August 2, 2007

More on meds and breastfeeding

Well, I've been e-mailing with a woman who wasn't at all happy with me after reading my previous blog on anti-depressants and breastfeeding. (She gave me permission to write about our communication on this blog.) She shared with me her experience of suffering from bipolar disorder and being on medication for it since she was a teen. When she and her husband were trying to get pregnant, she went off her meds. But by the end of her first trimester, she was having an absolutely horrible time so her doctor advised her to go back on her medication. She did so and went on to have a symptom-free, wonderful full-term pregnancy. Her baby is now nearly six months old and she's breastfeeding her baby and doing just fine. She feels very good about her decision to remain on medication and knows that she needed to do this in order to function and to be able to take care of her baby. She said she felt like she needed to defend her decision after reading my last post and make it clear that other moms shouldn't feel guilty about the decisions they make.

I absolutely agree with her. I applaud her for handling her illness so incredibly well and being so strong to know her options and then to choose the best one for her and her baby. Taking charge of our own health care is what each of us needs to do. The big stumbling block here, that I was trying to express in my previous post, is knowing our options. Often we're given information by the medical community (via pharmaceutical companies), without realizing we have other options. Or we're given just part of the information, or worse, complete misinformation.

I do feel fortunate that I didn't need to take an anti-depressant while I was pregnant, so I never faced that excruciating choice. I do know plenty of other moms who have and who felt like they wouldn't have made it through their pregnancies without medication. I totally respect and support their decision. I remain skeptical, however, about the safety of taking anti-depressants while pregnant or breastfeeding and think we need to demand more and better testing on these drugs. We shouldn't have to settle for an anti-depressant that is shown to cause birth defects, even if it is only a small percentage. We shouldn't have to settle period, but as women, that's historically what we've had to do when it comes to our health care.

I'm starting to ramble, but I guess what I really want to express here is that I think it's always good to discuss how we all need to respect each other's differences in opinion and different choices. Motherhood is tough enough as it is, but it's certainly way tougher if we don't pull together and support each other.

Just like the mom I've been e-mailing with felt attacked by my statement in my previous post that it's common sense to avoid anti-depressants during pregnancy and breastfeeding, I went through a similar experience when I made my decision not to breastfeed my fourth baby. I had really thought it out and made this decision because I knew it would be in my and my baby's (and my other children's) best interest for me to avoid postpartum depression so that I could be a functioning mother. For me, that meant not breastfeeding so that my hormones would become normalized faster and so that I could immediately go on an anti-depressant and not worry about it being in my breastmilk. It was a good decision for me, but I had a heck of a time expressing that to the nurses on the maternity wing of the hospital where I delivered. Although they didn't come right out and say it, they practically accused me of being a bad mom.

Twice a lactation consultant was sent to my hospital room to try to encourage me to breastfeed. I was given all kinds of "breast is best" cues and whenever I asked for formula for my hungry baby, it took forever for it to be delivered to my room. It was all I could do not to feel guilty for my decision, when I knew deep down, below the crashing hormones, exhaustion and pain from the C-section, that I had made the best decision for me.

These decisions are never easy, are they??

12 comments:

passing as myself said...

I just discovered your blog through BlogHer links. What a great topic!

I am currently late in my 6th month of pregnancy with my second child. I have dealt with severe depression since I was 13. My first pregnancy was depression free but the post partum thing kicked my ass. I chose to take Zoloft and continue breastfeeding.

I have required antidepressants during this pregnancy, and I am assuming I will continue them and breastfeed.

My only concern with your talk of risk is that you don't mention what the risks are when mentally ill women are not medicated when pregnant. Yes, the drugs introduce risk, but as I asked an unsympathetic doctor at one point, "what sort of risk do suicidal tendencies introduce?" Lots of studies show all sorts of problems in babies whose mothers are mentally ill and not being treated.

I applaud pointing out that the NEJM article was based on a study done by drug manufacturers. Of course most of our medical studies are funded this way. I also think it's important to point out that the seeming confusion of "increased risk" plus "small absolute risk" is a failure to understand statistics, not a failure in the study.

Kristin said...

Hi there! Thanks so much for your comment. You bring up some excellent and very insightful points.

And you're so right that there are plenty of women who need medication to have a healthy pregnancy. What I think is so awful is that we have to rely on drugs that we know are risky for infants. It's a no win situation.

And, yes, the risks for babies and children with mothers who suffer from mental illness are enormous too (developmental and cognitive delay, psychological damage, not to mention the risk of growing up motherless), and I have a grasp of this, at least the psychological damage aspect, from having a mother who was never treated for her mental illness. I totally agree with you there and see that I should probably write on this at some point.

I know this topic can be a real hot button and I really appreciate it when people are willing to voice their opinion even though there is still such a stigma surrounding mental illness. Thanks again for sharing your thoughts!!

Let me know whenever you're in Phoenix and heading to Ikea -- I love getting lost in that store too.

Best,
Kristin

Katherine Gray said...

Hello, Kristin!

Great to meet you this past weekend and thank you for the sweet comment on my blog.

Yes, these are horribly difficult choices. I was on Paxil briefly while nursing my first baby when she was about 20 months old. I killed my spirit and made my hair fall out in handfuls! So I went the amino acid and nuritional route. You can read more about this in The Mood Cure here: http://www.moodcure.com/ I still take tyrosine when anxiety hits, plus a multivitamin, Floradix (iron + B vits) and cal/mag and GABA at night. I used to take 5-HPT but it interferes with my milk regulation (I'm still nursing my 14 month old, as you know!). I was able to safely take all of these during my pregnancy, under the supervision of a naturopath. I also made sure I got at least 80 grams of protein a day while I was pregnant and shoot for at least 60 now. The best thing about amino acid therapy is that it actually makes you better, it's not a crutch. Once you get yourself back up to par you can ease of the meds without any withdrawel symptoms. By itself amino acid therapy doesn't work for everyone, but it can usually be used in conjunction with pharmas to increase their effectiveness (though I'd only do this with a traditional doc's or naturopath's supervision).

I'm so glad you're blogging about this. You write with wisdom and compassion. I only wish I'd known you when I was in the throws of my own PP crisis.

-Katherine

Katherine Gray said...

...And just wanted to add: Despite being a proponent of amino acid and nutritional therapy I still think TOM CRUISE IS A JERK.

Every woman has to make her own decision based on her unique situation.

passing as myself said...

Thank you for helping to give a face and voice to this topic as well!

I will let know when I'm in Phoenix next and ready for an Ikea run! I'll be in town tonight in fact, but I'm going to the downtown open studio tour to support a friend.

I look forward to reading more of what you write on this topic!

Kristin said...

Katherine,

Thanks so much for your comments! And I agree with you wholeheartedly on Tom Cruise!!

It's so interesting to learn about your experience with amino acid therapy. I know nothing about that, so I'm definitely going to check out the Mood Cure web site you mentioned. Thanks so much for sharing that!

You're the best,
Kristin

Ann Dunnewold, Ph.D. said...

I am so glad you brave women are talking about these issues. We need more honesty among women that this decision is hard--and that pregnancy or postpartum is not always a glowing Hallmark card experience.

The official professional position is that a comprehensive "risk-benefit analysis" is necessary, because there is no "Right Answer". This means weighing the possible effects on the mother and baby of either choice —medication or doing without. There are documented serious negative effects of not treating depression and anxiety during pregnancy, including low birth weight. Over the twenty years that I have worked with postpartum moms, information has changed as research and drugs continue to evolve. Responsible, caring healthcare providers are usually glad to look at the issues for any individual’s case. If not, get a second opinion.

For the facts about meds during breastfeeding, one of the key experts is Dr. Thomas Hale, who has a website at http://neonatal.ttuhsc.edu/lact/ and is the author of a great resource, Medications and Mother's Milk. Dr. Hale is VERY reassuring, feeling most meds are safe--but he is addressing breastfeeding, not pregnancy.

The most important point in the posts here that I want to re-emphasize is that women need to stop judging each other. Society as a whole is hard enough on us, setting up perfectionist, unreachable standards for mothers. We need to keep in mind the absolute truth, for the majority of women: that we are all doing the best we can do. No woman I have ever seen in my office takes medication for fun. Women take them to function. We need to support, not criticize, each other's choices—and know that there as many valid choices as there are women in the world. Trust that you have made the best decision for you, given available info at this point in time. Don’t second guess or torment yourself with “what ifs” once you have decided.

Kristin said...

Ann,

I can't thank you enough for your incredible comment!! You've really touched on the most important thing we should take from this conversation -- to be supportive of each other and remember that we're each doing the best we can as mothers.

Many kudos to you, Ann! You're the best for taking the time to share your valuable thoughts on this little blog.

Warmest regards,
Kristin

Moxie Mom said...

Wow. Stunning.
I took Lexapro a year after I had my daughter. I was never able to breastfeed her. But I continued on that even after I got pregnant with my son. Maybe especially after I got pregnant. Of course psychotherapy is a must for me in addition to the meds.

It was an incredibly tough decision, but luckily for me, my support network all agreed it was in everyone's best interest (risk/benefit analysis) to be medicated.
And what a difference it made. I finally have memories with my infant where I am not crying or beating myself up.
It truly helped me heal from feeling like a crappy Mom the first time around.

Kristin said...

Hi, Moxie Mom,

Thanks so much for sharing part of your story!! I'm so glad you found healing. And how powerful your statement is that you "finally have memories with your baby where you're not crying or beating yourself up." Wow. What a wonderful mom you are to take good care of yourself.

Best,
Kristin

Anonymous said...

A few points:

1. It's probably best not to conflate breastfeeding and pregnancy. With most of the meds we're talking about here, the baby gets a full weight-adjusted dose of the med through the placenta. With the meds I was on during nursing (Zoloft and Wellbutrin), the baby gets only a minuscule dose through breast milk - 1 to 3% of the weight-adjusted dose the mom gets. Yes, there could still be some risk, but the risk seems much smaller when you realize this fact.

2. You said it's too bad we have to take meds that are "known" to be risky. Some of these meds are only "known" to be risky in the sense that scientists haven't absolutely proven that there is no risk. And, unless you're advocating double blind testing on pregnant and nursing women and their unconsenting babies, that will ALWAYS be true of every med. In fact, that IS true of most of the meds moms routinely take while pregnant or nursing. For example, I took Zofran for vomiting during pregnancy and Percocet and Ambien while recovering from my C-section. Less is known about these meds than many antidepressant drugs, but who's going to go without pain relief after a C-section?

3. The risks of depression and anxiety during pregnancy and breastfeeding are well-established and significant, as mentioned above. Women who are bipolar are at very high risk of a post-partum psychotic episode. And here are some grim statistics for women with PPP: 5% suicide rate. 4% infanticide rate.

4. It sounds like you made a good decision for you about breast-feeding. But I don't think it's accurate to say that foregoing breastfeeding allows hormones to normalize faster - or perhaps a better way to say it - that having a "faster" hormonal crash is better than a more gradual one, with respect to risk of PPD. There is some preliminary evidence that breastfeeding is actually somewhat protective against PPD. Of course, the effect on individual women might vary. If you're very anxious about breastfeeding on meds, then that's a point against breastfeeding. If breastfeeding is one of the few things that makes you happy as a new mom, though, that's a point in favor of breastfeeding.

Full disclosure: I'm a patient of one the docs whose name is on the study you cite, and I personally was on Wellbutrin and Zoloft for much of one pregnancy, and on both, at different times, while breastfeeding (and my kids are fine). But believe me, I'm not a wholehearted advocate for antidepressant meds, partly because they actually may have caused more cognitive and emotional problems for me than they solved. But I don't feel particularly bad about my decision to be on meds during pregnancy or bad at all about my decision to breastfeed while on meds.

Kristin said...

Hi there! What an awesome comment -- thank you so much for sharing your thoughts!!

And how interesting that your doctor participated in the recent study. Regarding your point #2, it sounds so much like "innocent till proven guilty." I was horrified a couple of days ago when I was listening to NPR and heard about a baby who died after a mom took codeine for pain relief following her episiotomy. And how many thousands of breastfeeding moms have been given codeine?? And we're clueless (until now) about how it metabolizes in women with very high metabolisms.

Personally, there are certain meds that I'm extremely grateful to have in my life. But at the same time, there are situations (like when breastfeeding or pregnant) when you feel like you can't win no matter what your decision.

Thanks again for your comment!!
Warmly,
Kristin