The tropical storm whipped the palm fronds outside into a frenzy, while inside my elementary school, I was getting whipped into a frenzy, as well. I overheard someone say that if a hurricane hit, we’d all be under water. When I finally got home, my tiny, five-year-old body bolted through the house, ripped open the sliding glass doors and dragged everything from the backyard inside—my toys, even my brother’s toys. My panic knew no toy ownership, only that we were going to all be drowning any moment and all toys should be saved.
From that first anxiety attack on, I struggled with more anxiety, depression, and obsessive compulsive disorder. I did all sorts of talk therapy and took a variety of medications to remedy these afflictions—some worked, some didn’t. At 30, I finally found Wellbutrin XL. It was like somebody turned down the static in my brain. I could finally hear myself think. So when I found out I was pregnant six years later, I knew that I would not go off the medication. Not even if there was a slightly elevated risk to the health of my developing fetus. I was terrified of losing the tentative sanity I’d spent so long establishing in order to create another person, one who, more than anything, needed a caretaker who was stable enough to love and nourish them.
Since many antidepressants, in limited testing, show a low risk to fetuses, doctors often let pregnant people choose what they want to do. There isn’t a wealth of information on the subject because almost no one wants to test drugs on pregnant or nursing parents. You cannot Google your way to the right answer. This means that these decisions cannot be made based just on facts. They have to be made largely on priorities. The thing is, there is no way to be risk-averse while pregnant. Being pregnant is itself a life condition that is inherently risky.
On June 30, 2015, the FDA did away with the risk classifications A, B, C, D, and X for drugs in pregnancy. These assessed the risk of injury that pharmaceuticals taken during pregnancy could have on fetuses, ranging from A: “No risk in controlled human studies” to X: “Contraindicated in pregnancy.” The agency implemented the Pregnancy and Lactation Labeling Rule (PLLR) adding specific pregnancy and lactation subsections to include information (when available) on the effects of medicines on pregnancies and nursing babies. The site notes that half of the 6 million people who get pregnant in the U.S. each year take medications of some sort. According to the CDC, one in nine people experience depression before, during, or after pregnancy, and the National Institute of Mental Health puts the number for postpartum depression at 15 percent of births. There are likely many unreported cases. Stress in pregnant women can cause negative outcomes for the fetus, including premature births and low birth-weights. None of the options for depressed pregnant people are totally ideal.
“It’s not one size fits all here,” says Katherine Economy, an obstetrician-gynecologist with a focus on maternal fetal medicine at Brigham and Women’s Hospital in Boston. “It’s always a very personalized discussion. Each woman is different, their exposure to SSRIs are different.” She’s referring to selective serotonin reuptake inhibitors, a category of drugs usually prescribed for depression and anxiety and considered fairly safe for pregnant women to take. Wellbutrin, the drug I take is an atypical antidepressant, a norepinephrine-dopamine reuptake inhibitor (NDRI). “For some women [antidepressants] are life changing, and they can’t do their activities and everyday living without them,” Economy says. “If they have high blood pressure, you leave them on their hypertension medicine during their pregnancy. I think women who have mood disorders, if they are significant enough, they absolutely should stay on their medication.”
Not every physician feels the same way. Both of the psychiatrists I saw during my pregnancy had differing opinions on what drugs I should or even could take safely. When I called my psychiatrist to tell him that I was pregnant, the nurses called back with the message: “Go off everything immediately.” I was shocked that such a nuanced question would be handled in such a flippant, commanding manner. I demanded he call me back himself. When we spoke, I told him that without me, there would be no baby, and I needed to be medicated to function under the stressful transitions pregnancy brings. A few months prior, I had undergone a major depressive episode and my dose was increased. I told the doctor that I would go back to the lower dose, but I would not go off the medication entirely. He agreed. Months later, he told me I couldn’t take my medication while nursing. I knew that if I had to choose between being medicated or nursing, I was going to choose to be medicated. How could I care for a newborn while not taking care of my own mental health? Luckily, another psychiatrist kept me on my antidepressant while breastfeeding, but drew the line at anti-anxiety medication.
When you become pregnant, your body is no longer yours. Rather, it is a screen on which everyone projects their expectations of a gestating human. You are infantilized as people tell you how to act so that you are the best incubator for baby—in their opinion. I knew that I could not be a healthy mother to any child if my depression and anxiety were not being treated. I didn’t quite care what anyone thought about my decision, I was certain that I needed to be medicated to be the best mother I could be. I could not erase myself from the picture of my pregnancy. And physicians aren’t immune from this projection—for every woman’s situation, it seems there is a differing doctor’s opinion.
“Everybody gets a little freaked out by pregnancy,” Economy says of her colleagues. “There’s a lot of general fear when non-obstetricians and non-maternal fetal specialists take care of pregnant patients.” Her focus is on high-risk pregnancies. She sees women with more intense physical ailments and works closely with the patient and other specialists to determine the best course of treatment. To totally avoid any major birth defects that could potentially result from taking antidepressants during pregnancy, she counsels the most concerned patients to go off of their medication during the first trimester, when the risk is greatest. Or if a pregnant patient is on a newer antidepressant that hasn’t been tested, she might put them on a more tried-and-true drug.
Agnes Fulcher Smith is a 38-year-old emergency room nurse who was prescribed a low dose of Zoloft for situational depression two years prior to becoming pregnant. “My OB-GYN said it was safe to take, that they preferred us be ‘happy and pregnant,’ is how she put it. I decided on my own to come off of it,” she explains. “I wanted an all-natural everything—like organic foods, no meds. All the good stuff for my baby.” She went off cold turkey and is currently pregnant for a second time. “Due to being ‘advanced maternal age,’ I wanted to eliminate any chances of affecting the baby's development or causing any birth defects,” she reasons. She says she was taking medicine to deal with the anxiety that resulted from a difficult personal relationship. The only way she would have stayed on Zoloft while pregnant, she says, was if she felt like, “it jeopardized my sanity or if I had feelings of wanting to hurt myself or the baby postpartum.”
In the case of another nurse, Jaclyn McComb, antidepressants helped her deal with the trials of getting and staying pregnant. Like myself, she spent years on and off medications to deal with her anxiety and depression. When she met her husband, she was “in a good place,” she says, and not taking medication. She got pregnant on their honeymoon and only felt her depression return after coming home. She started to feel like she should go back on medication. “And then I lost the baby. Three days later we moved to Texas from San Diego.” She remembers being a “hot mess.” When she arrived, her job there fell through. When she went on her husband’s medical insurance, she started to see a therapist and also began trying to get pregnant again. “She referred me to a psychiatrist, because I was asking her about what meds were safe for pregnancy,” McComb says. She was also prescribed Zoloft. “It started making me feel better and things started looking up. We discussed how the stress level of being off [medication] can affect the pregnancy.” Miscarriages can be caused by a number of things, including chromosomal abnormalities, which hers was not. She worried that the stress she was under at the time caused the miscarriage. Zoloft eliminated that concern. After three rounds of in-vitro fertilization, she became pregnant. Her three-month-old daughter is healthy and doing well.
McComb and I both had to get some additional tests while pregnant to be sure that all was well. This included a few additional ultrasounds for us both, and I also was administered a fetal echocardiogram, because one study indicated a possible increased chance of a heart defect in babies with mothers taking Wellbutrin.
People with mood disorders are also at higher risk for postpartum depression, postpartum anxiety, and even postpartum psychosis. Economy—the Boston OB-GYN—encourages all of her patients to breastfeed as one way besides drugs to mitigate this risk. She notes that breastfeeding promotes mother-child bonding—thanks to the hormone oxytocin released during nursing—and has health benefits both short- and long-term for child and parent. Studies show that breastfeeding decreases the risk of, may protect new mothers from, or shortens the length of postpartum depression. That’s why Economy usually leaves them on their medicine while they’re nursing. She says, in most cases, “the overall benefits of breastfeeding vastly outweigh the small amount of medication that is excreted.”
All of the reasoning and debating on this subject made for a pretty good exercise in pre-parenting for me. When I look at my bright-eyed, vibrant, and very well-breastfed baby, I know that I made the right decision for us both while pregnant. I still wonder, on days when I am extremely anxious, if I should discontinue nursing so that I can increase my medicine or take anti-anxiety medication. I recently began seeing an acupuncturist for my anxiety. It’s helpful, but acupuncture is not Klonopin.
Not knowing what the “right thing” to do is a huge challenge for parents, and the insecurities that result from the necessity of making imperfect choices are one reason why people so harshly judge each other’s parenting decisions. Life is full of risks, and “undesirable” outcomes aren’t something we can control, not with an unmedicated birth or a medicated pregnancy. There is a period postpartum when the baby doesn’t know that it is an individual; the newborn thinks you two are the same. My baby was, especially in that time, my mirror. I am wholly responsible for us both. In my first decision as a parent, I weighed the risks and benefits, and decided that the way to keep us both healthy was to treat myself as I would treat him.