Medication & Pregnancy

Many women develop a serious depression after delivery of their child.  While the “baby blues” are quite frequent but mild and temporary, postpartum depression (PPD) is a serious complication of pregnancy that happens to almost 15 percent of mothers.  PPD includes all the symptoms of major depression—the insomnia, loss of appetite, guilt, self-blame, obsessive thoughts—but this is usually focused on the baby and motherhood.  You feel like a bad mother, unable to care for your child; you feel that you don’t love the baby, or it doesn’t love you; you feel that you made a terrible, irrevocable mistake and you’re hopeless about things ever getting better.  In the terrible irony of depression, your mental state, if it continues without treatment, may have a real effect on your relationship with your baby.  In the worst cases, PPD can become postpartum psychosis, and a new mother may develop delusions like her baby is a child of the devil and must be destroyed.

Fortunately, things rarely get that bad.  But being a new mother should be a time of great joy for you, and if it’s not, you should do something about it.  If you feel you might have PPD, see a good therapist as soon as possible.  Note that I emphasize good.  I have seen more examples of damage done by well-meaning therapists, nurses, doctors, La Leche coaches, and other professionals trying to treat new mothers than almost any other group.  I think this is because moms are extremely sensitive and vulnerable, and the professionals feel an urgent need to fix the problem before mom and baby are really damaged.  So get a good referral, perhaps from your doctor or the pediatric nurses at the hospital, and if you don’t feel a good connection and level of trust soon, shop around some more.  You can even ask your therapist:  I don’t think this is working for me.  Can you recommend someone who is very experienced with PPD?

PPD seems to be another example of stress acting on a vulnerable person.  In this case the stress includes both the sudden hormonal changes associated with giving birth (which we still don’t fully understand) and the equally sudden extra work load, lack of sleep, and confinement that new mothers experience.  Vulnerabilities include a previous history of depression, trouble in the marriage, and a lack of social support—though again, we all know mothers who have been hit by PPD “out of the blue.”  In many cases the depression begins during pregnancy, for some of the same reasons—hormonal changes and stress.  Often the pregnancy reveals faults in the marriage that have always been there but become more obvious.  Sometimes the husband will have a negative reaction to the pregnancy.  Friends and relatives can be jealous or insensitive.

The question of using antidepressants during pregnancy and breastfeeding is unfortunately complex.  There is increasing evidence that use of SSRIs, both early and late in pregnancy, is associated with birth defects, primarily cardiovascular.  Overall, the increase in risk due to SSRI use is rather small—on the order of two percent compared to one percent of  among mothers with no SSRIs.  But of course, other risks may show up later, as has tended to happen with SSRI research.  There are risks to the fetus associated with use of mood stabilizers, as well.  So for a depressed and pregnant woman, there is no easy answer.  Going off SSRIs can be very difficult, and of course increases the risk of another depressive episode, but there is real reason to be concerned about the effects on the baby.  Please refer to my discussion of the pros and cons of antidepressants in Chapter 13.  We have to balance the severity of mother’s depression, and all the effects that can have on a child, against the increased risk of birth defects.  If you are severely affected by PPD, consider that sometimes a brief trial of medication can result in a dramatic change.

references can be found in Undoing Depression, rev. ed. (c) 2010, Little, Brown, & Co.