Guest blog: pregnancy and antidepressants - a woman's right to choose(55 Posts)
Official advice to women who are taking anti-depressants is to be updated, in response to research which suggests that the use of SSRIs during pregnancy may double the risk of a child being born with a heart defect.
In today's guest post Anna Hedge, who blogs over at Economista Dentata, argues that this is a potentially dangerous step which adds to a 'growing atmosphere of moral judgment' about the choices women make.
"Women, being autonomous adults, have a right to medical treatment to treat any illness they may have on the same basis as men. It seems obvious, doesn't it?
Monday night's Panorama, called 'Pills and Pregnancy', is being described as worrying viewing for women. Not for people, note, but women. Worrying because drugs used to treat epilepsy and depression respectively had been found to have a correlation with an increase in birth defects.
I don't know about epilepsy, but I do know about depression - both during pregnancy and afterwards. My partner was killed when I was 3 months pregnant with our son, and I was tipped from a really-rather-happy-albeit-unplanned pregnancy into utter, bewildering despair which lasted for years. I was recommended, and took SSRIs. Without them I'm not sure I would have survived.
Would I have still taken them had this new research been available then? Probably, yes: I was ill, I needed the treatment: every treatment has risks. But there is a growing atmosphere of moral judgment around women who choose to take prescribed medication where there is any risk to the foetus.
Partly this is down to the explosion in 'lifestyle advice' to pregnant women: eat broccoli if you want a genius, play them language tapes to help linguistic development in utero, this or that food will/won't ensure healthy development and of course, the never-ending breast-feeding discussions.
But illness and medical treatment are not 'lifestyle' choices - and yet women are being encouraged to feel guilty and ashamed, as though recommended medication in pregnancy is an unnecessary luxury, akin to a self-indulgent half-glass of wine once a week. Feelings of guilt, shame and unworthiness are key features of any sort of depression and certainly was in mine.
The already flourishing view (not least in the media) that a Good Mother is she who puts herself last, coupled with the intrinsic guilt associated with depression could prove, literally, fatal.
Professor Pilling, the expert advisor to NICE, describes the use of medication in mild-to-moderate depression as 'in most cases, not worth the risk' of a 'doubling of the risk of a birth defect'. But early intervention may prevent mild-to-moderate depression from worsening into something far worse - a crisis whose treatment may well present more of a risk to both mother and foetus than continuing with the initial medication. And while a doubling of risk sounds terrifying, it is in fact an increase from two births per hundred being affected, to four.
Terrifyingly, it's not only pregnant women who must worry. Professor Pilling suggest warning all women who 'could [my emphasis] get pregnant' about the dangers of SSRIs - so, that's the vast majority of women between the ages of 15 and 45. Under this scenario, women could shun potentially beneficial medication due to a risk to a child they haven't even yet conceived, and have no intention of conceiving.
We are sleepwalking towards a situation where women are no longer thought of as autonomous individuals and patients, ie as equal to men, but to a greater or lesser degree as ante-chambers to another life (there are echoes of the broader issues of choice in pregnancy here: I note that can of worms but leave it unopened).
What does this approach tell girls about their primary purpose in life, and their importance as people in themselves to society? Women shift from 'People who live in the world on an equal basis' to 'Perpetual mothers-in-waiting'. A woman's right to appropriate treatment becomes eroded by the fact of her potential for motherhood, bolstering already-existing biases faced by women in the wider world, and making our well-being of lesser worth than men's.
Ironically, a paper published last month in the Journal of Psychiatric Research suggests there may be a possible test for ante and postnatal depression which would identify women at greater risk. This is great news - but only if we can agree an approach which is based on two maxims: that women, whether pregnant or not, are morally equal to men; and that they have a right to make their decisions on the basis of clear, unbiased information.
There needs to be more information about depression generally, and in/after pregnancy in particular (I commend the Royal College of Psychiatrists for this excellent leaflet, 'Mental Health in Pregnancy'). There is still a tendency amongst healthcare professionals (at least in my experience), to try to jolly depressed pregnant women out of it: 'You'll feel better when the baby comes', or 'when baby is here, you won't have time to be depressed'. But depression is an illness. It finds the time, even if you don't have it to spare.
Mental Health services need urgent attention, both in terms of resources and education. Yes, talking therapies can help with mild-to-moderate depression: but the waiting lists are horrendously long. CMHS have long been chronically underfunded.
And the media can do their part by avoiding sensationalist reporting of medical research into mental health diagnoses and their treatment (and a prize to the first newspaper to embed links to the original research).
The most crucial point is this: that women, mentally ill or not, pregnant or not, deserve to be treated with the same care and respect for their status as individuals as any other patient. This may involve our being faced with tough choices - see the examples above - but it is their very toughness that makes it so important that it is our choice. Give us the information, then let us make the decision, because as with any other decision involving our health, we are after all the people most intimately concerned with the outcome. Our bodies, our minds, our conscience."
I take SSRIs and they have transformed my life. Depression is an illness which needs to be treated. It is good to have the information in order to make a choice BUT depression is life threatening. Epilepsy is life threatening.
IMO Prof Pilling's remarks are damaging and play down the seriousness of depressive illness.
Frankly, I'm fed up with men telling women what they can and can't put into their mouths during pregnancy. I think it has all become way out of proportion.
I posted about antenatal talk after monday night's programme. I have had several discussions since with medical professionals all who agree that the benefits for me at least outweigh the risk. I did however scare myself into a panic there could have been so much danger if i abruptly stopped taking them to both me and my unborn child, the show are scaremongers in my opinion which as has been said is potentially fatal.
I have posted about how annoyed I am about this programme elsewhere on these boards.
I don't buy into the idea that depression is "just illness", I think for most women who experience it, it seems to be multifactorial. Very many women develop it because of life circumstances: lack of support, abusive and neglectful childhoods, losses such as yours, childhood disability, poverty, disability of their own.
Yet to me, paradoxically, this makes it even more cruel to make out that this is some sort of lifestyle choice. The reason women benefit from the drugs is because even when we are ill, unless we are borderline catatonic, we have to get up and mind children in the middle of the night even if it will make us a million times worse the next day, do school runs and nappy changes and kissing of bumps and bruises even if we feel we are dying inside. It's an issue of basic humanity that because we have these drugs and we know the long-term effects on mothers, babies and families of untreated depression that very small risks should not be hyperinflated in this manner.
I have just been discharged from Mother and Baby Unit treatment and I know the risks of ADs, they're pretty small when it comes down to it - 1 in 246, which is less risk than we all face of stillbirth every time any of us becomes pregnant. It's also a very small increase on the background risk, which is .5 to .8. I also know if I had seen that programme prior to taking them I might in my highly anxious state have chosen not to take them. This is horrendous to contemplate.
The thing I am most infuriated about though is the lack of discussion of the counter-risks.
The risk of relapse for women who have been on ADs prior to trying to conceive is, however, a shocking 68% if you stop taking the drugs.
So you are talking about weighing up a near-certainty vs a very small risk.
I agree this is about controlling women's bodies and I hate it. I hate the fact I ever needed ADs, I believe I needed them in the first place because of the abuse I had previously suffered at the hands of men but this is just a joke.
I actually feel like it needs to campaigned vociferously about because in truth I think it's misogynistic.
I couldn't agree more with the spirit of the blog.
However, in my own experience (two babies, SSRIs taken in both pregnancies) the consultants and other health care professionals were concerned with my well being first and foremost. They gave me choices, treated me with respect, pointed me to research papers. Knowing them (as well as you can possibly know your doctors) I suspect they would look at this new research and say, well, a doubling of risk is still a very small risk, and the risk of not taking SSRIs is significantly more dangerous, both physically and mentally.
What really concerns me (and this happens every time there is a new story on this topic) is the message it sends to pregnant women or new mothers who are suffering from ante or post natal depression and anxiety: don't seek help, you will be locked up/baby taken into care/labelled a bad mother/not given the help you need.
If anyone is reading this thread and is in this position, please please ignore this scare mongering and get help. There are brilliant, sensitive, sensible professionals in the NHS who understand, and want the best outcomes for you.
Dr Pillock sounds charming. How about all women of child bearing age stop drinking, eating Brie and changing cat litter too, just in case.
I didn't see it, does anyone know which epilepsy drugs they were talking about?
Agree with the central argument of the blog - women have a right to make an informed choice. Doctors should provide pregnant women, or women planning a pregnancy who are taking medicines, with all the available information and evidence but it is the woman's choice. It is her decision to weigh up the risks as they affect her.
That is what happened when I was pregnant. By good fortune, when I was diagnosed with epilepsy I lived across the road from a teaching hospital with a neurology centre, so they tried me on a drug that is, as far as they can tell, safe for pregnant women (Lamictal). When I became pregnant, my options were explained, the risks were explained, I was offered extra scans, and the neurology and obstetric teams worked together. I felt that I was always in charge - it was my choice whether to do X or Y and to weigh up the risks and benefits of each approach.
Sadly it is not always like this. Too many women have to wait for a year or more to be referred to a neurologist, and are dumped on sodium valproate by their GP - a drug which is known to be incredibly harmful to the developing foetus and which should not be prescribed to a woman of childbearing age unless there is no alternative and/or the woman concerned is informed of the risks. Happened to a friend of mine; I was outraged. She already had three children but could easily have fallen pregnant accidentally - after all, no method of contraception is 100%. Her GP didn't bother to tell her sodium valproate is teratogenic. Even though this has been known for decades.
Doctors need to listen to women and help women to understand their choices, then support the woman in whatever choice she makes.
(Part of making an informed choice rests upon doctors being honest about what they don't know - the level of uncertainty. My doctors told me lamotrigine was the safest option as far as the evidence available but were honest about the fact it had only been marketed for about a decade so the information was still limited - there had been too few pregnancies on lamotrigine to say for sure.)
Sorry for multiple posts but another important point - having access to all the information meant I was happy to help the research by having details of my pregnancy added to the register, so that my experience helped inform the evidence that will now be available to other pregnant women/women planning pregnancies. Working with patients has all sorts of important benefits.
Hello-I'm the author of the above post.
Thank you for all the lovely comments-can I just underline what several people have said here and elsewhere: please don't stop taking your medication without consulting a GP first, and do speak up if you need help.
Edam: the epilepsy drug was 'Epilim' (sp?).
Sorry - did we watch the same programme?
The programme I watched wasn't scaremongering or patronising to women. Nor did it suggest they were vessels for babies.
It said that there wasn't enough information given to women about potential risks. The woman whose baby had a heart defect complained that she hadn't been given information to be able to make an informed choice.
I didn't take out at all it was saying ADs are a lifestyle choice. It was saying women weren't given information to make an informed choice about what the risks were and whether to stay on the drugs if they wanted to in light of that.
Sorry have crossed with several posts. Completely agree with what Edam wrote.
mersealily, yes, that's the one - Epilim is the brand name for sodium valproate. No woman of child-bearing age should be prescribed it without a jolly good reason that is discussed with that woman - it must be her choice in full knowledge of the risks.
Shocking doctors are still using it as a first-line treatment for girls and women from teenagerhood to menopause - the teratogenic effects have been known for decades.
(Thanks MrsCurly, btw - I feel strongly about this because I had good care and that should be a given for every woman, not merely the lucky few.)
Mrs Curly: Hello-my post took the programme as a prompt-it wasn't intended as a review of the programme itself (although I thought it a little less even-handed than you).
I didn't write about the epilepsy issue as it's something of which I have no experience.
I spent the majority of my pregnancy with DD1 on Prozac and for 9 months after she was born.
I had a full nervous breakdown at 17 weeks pregnant. A combination of hyperemesis, working full time as a teacher and pregnancy hormones all contributed. I was at the point of researching abortions for a much wanted and planned for baby. If I couldn't get one, well it was simple I would kill myself.
It was a kindly clergyman that set me on the right track, one lunch time I stumbled into the Cathedral next to my school, I curled up in the back pews and silently sobbed. The Canon knew me from school and sat with me, not talking for a long time before gently encouraging me to voice my worries. He told me straight that I should go to the GP or midwife and even offered to accompany me if I needed support.
My next midwife appointment was the following Monday and, taking his advice, I wrote everything down for her to read. She was shocked at how low I was and I physically collapsed in her office. The pressure had finally got too much. What followed was a swift diagnosis and treatment schedule, I was to be managed at home initially to see how I responded to the ADs before assessment for further treatment. My husband had to lock away the knives and pills.
Without my treatment with ADs DD1 would not be here, I would not be here and I certainly would not be expecting DD2 (due Nov). I was made aware of the risks of using ADs but in my case it really was a situation where they were the only choice.
I didn't see the prog but saw the way it was reported on the BBC which IMO was shockingly scaremongering and so I started a thread about it (link below). An interview with the Prof is in the BBC piece and what he says is extremely concerning from a "women being sentient beings with rights" perspective.
OP I agree with what you say.
I only saw parts of the programme. I also have no experience of medication during pregnancy myself, so I am speaking from one step removed in it all.
I find the increasing creep of 'woman as baby vessel' really alarming. From the US idea of pre-pregnant and the creeping criminalisation of exercising very everyday freedoms like consuming and being served a single beer, to the "Well, I would never forgive myself" comments in the UK about alcohol consumption, cheese, parma ham...
I get very worked up about those kinds of things. And this programme was a perfect illustration why. IMO it was scaremongering and lacking in balance. It wasn't reporting in a balanced way that this may be something the woman may wish to add into the decision making balance.
And I am neither pre-pregnant nor potentially pregnant. Yes, I am of child bearing age. Yes, many pregnancies are unplanned. Yes, you can warn me (and should warn me) of potential consequences should I become pregnant on medication. But doctors must treat me as their patient, in my best interests, not based on some hypothetical future pregnancy.
Sorry, missed a bit.
This programme was the perfect illustration of why. Because encroaching on civil liberties may start small, but it always creeps out to big, big things. Like lifesaving medical care.
I stopped taking AD's when I found out I was pregnant because I feared it would hurt the baby. What followed was a horrendous pregnancy. I felt suicidal some of the time and ended up going into A&E a couple of times. I also got very drunk one night (dp had also just left me) and I collapsed.
It was only when DS was about 3 years old that I went back on ADs. Being depressed became normal to me, I had terrible OCD, paranoia, I would physically shake from stress and had other symptoms I had not associated with depression, for example aching bones.
Worse decision I ever made was to come off ADs! DS would have been much better off if I had stayed on them.
the programme was utterly disturbing. at least the spokeswoman gave a more balanced view but it still left a funny taste.
btw. anyone in the uk can report side effects only to the mhra yellow card scheme . I wish the programme had made it clearer where/how to do it, esp. when side effects are (as so often) dismissed by the doctors.
I took anti depressants, citalopram, in my fifth pregnancy and whilst some drs/conultants were great, others were crap. One refused to do my repeat prescription despite ,y con, the mental health team consultant phoning him to say it was OK and then once I had had dd one Dr was horrified I was bfeeding and threatened ss... As I was endangering my baby, i was taking 10mg of citalopram ffs and I had had post natal psychosis after my fourth baby so was being monoyered closely and it was agreed that to stay on a maintenance dose of citalopra, was best!
My friend has epilepsy and has jsit had a baby (a week ago) her local Dr was crap but the special sot she was referred to was great but she has had issues as baby has suffered withdrwal and it was totally missed by hospital etc and was not warned of this issue. Thankfully he is fine
There seems to be massive variation and most drs look in a book and say NO,refuse to research or consoder alternatives, I even had to battle to get anthistmines for severe eczema which consultant had okayed, yet gp said no.
I gather from the other thread that the programme was raising concerns about paroxetine - also known as Seroxat. There is huge history here - a major scandal where the drug company and medical establishment were denying/refusing to acknowledge serious side effects including suicide. Doctors are now advised against prescribing Seroxat to teenagers and young people due to the increased risk of suicide. Risks that would still be hidden were it not for some dogged campaigners (including some psychiatrists who blew the whistle).
I have no idea whether paroxetine is associated with an increased risk of heart defects in foetuses or if it is whether that is a causal relationship and how big the effect is. BUT I would certainly look into any concerns about side effects with this drug in particular very carefully indeed. And I would look seriously at any alternatives that might be available.
The issue is not doctors treating all women as pre-pregnant; quite the reverse, it is that some doctors are not really paying attention and do not stop and think 'ah, yes, this patient is a woman between puberty and menopause, maybe I should check this drug isn't going to cause serious harm should she be planning a pregnancy or become pregnant unexpectedly and maybe, just maybe, I should bother to tell the patient that there might be an issue...'
I really don't understand the concern here at all. It has and should always been the case that pregnant women's medication options are constrained by the effects of drugs on a developing foetus.
When I was pregnant and breastfeeding I had to drop my SSRI medication because at that time there wasn't the evidence to show that they were remotely safe for the baby. Medical science moved on and I was surprised to learn relatively recently that it is now possible to take these drugs when pregnant or breastfeeding. Great -- but we still need to be constantly open to further evidence and to keep the situation under review.
Women aren't disrespected by a continuing respect for the evidence. We are only disrespected when the unavoidable need to balance the child's and the mother's medical needs is made from a certain perspective -- one that downgrades women's interests in relation to the child and which fails to keep them as the central deciding agent, absorbing medical information with the assistance of professionals and making a decision within regulatory constraints -- where the regulations are determined by science uncontaminated by cultural distortions against the interests of women.
I do believe that a lot of lifestyle advice to pregnant and "per-pregannt" women is culturally distorted to women's disadvantage, but I see nothing of that in the continuing assessment of the safety of SSRIs, any more than I see it in the unavailability of the drug thalidomide.
for "per-pregannt" read "pre-pregnant"
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