Author: Jessica Hyatt
Bio: I'm 39 year old, living in upstate NY. I have Bipolar II (manifesting primarily as chronic severe depressive episodes), ADHD, GAD, and somewhat healed PTSD. It seems I've spent a lifetime learning how to manage my illness and find an identity beyond it. Helping people has always been my calling. Through my twenties and thirties I've offered informal peer support and advocacy to many who were dealing with similar symptoms. I got super into psychobiology research for about 12 years and briefly majored in it in college. Knowledge-seeking is a passion. My world finally stabilized in the past couple of years, thanks to a wonderfully supportive partner, good therapist, tons of work and an effective med cocktail. After many false starts, I found a life path that allows me to blossom. I became a doula and certified lactation counselor. (A doula provides consistent emotional, educational, and physical support before, during and after childbirth.) I adore everything having to do with babies. It allows me to support and empower people through the most incredible and bewildering time of their lives! I love it! I intend to focus on supporting expectant parents who have mental health challenges.
(This piece does not substitute for medical advice from a doctor.)
When I was pregnant with a much-longed for son, 21 years ago, I had a limited understanding of my childhood-onset bipolar disorder, anxiety and ADHD - which had only been partially addressed with antidepressants. As soon as I saw that second pink line, I stopped taking Effexor cold turkey. Like so many people, I did not consider my mental health to be as important as physical well-being, and had no true awareness of the mind-body connection or that mental illness has a physiological basis - and how that might affect my baby. I would come to deeply regret that.
I wasn't currently in therapy, nor had I ever gotten anything from it in the past. I hadn’t yet learned mindfulness or DBT, so my coping skills were nearly non-existent. The severity of my returning symptoms escalated quickly, leading to social isolation, overeating, reduced exercising, intense fights with my partner, obsessive worry about my baby and unchecked rage. How could I have known that relapse during pregnancy is extremely common?
At that time, there was hardly any available evidence concerning the safety (or danger) of psychiatric meds during pregnancy. I did not want to expose this little developing brain to drugs that alter neurological function, in fear that this would increase his or her odds of suffering the same way I had. I wouldn’t take anything more than Tums. I did all of the things I was supposed to do, like quitting smoking and drinking, taking tons of childbirth education classes, reading every book I could get my hands on, singing to my belly, getting prenatal care with a great midwife and improving my diet. All I wanted and hoped for was that my child would be happy.
As it turned out, my son is a lot like me. He had serious emotional and behavioral issues that were apparent before the age of 5. He struggled greatly, and life was extremely difficult for us for a long time. As a young adult, he still struggles. I felt so guilty for burdening him with my genes. Now, I question how much of a contributing factor my untreated illness was. I believe it played a much greater part than I used to imagine, and my wellness could have afforded him some protection against this genetic predisposition. In my determination to protect him, I may have actually caused harm.
A crucial piece of information I did not have back then: severe untreated illness carries it's own risks. For example, excessive anxiety is related to low-birth weight, preterm delivery and miscarriage… Mania itself can lead to unsafe behaviors: self-medicating with drugs or alcohol becomes much more likely. Symptoms can interfere with mother-baby bonding. There is evidence that exposure to ongoing high levels of stress hormones in the mother can have negative long-term effects on the child. These are but a few of the potential risks.
Self-care can become an overwhelming task. How can we ensure we are meeting our needs of nutrition, hydration, physical activity, relaxation, balance, and getting to prenatal medical appointments, when we find ourselves too deeply depressed to even get out of bed to shower?
I'm not suggesting that taking medication during pregnancy is the right choice for everyone - but pregnancy is not automatically a reason to stop taking psychiatric medications that are keeping you well. Ultimately, it is a very personal decision that rests with you and your treatment team.
Drug treatment needs to be contemplated on a case-by-case basis. All medications cross the placenta, but to varying degrees. Multiple drug exposure is even more complicated. In weighing risks versus benefits, we need to base the decision on the risk of untreated illness versus the risk of specific medication exposures at specific times in gestation. Often any given drug will have more potential risk at certain points in pregnancy, depending on what organs are developing at that time.
Maintaining stability without medication requires commitment to a wellness plan, utilizing all of the other tools we have for reducing symptoms and managing our illness. Cognitive-behavioral therapies, mindfulness groups, any type of movement meditation, and journaling are some options that would be beneficial.
Finding a knowledgeable care provider can be harder than it sounds. There is a startling lack of awareness and education within the medical community, regarding treatment of perinatal mental health conditions. A positive pregnancy test too often results in knee-jerk reactions, by inexperienced providers, to pull the patient off all meds - drastically increasing the risk of relapse and frequently causing intense yet avoidable mental and physical withdrawal. Experts in the field seem to generally agree on some reasons to continue medication use: moderate to severe symptoms, previous failed attempts to discontinue meds, a relapse has occurred early in pregnancy, or psychosis or suicidality is present. There seems to be across the board agreement: if a patient is stopping meds that are not known to be a teratogen, they should be gradually weaned off of them.
Knowing what I know today….If I were to plan a pregnancy, I would do things very differently. Over a decade of research into the biology of mental illness and its treatment have given me insight into what is known about underlying causes. Some really great therapy has helped me to better understand my strengths and limitations, my triggers, effective ways of self-soothing, and general insight into my own state of being. Becoming a doula, and studying perinatal mental health issues, has motivated me to closely examine the data regarding medication exposure as well.
Many commonly prescribed psychiatric meds actually have a pretty reassuring safety profile for use during pregnancy. (Be aware that the FDA classification system of A,B,C,D,X is outdated and is being phased out because it was found to be confusing and misleading.) On the other hand, the gold standard double blind research studies (providing the strongest evidence) are unethical to use with pregnant participants, so the data compiled has had to come from other methods - making the strength of the conclusions weaker than they’d be if based on double-blind studies. Still, quite a bit of evidence has been collected over the past twenty years, and it is worth hearing what perinatal mental health specialists have to say about it, and what research studies have found. Some of that information is available in the links at the end of this article.
I'm stable for the first time in a long time, taking 4 meds a day and seeing a therapist weekly. What would I personally do if I chose to have a baby now? I think I would:
●
Carefully review the scientific evidence regarding my current meds.
●
Consult with a doctor or nurse practitioner specializing in perinatal psychiatry to discuss my current medications and work together to formulate a plan, eliminating as many as possible, and talking about how to proceed, should debilitating symptoms return. Even if I could not afford ongoing care with them, I'd do a consultation for their expert opinion.
●
Gradually taper off the medications we decide to eliminate
●
Continue weekly therapy
●
Update my Wellness Action Recovery Plan
●
Practice mindfulness and yoga
●
Build a strong social support system
●
Create a balanced life and a healthy routine. Find enjoyable forms of exercise. Nurture my body. Get plenty of sleep. Spend time with people I love, time in the sun, time engaged in creative hobbies. Getting into this routine well ahead of time will make it easier to stick with during pregnancy. All of these things build up resistance to relapse and benefit baby.
●
Have a solid plan for the first several postpartum months. Arrange for help in the early days, possibly from a postpartum doula. Limit visitors. Prepare and freeze several weeks worth of meals. Give self permission to focus on healing and bonding.
If you are facing this decision, the most important thing you can do is educate yourself. Make sure to rely on factual, evidence-based information from reliable sources, so you understand your options. There are several good books on this specific subject. Avoid relying on information found on social media, message boards, blogs, websites trying to sell something, friends or family. Although often well-meaning, there is far too much misinformation and uneducated opinion being offered out there. You’ll need to dig deeper to look at the facts.
Ideally, we would all have easy access to a mental health provider specializing in perinatal psychiatry. Unfortunately, these specialists are few and far between. There are organizations, such as some of those listed below, that can help connect you to local specialists. If you cannot find someone local, you may have to strongly advocate for yourself with a prescriber who is out of their comfort zone.
It is never an easy choice. As people living with chronic mental illnesses, we face challenges that others don’t have to consider... decisions that are straightforward for most are not nearly as clear-cut for us. Choosing parenthood is most certainly an example of this. I can’t know for sure what I would have done differently, but I wish I’d had the option to make an informed decision instead of one based on fear, gut reactions, and assumptions. I believe my son would have greatly benefitted from it. In the end, we struggle with this decision because we are all trying to do what’s best for our babies.
http://www.cdc.gov/pregnancy/meds/treatingfortwo/index.html
www.infantrisk.com
http://mothertobaby.org/
http://motherrisk.com/women/index.jsp
https://reprotox.org (Summaries on the effects of medications on pregnancy - not available to the general public, but you can ask your prescriber to check it out.)
Great sources for further resources and support (both during and after pregnancy)
http://www.postpartum.net/
http://postpartumprogress.org/
-
The Dilemma of Psychiatric Medication During Pregnancy
When I was pregnant with a much-longed for son, 21 years ago, I had a limited understanding
of my childhood-onset bipolar disorder, anxiety and ADHD - which had only been partially
addressed with antidepressants. As soon as I saw that second pink line, I stopped taking
Effexor cold turkey. Like so many people, I did not consider my mental health to be as important
as physical well-being, and had no true awareness of the mind-body connection or that mental
illness has a physiological basis - and how that might affect my baby. I would come to deeply
regret that.
I wasn't currently in therapy, nor had I ever gotten anything from it in the past. I hadn’t yet
learned mindfulness or DBT, so my coping skills were nearly non-existent. The severity of my
returning symptoms escalated quickly, leading to social isolation, overeating, reduced
exercising, intense fights with my partner, obsessive worry about my baby and unchecked rage.
How could I have known that relapse during pregnancy is extremely common?
At that time, there was hardly any available evidence concerning the safety (or danger) of
psychiatric meds during pregnancy. I did not want to expose this little developing brain to drugs
that alter neurological function, in fear that this would increase his or her odds of suffering the
same way I had. I wouldn’t take anything more than Tums. I did all of the things I was supposed
to do, like quitting smoking and drinking, taking tons of childbirth education classes, reading
every book I could get my hands on, singing to my belly, getting prenatal care with a great
midwife and improving my diet. All I wanted and hoped for was that my child would be happy.
As it turned out, my son is a lot like me. He had serious emotional and behavioral issues that
were apparent before the age of 5. He struggled greatly, and life was extremely difficult for us for
a long time. As a young adult, he still struggles. I felt so guilty for burdening him with my genes.
Now, I question how much of a contributing factor my untreated illness was. I believe it played a
much greater part than I used to imagine, and my wellness could have afforded him some
protection against this genetic predisposition. In my determination to protect him, I may have
actually caused harm.
A crucial piece of information I did not have back then: severe untreated illness carries it's own
risks. For example, excessive anxiety is related to low-birth weight, preterm delivery and
miscarriage… Mania itself can lead to unsafe behaviors: self-medicating with drugs or alcohol
becomes much more likely. Symptoms can interfere with mother-baby bonding. There is
evidence that exposure to ongoing high levels of stress hormones in the mother can have
negative long-term effects on the child. These are but a few of the potential risks.
Self-care can become an overwhelming task. How can we ensure we are meeting our needs of
nutrition, hydration, physical activity, relaxation, balance, and getting to prenatal medical
appointments, when we find ourselves too deeply depressed to even get out of bed to shower?
I'm not suggesting that taking medication during pregnancy is the right choice for everyone - but
pregnancy is not automatically a reason to stop taking psychiatric medications that are keeping
you well. Ultimately, it is a very personal decision that rests with you and your treatment team.
Drug treatment needs to be contemplated on a case-by-case basis. All medications cross the
placenta, but to varying degrees. Multiple drug exposure is even more complicated. In weighing
risks versus benefits, we need to base the decision on the risk of untreated illness versus the
risk of specific medication exposures at specific times in gestation. Often any given drug
will have more potential risk at certain points in pregnancy, depending on what organs are
developing at that time.
Maintaining stability without medication requires commitment to a wellness plan, utilizing all of
the other tools we have for reducing symptoms and managing our illness. Cognitive-behavioral
therapies, mindfulness groups, any type of movement meditation, and journaling are some
options that would be beneficial.
Finding a knowledgeable care provider can be harder than it sounds. There is a startling lack of
awareness and education within the medical community, regarding treatment of perinatal mental
health conditions. A positive pregnancy test too often results in knee-jerk reactions, by
inexperienced providers, to pull the patient off all meds - drastically increasing the risk of relapse
and frequently causing intense yet avoidable mental and physical withdrawal. Experts in the
field seem to generally agree on some reasons to continue medication use: moderate to severe
symptoms, previous failed attempts to discontinue meds, a relapse has occurred early in
pregnancy, or psychosis or suicidality is present. There seems to be across the board
agreement: if a patient is stopping meds, they should be gradually weaned off of them.
Knowing what I know today….If I were to plan a pregnancy, I would do things very differently.
Over a decade of research into the biology of mental illness and its treatment have given me
insight into what is known about underlying causes. Some really great therapy has helped me to
better understand my strengths and limitations, my triggers, effective ways of self-soothing, and
general insight into my own state of being. Becoming a doula, and studying perinatal mental
health issues, has motivated me to closely examine the data regarding medication exposure as
well.
Many commonly prescribed psychiatric meds actually have a pretty reassuring safety profile for
use during pregnancy. (Be aware that the FDA classification system of A,B,C,D,X is outdated
and is being phased out because it was found to be confusing and misleading.) On the other
hand, the gold standard double blind research studies (providing the strongest evidence) are
unethical to use with pregnant participants, so the data compiled has had to come from other
methods - making the strength of the conclusions weaker than they’d be if based on double-
blind studies. Still, quite a bit of evidence has been collected over the past twenty years, and it
is worth hearing what perinatal mental health specialists have to say about it, and what research
studies have found. Some of that information is available in the links at the end of this article.
I'm stable for the first time in a long time, taking 4 meds a day and seeing a therapist weekly.
What would I personally do if I chose to have a baby now? I think I would:
● Carefully review the scientific evidence regarding my current meds.
● Consult with a doctor or nurse practitioner specializing in perinatal psychiatry to discuss
my current medications and work together to formulate a plan, eliminating as many as
possible, and talking about how to proceed, should debilitating symptoms return. Even if
I could not afford ongoing care with them, I'd do a consultation for their expert opinion.
● Gradually taper off the medications we decide to eliminate
● Continue weekly therapy
● Update my Wellness Action Recovery Plan
● Practice mindfulness and yoga
● Build a strong social support system
● Create a balanced life and a healthy routine. Find enjoyable forms of exercise. Nurture
my body. Get plenty of sleep. Spend time with people I love, time in the sun, time
engaged in creative hobbies. Getting into this routine well ahead of time will make it
easier to stick with during pregnancy. All of these things build up resistance to relapse
and benefit baby.
● Have a solid plan for the first several postpartum months. Arrange for help in the early
days, possibly from a postpartum doula. Limit visitors. Prepare and freeze several weeks
worth of meals. Give self permission to focus on healing and bonding.
If you are facing this decision, the most important thing you can do is educate yourself. Make
sure to rely on factual, evidence-based information from reliable sources, so you understand
your options. There are several good books on this specific subject. Avoid relying on information
found on social media, message boards, blogs, websites trying to sell something, friends or
family. Although often well-meaning, there is far too much misinformation and uneducated
opinion being offered out there. You’ll need to dig deeper to look at the facts.
Ideally, we would all have easy access to a mental health provider specializing in perinatal
psychiatry. Unfortunately, these specialists are few and far between. There are organizations,
such as some of those listed below, that can help connect you to local specialists. If you cannot
find someone local, you may have to strongly advocate for yourself with a prescriber who is out
of their comfort zone.
It is never an easy choice. As people living with chronic mental illnesses, we face challenges
that others don’t have to consider... decisions that are straightforward for most are not nearly as
clear-cut for us. Choosing parenthood is most certainly an example of this. I can’t know for sure
what I would have done differently, but I wish I’d had the option to make an informed decision
instead of one based on fear, gut reactions, and assumptions. I believe my son would have
greatly benefitted from it. In the end, we struggle with this decision because we are all trying to
do what’s best for our babies.
http :// www . cdc . gov / pregnancy / meds / treatingfortwo / index . html
www . infantrisk . com
http :// mothertobaby . org /
http :// motherrisk . com / women / index . jsp
https :// reprotox . org (Summaries on the effects of medications on pregnancy - not available to
the general public, but you can ask your prescriber to check it out.)
Great sources for further resources and support (both during and after pregnancy)
http :// www . postpartum . net /
http :// postpartumprogress . org /
