Motherhood, mental illness and beyond

Today the BBC has reported that according to an adviser for NICE (the National Institute for Health and Care Excellence) women who are fertile should be discouraged from taking SSRIs, a class of anti-depressant. The rather aptly named Professor Stephen Pilling was quoted as saying:

“The available evidence suggests that there is a risk associated with the SSRIs. We make a quite a lot of effort really to discourage women from smoking or drinking even small amounts of alcohol in pregnancy, and yet we’re perhaps not yet saying the same about antidepressant medication, which is going to be carrying similar – if not greater – risks”.

Professor Pilling claims that there is evidence that taking SSRIs in early pregnancy increases the risk of a baby being born with a heart defect from 2 in 100 to 4 in 100. If this is true then of course new guidelines need to be considered. (Having said that, in my experience doctors are already extremely cautious when prescribing any kind of medication to a woman who is pregnant or breastfeeding.) However it is other quotes attributed to him that have infuriated me. According to the BBC article :

He says that women not suffering from the most severe depression who become pregnant whilst taking the drug are taking an unnecessary risk.

“You’ve got double the risk. And for women who are mild to moderately depressed, I don’t think that those risks, in most cases, are really worth taking” he said.

“It’s not just when a woman who’s pregnant is sitting in front of you. I think it needs to be thought about with a woman who could get pregnant. And, that’s the large majority of women aged between 15 and 45.”

First of all the diagnosis of depression is extremely subjective, often relying on the individual answering a multiple choice questionnaire that has points assigned to each answer. If you score above a certain number then bingo! You’re depressed. But what one person interprets as mild depression may be what another person feels is moderate depression. Someone who is severely depressed may not believe they are because they’re not considering suicide.

I’ve had episodes of depression since my early teens, including 2 bouts of post-natal depression (PND) and 1 bout of ante-natal depression (AND). The first time I had PND I refused to take any medication because DD was breastfed and I was scared that the anti-depressants would affect her through my milk. As a result I was severely depressed for a very long time despite various other therapies and I planned my suicide on multiple occasions. I am concerned that if Professor Pilling’s reported opinions become guidelines the same may happen to women who are pregnant.

If, through the media sensationalising this or through poorly worded new guidelines, a pregnant woman is made to feel the way I did it’s entirely possible that she may consider taking her own life (and therefore that of her unborn child). If a woman suffers from depression that requires a particular treatment then she should be given that treatment. At the end of the day, uncomfortable though it is for me to say, the life and wellbeing of the woman is more important than that of her foetus.

Any suggestion otherwise removes a woman’s bodily autonomy, her right to decide what happens to her body. This is dangerously close to a number of anti-abortion laws that have been proposed in the United States, where the supposed rights of the foetus (usually a non-viable foetus) would outweigh the rights of the mother, who is reduced to the status of a mere incubator.

As for Professor Pilling’s apparent suggestion that “pre-pregnant” women (so any woman who is capable of conceiving, and therefore presumably including pubescent girls) might be refused access to SSRIs, it’s ludicrous. Would a doctor refuse a diabetic woman her medication? Or an epileptic woman? Both of these conditions often require medications that can be risky for a foetus yet I doubt that many doctors would recommend their patients stop taking them merely because they might conceive a child.

What are your thoughts?

Comments on: "Depression, SSRIs and pregnancy" (15)

  1. Claire SA said:

    Oh goodness. This is quite a can of worms! As you say, if mental illness was a ‘physical’ illness, it is highly unlikely that medication would be refused if it kept the mother safe, unless there was a very severe risk of detrimentally affecting the child, in which case I would think a termination might be suggested. Honestly I have no idea, never having been pregnant, but those would seem the most sensible options to me – whatever your beliefs.
    Moving on…. There are so many things now that might affect an unborn child – exercise, drinking, smoking, working, eating this food, eating that food, walking, breathing (it’s a wonder the species has survived this long, really!) – and this is just another one of those things. One set of results shows there’s a 4% chance of a heart problem, another shows heart problems need to be combined with other things. A human body is such a complex and wonderful thing to create that on occasions that unfortunately sometimes it just goes wrong.
    Despite the possible (yes, that’s possible, not probably) risk, I simply cannot believe that withdrawing something that a woman is dependent on for her well-being and stability can be counteracted by a 4% chance of her baby having a heart problem. Maybe this makes me hard-hearted, and mothers will say ‘you obviously haven’t got children’. They’d be right. I do have a degree of removal in this situation. From what I can gather, having a baby brings many joys but also many lows. New parents have to cope with limited sleep, added baby weight, leaking breasts, well-meaning but ultimately irritating family/friends giving them every piece of advice under the sun which only serves to confuse theminto thinking they need to change a nappy on the floor so the baby won’t fall but at the same time on a table so they don’t strain their already-pulled muscles while they’re next to a bin but not the food bin and got forbid anywhere near the cat and oh-I-ve-gone-cross-eyed……..
    Ahem. I know what I’m like without my SSRIs, and that’s not a person I’d want to be around any other member of the human race when combined with the above issues. Make that person into a small, breakable, dependent, squalling bundle of poop and sick that demands attention 24/7 except when sleeping (but of course is ultimately lovable), and you’ve got a recipe for a long drive off a short pier.
    What was my point? Oh yes. As with everything in pregnancy (from what I can see), a child gets their first steer in life from their mother. If mum is consumed by depression, anxiety and fear because her misguided doctor has withdrawn the tablets for her ‘mild’ depression, life is going to be fairly rubbish for baby. If not dangerous. Severe depression is probably going to follow swiftly.
    In order to put your child first, you must first put yourself first. If that means continuing to take tablets which keep me stable, and risking a 4% chance of heart problems, then this ‘pre-pregnant’ woman is happy to take it.

  2. This news terrifies me. I’ve just come home from a scan at 22 weeks which shows that my baby has arrhythmia. I have to go back for more tests altho they are saying that there is “probably” nothing to worry about. Of course i AM worried and now i am even more worried that it’s my fault. I am on an SSRI. I was with my first child and he wasn’t affected at all so assumed this one would be fine too. And of course, she might be, but right now i just don’t know. I feel massive guilt. But then again, i know, certainly at the beginning of the pregnancy when I was very ill and quite depressed with it, that i couldn’t function very well without my AD’s and i certainly would be a much worse parent for my current child. It’s altogether unsettling news.

    • I’m sorry to hear that and I’m sorry that you feel guilty. As you say though, SSRIs are often necessary and the consequences of not taking them, whatever the reason, can be dire. I hope the next scan is more reassuring.

  3. I took SSRIs when pregnant (an age ago-my son is now 13!): would I have not done so, had I read this advice? Nope. Because whilst there was (on this evidence) a risk to the foetus, the risk to me, the person most intimately concerned with my unborn child’s welfare was greater. Without medication, I could well have had a massive crisis, affecting us both. I needed the treatment. And treatment should be available, if the doctor advises it and the patient consents, on the basis of clinical need.

  4. Sophia said:

    Seconding all the above comments. I have just survived a gruelling twin pregnancy with the support of a fabulous perinatal psychiatrist and indispensable SNRIs. We discussed my medication, and she made sure I understood what the risks were, but that included the very real risks involved in the hideous ante natal depression I was struggling with.
    And they are my risks to take!
    I can’t believe someone is seriously suggesting all women of childbearing age should be warned against these drugs, when it is already hard enough to find the right antidepressant for any individual.

  5. Well done you, Sophia, for coming out the other side. Sounds hideous. Which SNRI were you on?

    The thing is, untreated depression in the mother is known to be associated (some have argued persuasively for a causal link) with poor outcomes for children. I would hope this has been factored in to any cost-benefit analysis but I bet it hasn’t. I haven’t read the original study: what other factors have been controlled for? Does anyone know?

    To the poster above who mentioned the baby having arrhythmia – I think this a common finding on ultrasound isn’t it? I hope the further tests you have bring reassurance.

    On the other hand… I have to admit that the evidence for SSRIs’ effectiveness is far from compelling (cf. Ben Goldacre) and I do wonder about their overprescription – even though I am on them myself, have been for many years, and credit them with sorting me out. I am certain, in the way of these things, that the side-effect profile of SSRIs is fairly poorly understood too. For example, there is research suggesting they could be linked to osteoporosis but you don’t hear about that very often….

    • Yes, it all seems a bit of a muddle doesn’t it? I’m on SSRIs and they stabilise me, I don’t have the cyclothymic mood swings any more and I am a better mother for it. But I know there is some contradictory evidence.

  6. I suffer from mental health problems, including severe depressive disorder. When I was pregnant I stopped taking medication under guidance from Dr. By the 2nd stage of pregnancy I knew I needed to go back on them. I spoke to a clinical pharmacist and the a psychiatrist who has written about medication in pregnancy & breast feeding. They told me that continuing at a ‘normal’ dose was better that having to be medicated to cope with a crisis, apparently 4 times the medication is required (I think that was the figure, was about 18 months ago). I ended up being hospitalised and apart from baby being monitored, she was fine, even with breast feeding. I was told the amount of medication passed in breast milk is also trace.
    I felt guilty enough taking medication with relatively limited numbers of official results in pregnancy. I don’t need extra guilt telling me I shouldn’t be taking them.

    • I’m glad you were supported. I should have been taking meds during my second pregnancy but I refused to even consider it which, with hindsight, made things a lot harder.

  7. I have taken SSRIs for the past two years, since my diagnosis with PND after my second child. I don’t think a third pregnancy is likely for us. But in the event that it did happen, I don’t think this increased risk would be enough for me to stop taking my meds. I’ve seen and felt too much of how crippling depression can be for me to voluntarily inflict it on myself and my children. It’s no way to live. As you said above, I am a better mother for taking them. No question.
    Glad to have found this post via the new mumsnet linky and looking forward to reading more.
    You can find more from me at http://www.mummykindness.com, if you like.
    R x

  8. I’ve been on Citalopram since the end of my daughter’s pregnancy (and on and off before that) and while I was a bit worried that it made my baby sleepy at first – and I did agonise about whether I should come off them, in the end I stayed on them and I’m glad I did. What this guy is suggesting is ludicrous. A woman not taking anti-depressants when even moderately depressed because she is pregnant could be more dangerous than her not taking it. Who knows how quickly she could swing into deep depression and it might be too late to intervene! Absolutely ridiculous. Hugs x

    • That’s my concern. My ante-natal depression was undiagnosed and therefore unmedicated and there were times I came dangerously close to doing something drastic.

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