Emily Dossett, MD, is a psychiatrist focused on helping women with anxiety, depression and other mental health challenges achieve happy and healthy pregnancy and postpartum periods. She is a professor of Psychiatry and Obstetrics and Gynecology at the Keck School of Medicine at the Los Angeles County and University of Southern California Medical Center. She is also the Medical Director of the Los Angeles County Perinatal Mental Health Task Force, a non-profit consortium dedicated to championing perinatal mental health for all women in the region. Dr. Dossett also works with women and families in her private practice in Pasadena. She can be reached at firstname.lastname@example.org.
Pregnancy, Mental Health and Medications:
Questions and Answers
By Emily Dossett, MD (as told to Hailey Murray)
Many women take medications for depression, anxiety and other mental health conditions. In your experience, what happens when those women become pregnant?
If a woman has depression or anxiety to the point that she needs to be on medication, when the time comes to get pregnant the typical message she hears is “you should stop the medication.” Sometimes that message comes from the media, often she’ll hear it from her care providers, and she may also hear it from her family and friends. It’s enough to make many women terrified and think “If I stay on my medication, I’m a bad mother. I’m hurting my baby from the very beginning,” and that’s a hard feeling to counter. Of course, the last thing any woman wants to do is hurt their baby! But so much of that fear is based on stigma and misinformation.
How difficult is it for women to find care providers who are up-to-date and informed regarding mental illness and pregnancy?
It can be very difficult. Many women have problems accessing good information even if they’re already seeing a psychiatrist. Unfortunately, the way that psychiatric training and residency programs are carried out right now, most psychiatrists have very little training in reproductive psychiatry. A lot of psychiatrists will advise women to “just go off” their medication(s) if they’re pregnant or they want to get pregnant. When you combine that with OBs who’ve had even less training in reproductive psychiatry and just managing mental illnesses in general, it becomes very hard for women to find care providers who can help them feel comfortable making informed choices about their medications. Thankfully, there is a growing acknowledgement and comfort level with mental illness in perinatal women among health care providers, though we have a long way to go.
That sounds like a chorus of voices saying “stop taking your medication.”
Yes. Combine it all and it’s easy to see why many women feel they have no choice but to stop. They hear so much well-intentioned advice – it is well-intentioned, no one wants to hurt a baby – telling them “just stop.” And there’s their own voice; their own fears that they could hurt their baby in some way. Then there’s a simple lack of access to providers who feel comfortable giving women options. I also see a generally held belief that when you get pregnant, you should stop your antidepressant. I believe many women internalize that belief well before pregnancy is even on their radar.
Let’s move on to pregnancy. Do you believe it’s challenging for a pregnant woman to voice that she’s struggling?
Absolutely. When we do trainings on this we talk about ‘the myth of pregnancy.’ As a culture, we have this expectation that a pregnant woman is supposed to be happy, glowing, feeling fabulous, joyfully preparing the nursery… but no pregnant woman feels that way 100% of the time, even if they’re not depressed or anxious. For women who do struggle with depression or anxiety, that myth just makes them feel that much more ashamed. I think we’re also in a culture now where mothers are expected to do everything perfectly – to be a good mother, you have to eat all-organic, you have to exercise five times a week… those ideas can be helpful, but they can also backfire when a woman feels so much pressure to do everything perfectly that if she can’t, she then feels like she’s failed.
What about postpartum?
I think ‘the myth of pregnancy’ also carries over into ‘the myth of new motherhood.’ You’re supposed to be happy and cheery and breastfeed exclusively and from the very beginning, and then make your own baby food… all these ideas about ‘the right way.’ And again, even for a woman who is not depressed or not anxious, it’s not that way all the time, and for a woman who is depressed or anxious the shame is just tremendous. It’s hard to speak up. Even the people who are around a new mother and notice that she’s struggling often say things like “this is normal, this is how it is for everybody.” Most women do experience the baby blues, that’s a very normal phenomenon. But there are a significant number of women who have feelings postpartum that are not normal, and they’re almost made to feel that their feelings are not significant. They’re just given this message that it’s normal and think “I shouldn’t complain, I should just get through it.”
But “getting through” postpartum depression is not easy…
No. It’s a really scary time for women. And it’s a really scary time for husbands, and partners, and friends, and everyone around a new mother. I see a lot of confusion in families about what’s going on – is it just the baby blues or is this not normal? – and then about what they should do.
That’s an interesting point about family confusion. I’m often struck by how quickly the media brands a mother as “evil” because she did something that could have or did harm herself or her children, when so often the people close to that mother report that they’d seen multiple warning signs that she was struggling or “wasn’t herself.”
Of course, it’s tragic when a woman acts because of her mental illness in ways that may harm herself or her children. But what is really unfortunate about those media reports is that they only add to the stigma around postpartum depression and mental illness. I see women in my office who say, “I’m worried I’m going to go crazy like…,” and they’ll name someone who has been in the news. It feeds on that fear.
You’re on the front lines in this battle, so to speak. How do you work to reduce that fear?
I do a lot of pregnancy and pre-pregnancy consultations. Either way, reproductive psychiatry is like any other kind of psychiatry, there’s no single answer that fits everybody. It’s important to understand each woman’s history and what they’re dealing with, and we talk about whatever they’re taking – Prozac, lithium, lamotrigine, whatever it is – and have a conversation about what to do, whether they are already pregnant or, ideally, pre-pregnancy.
I try to emphasize that yes, there are risks with medications, and I break those risks down medication by medication, but I also talk about the risks of going off those medications. There is the risk of relapse, and if you do relapse, these are the risks of untreated illness for yourself, for your fetus, for postpartum, and for the ongoing development of your child. I think it’s that risk of untreated illness that is not brought up for the most part when women are getting prenatal care. Everyone is very frightened of the medications, but the reality is that untreated illness has very well documented negative effects. I think we best serve women by giving them all the information we have that’s up-to-date, and then really letting them make their own choices. And I’ve seen it – I’ve seen women in very similar situations make completely different decisions about what to do. I also try to emphasize that there are many strategies for managing mood or anxiety disorders beyond medications, including psychotherapy, increased social support, and moderate exercise.
What would you say a woman needs to do to be informed and empowered regarding mental illness and pregnancy?
The best thing she can do is try to get all the information she can. And she should try to get it from sources that are going to give her a valid, up-to-date perspective. I’d also encourage her to seek out this information as soon as she can – ideally before pregnancy. I’d like every woman who has struggled with a mood or anxiety disorder, or worries that she will, to make a plan that she and her partner feel comfortable with that can carry her through pregnancy, into delivery, and through the postpartum. That road map might include medication, therapy, physical support, social support… And I’d really want her to know and to feel confident that with the right planning, women with even the most serious mental illnesses can do really well in pregnancy and as parents.
I like that you said every woman should have a plan.
Yes. Every woman would be ideal. Of course if you have a history of mental illness or there’s a history in your family, it’s especially important to have a plan. But every woman needs to be informed. She needs to know, for example, that postpartum depression can happen to anyone, but with the right knowledge and support, it can be prevented or treated. Just opening up the conversation helps remove the stigma, and there shouldn’t be a stigma any longer.