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Guest blog: pregnancy and antidepressants - a woman's right to choose

(55 Posts)
KateMumsnet (MNHQ) Wed 03-Jul-13 14:38:54

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."

ButThereAgain Thu 04-Jul-13 09:21:06

And add to that the fact that SSRIs are massively overprescribed, thanks to the willingness of GPs to use them as a means of avoiding the necessity of more difficult, ambiguous, and (heaven forfend) expensive options of various talking cures -- and thanks also to society's unwillingness to address some of the systematic social causes of sustained unhappiness of women.

If there is a fair old chance that the pills are being unhelpfully prescribed, then we don't want the bad effects of that to be compounded by inattention to the full range of risks.

(I say this without wanting to distract from the fact that they are sometimes very helpful indeed, and should then be as fully available to women as the evidence suggests to be safe)

ButThereAgain Thu 04-Jul-13 10:05:13

Oh, sorry for posting marathon but I also wanted to add my voice to those who have praised doctors for talking in a sensible and unpatronising way to pregnant women about the various risks. That has been my experience. After my first pregnancy, and while I was breastfeeding, my consultant even went so far as beginning a dialogue with Seroxat's suppliers about the possibility of my taking the drug. At the time, it wasn't approved for use while breastfeeding but she was trying to move things forward on my behalf. It didn't work, but that was because of the state of knowledge at the time. (I was also excluded from giving blood, an exclusion which has since been lifted.)

I do usually find that my GPs are respectful of my choices almost to a fault. Just sometimes I want to say to them "Tell me! Just tell me what is right and I will do it!" But they persist in carefully explaining the pros and cons and leaving the balls in my court. grin

I don't think my interests would be served by an unwillingness to present negative information about a medication for fear of playing into a increasing possibly increasing cultural willingness to view pregnant women as containers for rights that trump their own. That would just further reduce my capacity to make autonomous choices.

AmandaPandtheTantrumofDoom Thu 04-Jul-13 12:39:23

Edam - I agree with what you've said about treatment. I don't have personal experience of prescriptions or care of this nature, so I was responding directly to the statements of the Dr on the programme, and he (unless he was very unfairly edited) seemed to be suggesting that women should be treated as pre-pregnant throughout their child bearing years, not (as I agree must be the case) that they should be warned of the potential effects and risks of the drug on a fetus should they plan a pregnancy or accidentally become pregnant. I totally agree pregnancy must be part of the complex discussion about medication choices, but he seemed to be going that extra step and suggesting that the doctor should be considering potential pregnancy without, you know, engaging the patient with that (again, unless he was unfairly edited).

working9while5 Thu 04-Jul-13 12:45:46

There's nothing wrong with the continuing assessment ButThereAgain, but the programme totally hyperinflated the risks of taking the drugs vs not taking them. When you start saying a risk is "doubled" but the doubling is from .5 to 1%, you are still talking about very tiny numbers that don't need to be hyped up when there's a 68% risk of a woman with recurrent depression relapsing without them.

I was told by my GP that it would be irresponsible to take ADs in pregnancy. Despite having a crisis and being sent to the perinatal mental health team, that stuck in my head (as negative information about risk is inclined to do when you have OCD like I do) - and I didn't take them. I was in a very bad way before birth and I am still signed off work (though nearly there, I think) and my son is 1 year old. It's been tough.

Again, my issue is with the way it's been put out: "pregnant women risking their unborn children's lives" vs worrying information about some of the drugs prescribed to pregnant women. Who is the agent of this here?

edam Thu 04-Jul-13 17:20:19

amanda - I don't think it's just about warning women of the risks, I think doctors need to pay attention and be aware of the risks in the first place, and then if possible avoid prescribing a teratogenic drug to a woman of childbearing age without good reason.

Doctors should never use Epilim as a first-line treatment for epilepsy in women of childbearing age unless they have a very good reason that has been discussed with the patient - in someone who is newly diagnosed and hasn't tried any other anti-epileptic drugs, you try something safer first.Just in case.

Why start with a drug that is known to cause foetal malformations in a woman of childbearing age? They should only even consider this if every other anti-epileptic is unsuitable - the latter would be a very rare case indeed. (Or, I guess, if the woman is 100% infertile - not just a history of fertility problems but something definitive such as having had a hysterectomy.)

NancyConnie Thu 04-Jul-13 18:48:52

I just want to reiterate the importance of all women accessing their GP and MW so an individual plan of care is agreed and women are informed.

AmandaPandtheTantrumofDoom Thu 04-Jul-13 19:23:46

Edam - Sorry if I wasn't clear. What you have written about is exactly what I meant when I said 'complex discussion about medical choices' and my reference to warning was meant in the context of an otherwise best choice medication having contra-indications of that sort (and, of course, the woman may then choose to have the next best without such issues, and you'd really like a situation where there is an equal alternative).

My real issue with this is that the Prof seemed to be saying that, when a patient walked into the surgery with mild/moderate depression, for a male patient they should see a male patient, and for a female patient they should see a woman and possible fetus. I think that this is fundamentally wrong. Yes, potential pregnancy (planned or unplanned) is very much part of what should be considered when working with a woman on her treatment plan. But, especially in relation to depression, I think it is dangerous to effectively create a 'two person patient'. With one of those patients being hypothetical. It should be part of the picture. Like medical history, family history, lifestyle and ability to manage a treatment plan, all the other things that get taken into account.

I also disliked strongly the implication (again, it could be bad editing) that you just wouldn't prescribe anything. Because, you know, it was only moderate.

edam Thu 04-Jul-13 20:37:23

I think we are pretty much agreeing - it should be a routine part of the picture, like your own medical history and family history etc. etc. etc.

NiceTabard Thu 04-Jul-13 20:58:04

If you look at the BBC article and the interview shown on that report - which many people will have read and seen - the message comes across in a very straightforward way. Alternatives are not mentioned and what the Prof seems to be saying is that in all women of childbearing age, considerations of their care should be secondary to that of a hypothetical foetus.

In case anyone hasn't seen the BBC piece and the clip, link is here.

Women taking anti-depressants is compared by the prof to smoking or drinking alcohol:

""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," "

The way he is talking about it is as if women are taking ADs for a bit of fun and should be warned against that as they are drinking and smoking in pg. But surely taking ADs isn't a lifestyle choice, it's a medically prescribed treatment and the correct approach (assuming there is a genuine risk) is to alert HCPs and to warn women that if they are thinking of having a baby to go and see their doc (as happens with many other medications).

Read the link and watch the clip. A lot of people are assuming this has been reported in a reasonable fashion, and that the Prof speaking is coming at this from a caring HCP perspective. That was not the gist I got from the piece or the interview linked (hence starting a thread about it).

NiceTabard Thu 04-Jul-13 21:01:37

More explanations of why people are narky about this on the thread here

aliphil Thu 04-Jul-13 21:38:28

I was told no ADs in pregnancy, and all the NHS would do was refer me to counselling with a useless agency (now no longer used because they were so bad). When I went back after DD was born, I was told no ADs with breastfeeding, and I would have to choose between them. Fortunately by that time I was together enough to do a little research, and spending five minutes on the NHS website informed me that the GP's statement about it never being possible to combine bf-ing and ADs was incorrect. I have been on sertraline for about six weeks now, and it has made a huge difference. I have more energy, I can play with DD, I don't shout at her nearly as often, and I can feel real love towards her now rather than a mixture of irritation and indifference. And I "only" have mild PND ...

NiceTabard Thu 04-Jul-13 22:09:52

Aliphil I am glad you are feeling better smile

There is also evidence that stress during pg can adversely effect the baby, as, TBH, a million other things. I can't think of how it's possible to be more stressed than pregnant with anxiety / depression and not able to access / not feeling you ought to access medication. Sometimes wheatgrass drinks and a spot more exercise just don't cut the mustard, unfortunately. It took me a long time to go to the doc but the drugs (low dose SSRI) made all the difference in the world.

While I agree with others than taking potential risks into account is always the right thing to do, and to consider everything about the patient, I think this runs to scaremongering. The risk is doubled from pretty low to still pretty low. There is no mention of using other treatments. There is a comparison to alcohol and tobacco. It smacks, to me, of that recent advice that said to avoid pretty much everything when pregnant as potential risks are not known. It's not helpful.

AmandaPandtheTantrumofDoom Thu 04-Jul-13 22:27:55

I agree nice. I also think you aren't comparing SSRIS to healthy mother who doesn't take SSRIs - which is what reporting implies (like smoker/non-smoker). It's a more complicated picture.

Woofers Fri 05-Jul-13 00:05:45

I feel I ought to post, I did not watch the bbc programme on two counts.
1 I'm 32 weeks preg and what I have taken is too late to worry about
2 these programmes always sensationalise the evidence and IMO do not show the other robust worldwide data.

Helpfully my MIL called me to tell me it was on and that I might find it 'interesting' but 'don't be alarmed'. I interpreted that as you should watch this so you can feel abit more guilty about taking drugs for something which isn't real - you just need to pull yourself together

As I said, I'm pregnant. I take sertraline. When I began taking ad's I had to work my way through a few to find one which works for me. Each time I asked and was given journal articles about the risks in preg and bf. my gp has a specialist interest.

I will Find a link to the journal of American psychology who did a meta analysis of several women on ads vrs the same number not on ads and the result was that there was little risk.

Throughout my preg I have had increased monitoring of both baby and mood. During weeks 18 - 24 I was so sick that I was unable to take my medication. I really did fall hard into a depression. I told my gp that I didn't want to be preg any more that I was fed up of being so so sick that I had to have an abortion but by doing that everyone would hate me so could she sedate me until it was time to give birth. As I said. I was unwell.

I don't drink. I don't smoke. I don't do recreational drugs. I'm fit and active. I eat 5 a day and I am longing for Brie and Stilton.

Depression is not a lifestyle choice. I don't choose to take these meds. I have to.

ButThereAgain Fri 05-Jul-13 08:50:30

Isn't there a danger that any presentation of AD drugs as a "lifestyle choice" is being doubly exaggerated here by a need to present provocative copy/programmes/etc? Exaggerated once by the media presentation of the research (Panorama) and then again by a desire to blog about that programme compellingly and polemically, in the face of the overmonitoring by society of all of women's choices while pregnant (and the terrifying additional background in the US where women in some areas seem demoted by legislation to the status of mere vessels.) Should we try to keep that pernicious background of overmonitoring a little bit more distinct from our reaction to this specific issue of a drug that is potentially harmful in pregnancy?

I think it is important not to forget the history of SSRIs. When they first came out, as Prozac (in the 80s I think?) they were pushed very very hard by the company that produced them; the surrounding hype created an impression that almost anyone who ever felt unhappy could benefit from them -- they were said to make you "better than well." For depressive patients they sure as hell aren't a "lifestyle choice", but there was certainly a lot of commercial pressure to present them as such. And we still see pressures to shape mental health diagnosis in support of commercial interests of drugs manufacturers: the American Diagnostic and Statistical Manual is fraught with controversy about the creation of medicalised labels for any state of being that might produce a selling opportunity for a drug. And while I hope GPs are more cautious now in their prescription of SSRIs than was perhaps the case in earlier decades we still have the problem that SSRIs are a ready option available in situations where they might not always be the best solution for the patient. They aren't a "lifestyle choice" of individuals but they are at least sometimes prescribed because of a social/cultural context which has influenced their career far more than other drugs have been influenced in this way.

What worries me a bit is the media pressure (both the broadcast media and here on Mumsnet too) to package up uncertainty and discussion in the kind of dramatic controversial terms that generate the audiences they need. That undermines our ability to monitor developments and make the kind of authentic informed choices we need to make. There are pressures of several sorts to prescribe these drugs more often than is necessary. And any new research about potential risks needs to be viewed in the light of those pressures. It would be a shame to lose sight of that just because of a more generalised fury about society's oversight of pregnant women's choices.

I'm speaking as someone who has been on these bastard drugs most of the time since they came out, and who has often tried hard to come off them. They help, but they don't help enough to stop me being constantly regretful of their downsides.

(Just on a point of detail, this discussion has tended to use "anti-depressant" to refer specifically to the SSRIs t which the recent research presumably relates. But presumably the older generation of anti-depressants are still around, still being prescribed, and are an option that GPs can discuss with pregnant women?)

notcitrus Fri 05-Jul-13 09:30:10

Butthere - yes, tricyclic ADs are still around, but I've found that GPs younger than about 35 are scared to prescribe them because they've been told to use SSRIs. I've taken tricyclics every winter since before SSRIs came to the UK, and moved a lot, so that's at least 30 GPs, half of whom have gibbered a bit and sought out the senior GP/refused to prescribe and referred to a psych/phoned a psych/eventually given in when I've quoted all the research at them.

Especially when pregnant - I'd previously been told to take them if needed, after a non-pregnant year trying to avoid them. Thankfully with ds I stopped taking them before finding I was pregnant, so non-issue, though new GP argued I shouldn't take them while bfing (told him off, took them). With dd I was 5 months pregnant, went to get scrip when my stash ran out, and was told by a new young GP, "You are putting your unborn child at risk; I will not prescribe these."

Luckily I acquired a huge arsy streak with ds and told him that actually I have a PhD in embryonic neurobiology and am familiar with the teratology database and all other research on the effects of lofepramine in pregnancy, and clearly all he knew was Computer Says Hmmm - so made him get the BNF out. Which does at least now say fine for bfing but wanted a referral to experts for pregnancy. Burst into tears in waiting room and lovely receptionists had a word, got me to see a MW that day, who phoned the psych, whose message back was "Take the tablets and tell everyone to chill out already"!

For reference the only cases of birth defects associated with lofepramine I found were where the woman had also taken heroin, cocaine etc. Which is way better than SSRIs. Thing with tricyclics is loads of people can't hack the constipation and dry mouth, especially if they get constipation when pregnant. Though people on SSRIs seem to get stomach upsets...

As working9to5 points out, doubling a very low risk is still a very low risk, but makes for scary headlines - Ben Goldacre and others campaign against this scaremongering presentation of risk, but newspapers are never going to go for headlines "Pill ups risk from 1 in 3000 to 2 in 3000", especially when "risk of X in pregnancy is 3 in 3000"!

nanonagle Fri 05-Jul-13 12:24:04

This a very good article. And it comes back to the autonomy and standing of any childbearing woman to have charge of her own condition, every time.

NiceTabard Fri 05-Jul-13 19:27:06

It was the Professor himself who compared taking ADs to smoking and alcohol, and that women should be "discouraged" from taking them (as if women are taking them by choice off their own bat rather than being prescribed them for a medical condition), rather than that being the media spin:

"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"

He says it in the clip embedded in the BBC link.

ButThereAgain Sat 06-Jul-13 08:36:33

Yes, and that was certainly an offensive and misleading thing for him to say. But can we jump from that utterance to the view that many health professionals, or even he himself, regard the use of ADs as a "lifestyle choice", or as someone said above a "bit of fun," or in any other manner that is dismissive of the medical needs of depressive patients, or that downgrades them in relation to their foetuses/babies?

If pressed on what he said I guess he might say that what he meant was that SSRIs are powerful potentially dangerous drugs that shouldn't be taken lightly, and that they are nonetheless arguably overprescribed, and sometimes prescribed too lightly, perhaps for cultural, social, historic reasons as well as strictly medical ones.

These reasons might include the commercial pressures exercised by the manufacturers, the difficulties for GPs in spending the time and money to work out alternative treatment strategies where ADs aren't necessarily the best option, and the particular difficulties of treating conditions where there is of necessity a heavy reliance on patients' self-reports. (Regarding self-report, even after years of AD medication I feel unsure if they are actually helping my condition or simply covering its most obvious symptoms: it is very hard to self-monitor the effects of medication, very different from the comforting reliability of a blood-pressure number etc.)

It makes sense in discussions like these to interpret opponents' words in the manner that makes those words most plausible: we make our own best cases when we respond to the best case we can make for others' words.
Our rightful anger at the wider cultural context of overmonitoring the choices of pregnant women, seeking to suppress abortion rights, and so on, means that we sometimes need to speak more polemically, and to seize on unflattering characterisations of the opinions we argue against but in a discussion like this, that seems possibly out of place.

NiceTabard Sat 06-Jul-13 09:59:54

But the Prof is an expert for NICE and was talking about forthcoming changes to the NICE guidelines.

What he said was incredibly stupid, and he said it as the expert on this who is involved in making the rules. He's not just some random off the street. I think it is reasonable to assume that he meant what he said when he was interviewed. And I think that what he said (and the way it was reported) was dangerous scaremongering.

NiceTabard Sat 06-Jul-13 10:01:33

Sorry missed a bit.

Dangerous scaremongering with an apparent total lack of interest in dealing with women as actual sentient beings with rights, and a stated large interest in treating them as "pre-pregnant" from puberty to menopause.

edam Sat 06-Jul-13 11:29:15

I think this is a bit like the outrage when Professor David Nutter pointed out taking ecstasy was no more dangerous than horse-riding. He was right - horse-riding is a dangerous sport (as is ski-ing) yet it is seen as OK while taking E is portrayed as incredibly dangerous. (Of course there are other aspects inc. legality, but in terms of pure risk he was right.)

This Prof was saying there are X, Y and Z things that may have risks for the developing foetus. Ignore the fact that some of them are regarded as 'bad' anyway. Just look at the relative risk and consider why it is that X and Y are treated as huge no-nos in pregnancy, yet Z isn't (generally, there are some foolish health professionals who know fuck-all about psychiatry who make an incredible fuss about any pregnant woman on ADs - my sister came up against some of these, despite having carefully considered and discussed all the evidence with her GP and midwife).

Possibly because Z is backed by big drug companies who have an interest in playing down any evidence of risk -as they did with Seroxat and suicide. And because our baseline assumption is that smoking and drinking are inherently bad.

That doesn't mean all ADs are evil and women who need ADs should be immediately stopped from taking them. It does mean more careful consideration of the advice given to women, more research on the potential effects, and more discussion with women on ADs who are planning pregnancies or who become pregnant. Just as my doctors discussed epilepsy medication with me.

MrsCurly Sun 07-Jul-13 19:57:20

Thanks Edam you put that much better than I could. Couldn't agree more.

edam Sun 07-Jul-13 19:59:14

Thanks MrsC - I happen to know a bit about the Seroxat scandal through work so it's something I feel strongly about.

ButThereAgain Mon 08-Jul-13 08:54:34

Yes, I like that way of putting it too. He's only saying that X, Y, and Z are similar in a certain respect: they are all activities which are fairly widespread, possible risky in pregnancy, and capable of being productively addressed by being routinely raised as cause for thought in consultations with pregnant women, or women about to try and conceive. To call things similar in certain relevant respects isn't to imply a similarity in other respects (in this case, it isn't to say that they are all "lifestyle choices" etc.).

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