Wednesday, October 7, 2009

How women deal with depression during pregnancy

by Amelia Thomson-DeVeaux

I was surprised and pleased to see this article in the NYT yesterday, discussing the unspoken taboos surrounding depression during pregnancy. I actually wrote a paper on pregnancy advice books last semester, focusing specifically on the language that the books used to advise pregnant women on putting substances (medication, alcohol, and food) into their bodies, and although post-partum depression was fairly extensively covered (thanks, perhaps, to Tom Cruise and Brooke Shields), there was barely a mention of what women should do if they were taking anti-depressants before becoming pregnant, or if they became depressed during pregnancy. There is such a proscriptive language surrounding what pregnant women should ingest during pregnancy that this isn't surprising - most pregnancy advice writers would have women forget about their own bodies entirely, and concentrate on what would most nourish the fetus. There is a gaping absence of any advice about what expectant mothers should do for themselves.

The problem is that if there is any chance of danger to the fetus because of a particular medication, like anti-depressants or even asthma medication, most people advise pregnant women to refrain, "for the good of the baby." The idea that it might be more important for the mother to be happy and healthy rarely enters into the picture, which is why anti-depressants seem unfeasible to most pregnant women. Disappointingly, the NYT did not really interrogate the social taboos of pregnancy (something I've written about, particularly with respect to alcohol, several times on this blog), but they did begin with a telling story from a mother-to-be who eloquently describes the dilemma that pregnant women face.

“Every single thing you put in your body when you’re pregnant, you wonder, ‘Oh, my God, am I growing my baby an extra finger?’ ” Sherean Malekzadeh Allen said. “I was worried that I would hurt the baby if I took the pills, and I was worried I would hurt the baby if I didn’t.”

There have been connections between heart defects, fetal malformations, and pulmonary hypertension in babies and anti-depressant use in pregnant mothers. But the risks surrounding anti-depressants are relatively low. The APA and ACOG both agree that therapy should be the first recourse for pregnant women suffering from depression, but also recommend that decisions should be made on a case-by-case basis. Their research is full of caveats, and I'm not sure how much it will do to shatter some of the paralyzing guilt that is placed on pregnant women who might be in need of anti-depressants, even though it might actually be more harmful to the fetus to refrain from taking them. And indeed, according to the NYT, "studies have linked depression during pregnancy to premature births, growth changes, and irritability and inattention in the baby after birth."

The bottom line is that undertreatment is the main issue. “By the time I get to hear about somebody’s perinatal depression,” said Dr. Shari I. Lusskin, director of reproductive psychiatry at N.Y.U. Langone Medical Center, “it’s usually worse than what can be treated with psychotherapy alone, because women go out of their way not to complain; they don’t want to be put on medication, and they feel guilty."

I can attest from my extensive reading of pregnancy advice literature that the guilt placed on pregnant women is pervasive and powerful; I always think of a line from What To Expect When You're Expecting where the author instructs women to, "as they lift fork to mouth," to think, "is this a bite that will benefit my child?" Where are the pregnancy books telling women to do what they need to do to have a happy, healthy pregnancy? Where are the acknowledgments that maternal and fetal health are intimately connected? This article is a good first step, but we need far more information - and far less proscriptive rhetoric - before pregnant women will be able to make healthy decisions for themselves, guilt-free.


At October 7, 2009 at 1:45 PM , Blogger Jay said...

I wasn't pregnant, but I suspect I would have hated that "What to Expect" book as much as I hated "What To Expect The First Year", which was a gift when my daughter was born. Grrr.

There are a number of studies showing that for most people with depression, if it's caught early, therapy and meds are equally effective, but there is a strong financial pressure to use meds. Meds are covered by insurance; therapy is not, or at least not to a degree that's helpful. This adds significantly to the problem described by the psychiatrist, as does the continued stigma associated with seeking psychiatric care. And then there's the terrible struggle women face when they do not react with unalloyed joy to what is billed as the signal event of our lives. More guilt.

In addition, very few non-psychiatrists are actually good at using meds appropriately (and I say this as a doc who practiced primary care for 20 years, and did a lot of such presribing). Some OBs know what they're doing. Most do not.

Oh, for a truly integrated practice with therapists and psychiatrists available in the same space as primary care and OB, and true collaboration.....

At October 8, 2009 at 8:55 PM , Anonymous Angela said...

Single motherhood is economically attractive in Scandinavia, as it is not here. Evidence confirms the common assumption that separation is a recipe for disaster for most women in the U.S. In Scandinavia, they maintain their incomes, thanks to their government-sector jobs, child support, and, if income is low, housing subsidies. One may say, therefore, that Nordic women in many cases divorce or leave their husbands/boyfriends and marry the state instead.

What we need here is for the government to create lots of new woman-friendly jobs and allow women to be reliant on the state rather than Patriarchal men.


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