness is too severe, and other treatments are needed. Medications can help save people’s lives and should not be viewed as “the bad guy.”
The more research that comes out about perinatal mental health and treatment, the more evidence supports that we were inaccurately focusing our concerns on the wrong thing. It’s not the medications used to treat mental illness that we need to fret about, as much as it is mental illness itself that should be worrying us.
Look for my next blog post in the winter about the risks that mental illness poses to a woman and her baby during pregnancy and postpartum.
When Mother's Day HurtsWhen Mother’s Day Hurts“There is, I am convinced, no picture that conveys in all itsdreadfulness, a vision of sorrow, despairing, remediless, supreme.If I could paint such a picture, the canvas would show onlya woman looking down at her empty arms.”-Charlotte BronteAs Mother’s Day approaches, I’ve been speaking with several of my clients who’ve struggled to become mothers and/or have lost a child in utero about what this day means to them and how they feel. I’d like to share some of the themes that have emerged through our discussions. Unfair. For many women, the veneration of mothers on this day is deeply painful. Feelings of anger, irritation, envy, and confusion arise. Why me? Why haven’t I become a mother after so much effort? Why did I lose this much sought-after pregnancy? The women I see in my practice have typically spent months, sometimes years, trying to birth a healthy baby. They may have sacrificed tremendous time, energy, and spent the reserves of their emotional and financial resources to try to conceive. They may have given birth and held a dead baby in their arms. The legacy of their losses becomes their new reality, and they must learn to navigate the world with the constant presence of someone’s absence. This, my friends, is unfair. Isolation. Infertility and/or pregnancy loss is often a silent struggle. Research reports that women who are struggling to become mothers experience increased feelings of anxiety, depression, isolation, shame, guilt, and loss of control. Depression levels in people with infertility have even been compared with patients who have been diagnosed with cancer, and couples tend to report that infertility or pregnancy loss have been the “most difficult” events in their lives thus far. This silent sorority of women is estimated to affect 1 in 8 couples (or 12% of married) who struggle to get pregnant or sustain a pregnancy (Rooney & Domar, 2018). That’s roughly the size California, folks! And yet, we don’t talk about it enough, and that’s especially true for men. Sadly, when these discussions do come up, well intended yet uninformed family, friends, or coworkers can say thoughtless, hurtful comments. This can further the cycle of silence. Grief/Loss. If you wonder what that constant tension is in your body, that heavy feeling that sits on your chest – it’s grief. Feelings of anger, depression, anxiety, fear – all different colors of grief expressed. Loss is ever present in the stories of those struggling to create their families, and it doesn’t just disappear when a baby arrives. For some of my clients, the losses can be layered, so let’s take a look at some of them:What’s been lost?Loss of the experience of pregnancy and birth – you feel you are missing out on one of the most miraculous events of lifeLoss of sense of belonging – you don’t quite fit amongst your friends, family, or society at largeLoss of being in control – of your body – of your life. This wasn’t how it was supposed to beLoss of feeling healthy and normal – your identity shifts from “healthy person” to “infertility patient”Loss of feeling competent – you feel you can no longer achieve what you set out to doLoss of sexual intimacy, identity, and privacy – what had been the most private and intimate acts is now publicThe Eagles band has a song titled “Hole in the World” and I think it certainly applies here - -There's a hole in the world tonightThere's a cloud of fear and sorrowThere's a hole in the world tonightDon't let there be a hole in the world tomorrowIdentity Disruption. Talking with a client who had experienced three recurrent pregnancy losses in the recent past, she noted how her relationship to mother’s day had not transitioned the way she expected, from honoring your mother figure to honoring yourself as a mother. She further described feeling excluded from parenthood and being relegated to still sit at the “kid’s table.” For so many women, they had constructed (whether conscious or unconscious) a reproductive narrative, a story of the family they would have one day and the role they would play in that family. And this story can be largely influenced by the dominant cultural narrative regarding becoming an adult – separating from your parents, establishing your own residence, taking responsibility for your life, and creating your own family. Being denied these important rites of passage and roles can be experienced as an existential crisis. Who am I? Where do I belong?Heroism. The people that I’ve had the privilege to work with during their parenting journey are nothing short of courageous as they attempt to create life against the odds. Some of those people came home with a baby, while others made the heartbreaking decision to be childless due to financial constraints and/or unwillingness to undergo fertility treatments. Some of them only have pictures of the child that never breathed air. As Dr. Ilona Laszlo Higgins expressed in her book “Creating Life Against the Odds,”The struggle of these individuals to create and nurture children goes well beyond the desire to produce a new generation in one’s own image, or to have a living repository for one’s inheritance. It is about the sense of completion that comes from the conscious commitment to be responsible for the well being of another. It is the wisdom that comes from the ashes of loss, translated into new life. (Intended) parents such as these set an example for all of us about the hard work of love. I couldn’t agree more. Society often pathologizes and judges the lengths these folks go to in order to become parents. I’ve had several clients exclaim, “I would never do that,” and then when faced with no other alternative, start down the path they said they would never go. To me, these individuals aren’t crazy, they’re heroes. They are willing to recreate their story and consider what could be versus what should have been. They grieve their losses and nurture their wounds, then carry on. On this day, it is my hope you can do the following for yourself:Practice being with grief, in whatever form it takes, unconditionally and nonjudgmentally. Be with your deeply wounded self.Acknowledge that there’s a missing piece to your life puzzle. A hole in your world.Take good care of yourself. Far from being selfish, self-care in grief is courageous.Forgive yourself. You did nothing wrong. Create a ritual to acknowledge what or who is missing. Write a letter, bury an object, say a prayer, light a candle, carry flowers, whatever honors the void. Ritual acts, whether private or public, are ways in which we give way to the feelings of love, pain, and connection. References/Recommended further readings:Cacciatore, J. (2017). Bearing the unbearable: love, loss, and the heartbreaking path of grief. Wisdom Publications, Somerville, MA. Fast Facts About Infertility. Available at: http://www.resolve.org/about/fast-facts-about-fertility.html. Resolve: The National Fertility Association. Higgins, I. L. (2006). Creating life against the odds: the journey from infertility to parenthood. Xlibris Corporation. Jaffe, J., Diamond, M., & Diamond, D. (2005). Unsung lullabies: understanding and coping with infertility. St. Martin’s Press, New York, NY. Rooney, K. & Domar, A. (2018). Dialogues Clin Neurosci. Mar; 20(1): 41–47.
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