These interviews make my blood boil. What Dr. Raison really should be saying is this: "I think that taking antidepressants while pregnant is overall better than having terrible WITHDRAWAL." Yes, folks, the reason doctors recommend antidepressants during pregnancy is because it's no time to be going through withdrawal but that sure doesn't make it safe to be on them either. The solution is, as I've stated numerous times before, is not to give these drugs to women of child-bearing age at all -- yes, radical thought, but that's what I believe. If there's any chance you want to have a baby at all stay off antidepressants.

Some of what the doctor is talking about with regards to stress hormones affecting the fetal genome is epigenetics. That is, some environmental stressor results in some change in the genetic code through a process like methylation. In effect, a gene that is methylated is turned off. The genetic code hasn't been changed, but the methylation prevents that gene from being read. Epigenetic effects have been demonstrated in both mouse and human models. For instance, it has been shown that genes turned off in a grandfather were still turned off in the children. The epigenetic code is passed down like the the genetic code. Epigenetics may go a long way in explaining how the stress by the environment leads to some of the genes involved in intercellular communication in the brain being turned off and leading to mental illness. Intercellular communication generally involves a myriad of proteins interacting for the signal to work. Knock out one of a dozen and you have a problem: the signal is not processed properly. Epigentics may knock one of those proteins out or that protein may not be well formed in the genetic code. That is why there won't be a single mental illness gene, but the hundred that are suspected to cause a vulnerability to mental illness. That is because signalling, which is all the brain does, involves so many genes to work together.

Generally, ALL the outcomes evidence for prepartum depression is weak. There are psychosocial interventions that seem to be effective - personally, I would rally this type of help for my wife. Prepartum depression may be hormonally driven, so it is not so clear cut compared to the typical person walking into the clinic with a case of depression. Along with all that: I would most definitely be more afraid of a medication harming the baby prenatally than some extreme conjecture about stress hormones from depression or anxiety. Additionally, anxiety is certainly almost always clearly amenable to psychotherapeutic interventions. It is a physiologically based depression, such as that evoked by interferon-alpha treatments, that can be a challenge to treat without meds. Even at that point: my guess is that most moms, hearing that the depression will likely resolve, and they need to make sure to stay physically active and do other things such as eat right, avoid alcohol etc., would tolerate the depression as yet another sacrifice for the sake of their child, rather than get some modicum of benefit from a potentially dangerous drug. I don't see any reason to invoke fear about transmitting depression to the fetus.

And P.S. it sure can't be good for the fetus to have a mother going through withdrawal -- probably far more damaging than depression itself is ever going to be, fancy theories or no. A mother is damned if she does and damned if she doesn't if she's on antidepressants when she gets pregnant. That's why these doctors hem and haw when they get interviewed on these issues although they haven't even articulated the problem properly. They have it all screwed up. It all really has very little to do with "underlying depression" and a heck of a lot to do with the harm these drugs cause both to the mothers and the unborn children -- and the chemical dependency that underlies their mechanism. Anyway. . . you can tell I'm annoyed.

I wrote about this earlier Phil.

On one hand he is telling the concerned reader not to take Paxil then on the other he is telling her that her baby could be born with abnormalities if she does not treat depression.

The whole 'Talk to your doctor' thing really grinds my teeth.

Here with have an Emory psychiatrist more or less referring this concerned reader to her doctor. What does her doctor know about antidepressants?

Basically what the Pharma rep told him/her!

Fid

That's a question that better be asked before marriage and/or becoming pregnant, because becoming divided over medication use can be a reason people divorce and separate.

It's more serious of a question that which side of the bed do you want that's for sure.

How about increased risk of cardiac abnormalities and primary pulmonary hypertension in the fetus exposed to SSRIs?

I've just remember this answer Dr. Raison has answered about Cymbalta and aggression:

"I don't know the circumstances that have led you to ask about Cymbalta, but in general I think data strongly show that for most people with depression, agents like Cymbalta can be extremely helpful and the benefits outweigh the risks. Nonetheless, all antidepressants are serious medicines that need to be started and administered under the care of a clinician with experience using these agents."

Note: Dr. Raison serves on the speakers' bureau and on advisory boards for Eli Lilly, the manufacturer of Cymbalta.
http://www.cnn.com/2008/HEALTH/expert.q.a/12/19/cymbalta.aggression.raison/index.html

Don't even think about commenting on CNN site. It will not be accepted.

"Although it hasn't been definitively proven yet, there are a number of reasons to suspect that depression and anxiety damage fetal development because these are conditions in which the body is flooded with stress hormones, as well as changes in the immune system."

This is strange to say the least.
Perhaps the we should create an artificial wound to prevent the baby being expose to any harm.

I believe I have read somewhere that it's good for the fetus being exposed to stress hormones so that it can learn to improve the immune system.

Hi Ana,

Dr Raison went on to say this about agitation and antidepressants in his cymbalta answer.

"There is an interesting pattern to the issue of agitation and suicidal thinking with antidepressants: It is much more likely to happen in people under the age of 25 than in people who are older, and doesn't seem to happen at all in elderly people. These data have led many psychiatrists -- myself included -- to suspect that the agitation associated with antidepressant use likely reflects the fact that people with manic depression -- also known as bipolar disorder -- are at increased risk to become manic and agitated when given an antidepressant. I say this because many young people who have a depression bad enough to require an antidepressant will eventually go on to have manic or hypomanic [mildly manic] episodes. And we have known for years that antidepressants can sometimes make people with a tendency toward bipolar disorder develop states of mania and agitation."



If I hear this crap one more time, I am going to scream. I got agitated from SSRIS and I am about as bipolar as George W. is a Democrat. Funny how once the offending drugs were gone, I didn't have any more BP symptoms.


I have been critical of my psychiatrist for many good reasons but I do give him credit for not claiming that because of my bad reactions to SSRIS, I was BP. But it is scary to think of how many people are wrongly getting this diagnosis due to med reactions and put on meds they shouldn't be on that cause horrific side effects.

Well, mental and all, I'd quit all drugs if I were pregnant. In fact if planned, I'd do it before. The horrors of crack-, alcohol- and other dependent newborns would make me.

That said, my now sober alcoholic mum has told me that it's good I have no kids. You know, on account of my alcoholism (sober five years now) and "that other stuff" (my manic-depression, etc).

I keep reading your blog because it is so good. But like NPR I find it too hard to take sometimes. My p-doc and I have been working on getting me off meds, but my moods have not been stable enough.

That said, I have been on Depakote. I went into the hospital in 2006 for an unremitting pain diagnosed as a ruptured ovarian cyst. I'd gone into the ER after ignoring the pain, thinking it was a pulled muscle.

By the time I was brought in, I was breathing like I was going to pop a child out. They asked me my pain level on a scale of one to ten, which I rated as an eight because I was still aware. The admitting nurse made it an eleven, which is cheating.

More than five shots of Morphine later, my humour returned. But I've had pain there ever since. My g-doc has had every test done. The only thing that shows is an ovarian cyst. My side-stabbing pal.

Guess I'll have to call Depakote, to see if they'll pay for the removal of this thorn. SSDI won't. They want to close me down as a thorn in their side.

Philip, thank you for doing what you do. It takes incredible strength and compassion.

Fluffies and stuffies, D

"Don't even think about commenting on CNN site. It will not be accepted."
--Exactly. There happen to be NO comments for that CNN health question to Raison on antidepressants and pregnancy. Since I have actually reviewed the topic, a week ago I put a decent, fact-filled, respectful but truthful comment in response to this "discuss with your doctor" answer from Raison. My note happened to have more true info and more supporting evidence than his. To no effect. So I have also found that CNN will censor such comments.

AA:

Let's be reasonable about this.

Dr. Raison did NOT say that ALL people who become manic on an SSRI are bipolar. She only stated the correct statement that if an adolescent, for example, becomes manic on an antidepressant, then there is an increased likelihood of an unfolding bipolar disorder over time.

This is not enough to diagnose someone with bipolar disorder, because the manic episode was secondary to a medication or substance, but it is an important piece of information to consider depending on how the person's furure course develops.

I wouldn't start someone on a mood stabilizer if they had a manic episode following SSRI treatment for depression, but would look carefully at the elements of their depressive episode, their family history, and other relevant factors, and might tell them that it is possible that they have an unfolding bipolar disorder, but that only time will tell.

Take care.

AA,
Please, don't scream.
If you want to scream do it in your own bedroom and make sure nobody listen.
You've been diagnosed BP.
:)
I've been diagnosed depressed and "You're a little bipolar, aren't you?"
Once one psychiatrist told a family member that I was histrionic.
I believe this is good since he was diagnosing side effects.

Stephany is 100 percent right here. It's a marriage breaker. it was for me. Before I got married, I went off all my meds about 2 months before the wedding after talking to the doc and finding out that lithium needs about that much time to get out of the system so a baby would be born without any of the birth defects that lithium users can get.

Before we got married we agreed birth control would be both my responsiblity and his- after the wedding it was totally up to me. I told him flat out I was not using any birth control from honeymoon on. He said he was cool with it.

He wasn't and hit the roof when I showed him the EPT test was positive. Hence an annullment from a faith that hardly ever gives those out, and my state hardly ever gives them out either.

I wouldn't wish this kind of emotional pain on anyone, male or female. It is something to be discussed prior, unless both partners are adamant they don't want to be parents at all.

I would hope for the men reading this to share any information they can glean with their wives/girlfriends/SO's, and explore other methods for dealing with depression or post partum depression. Right off the bat sex is good for depression......as is cuddling.

And for the record, i lost the baby at somewhere between 7 and 8 weeks.

"Dr. Raison did NOT say that ALL people who become manic on an SSRI are bipolar. She..."

First: She is a HE... Charles Raison...

Second: A HE who works for Eli-Lilly and is Emory's psychiatrist.

Third: ALL people should be maniac to a side effect be recognized.

Susan,
I'm very sorry.

DGuller, tell all the people who have been misdiagnosed as BP due to AD reactions with devastating drug side effects to be reasonable.

I don't understand how "experts" can flat out lie and the news media just prints or puts it on TV.

I'm not talking about having to do in depth investigating, I'm talking about contradicting the FDA Label and telling people, in other words, what the label says doesn't mean a thing.

Animal studies that show harm to the fetus and miscarriages, ETC. are then discounted by saying, it's not expected to happen in humans. (paraphrasing from Lamictal's label)I guess that justifies the doctor's not mentioning it.

Back to CNN: the little note at the bottom, "Dr. Raison serves on the speakers' bureau and on advisory boards for Eli Lilly, the manufacturer of Cymbalta"

If I were just your typical reader, I would not realize this meant there was a conflict of interest and he is paid by the company that makes the drug he's discussing. It sounds like he gives advise to Eli Lilly as an independent concerned doctor.

I think it's because the reality (that "experts" are pretending to be unbiased!) is so insane it never would have crossed my mind before.

DGuller, do you know about physical tests that can determine and pinpoint the physical causes of depression? If you do not, please look at The Extraordinary Walker Exam and the 29 Causes of Schizophrenia articles, both at Safe Harbor - http://www.alternativementalhealth.com/articles/default.htm

~~~~~~~ And Susan - my heart goes out to you.

Lilly NC:

I do not know all of the medical causes of depression, but I do know many of them, mainly the common ones and the rare ones that are lethal if missed. I looked at the websites, and they are interesting and helpful. I find it quite remarkable how thorough Dr. Walker is, and I will try to incorporate that thoroughness into my practice.

They are always important to look for, because we do not want to be missing an organic cause of psychiatric symptoms that would better be addressed through treatments other than psychotropic medications. That is why it is part of the treatment guidelines to do an organic work-up for every psychiatric patient as part of the initial assessment, which includes bloodwork, urinalysis, brain imaging, and other tests, if necessary. It is very rare that these examinations show anything significant that could be contributing to a patient’s psychiatric symptoms, but it does happen. Furthermore, this is phenomenon is directly stated in the DSM-IV as mental illness “due to a general medical condition” or GMC. It is ALWAYS on the differential. Recently, we diagnosed a gentleman who presented with a manic episode and severe cognitive impairment in the context of heavy drug use with neurosyphilis, which resolved the cognitive impairment problems nicely with penicillin treatment.

However, it is also important to know that the causation works both ways. Some physical signs are caused by psychiatric illness. For example, I recently assessed a female who had tension headaches that were preventing her from working to support her children, and were being treated with pain killers without success. She also had severe anxiety and panic attacks related to her need for control and perfectionistic streak. The combination of physical pain and psychological distress resulted in a major depression, as well. I explained to her what panic attacks were, taught her some relaxation and deep breathing exercises, and started her on a low dose of Effexor to test her tolerance to it, because Effexor can be helpful for headaches, depression and anxiety. Two weeks later, her headaches were gone, her depressed and anxiety were gone, and she was happy! We discussed the pros and cons of staying on her Effexor or discontinuing it, and I recommended that she discontinue the Effexor, but she wanted to stay on it for a few months, and then discontinue it.

So, you are absolutely right that physical illness can cause mental illness as a direct cause (e.g. depression secondary to hypothyroidism) and as a consequence of being a significant stressor (e.g. depression secondary to the loss of one’s wife following weight gain during steroid use for sarcoidosis). However, just remember that physical symptoms can also be due to mental illness, and thus the causation goes both ways. :)

Take care.

AA:

It is always tragic when someone is misdiagnosed and treated with the wrong medications, especially those that carry significant risks of harming them. They are fully justified to be outraged, but it does not follow that everything they say and do in their outrage is true and right. It certainly does not mean that they are free to claim that someone made a gross generalization when they did not. That was all I meant about being “reasonable” about Dr. Raison’s statement. Let’s just stick to the facts of what was written without distorting it in order to make them seem far more sinister than they really are. :)

Take care.

Even at that point: my guess is that most moms, hearing that the depression will likely resolve, and they need to make sure to stay physically active and do other things such as eat right, avoid alcohol etc.

What makes you so sure of that? I think that's the issue, right there; it's not just that stress can cause damage to the developing fetus, but that stress combined with severe depression can cause the mother to act in ways that are pretty objectively bad for the fetus -- using recreational drugs, not eating, not sleeping, engaging in self-harm, etc.

I think, in these cases, appropriate treatment really depends on the severity of the depression or other mental illness. Is it great for a fetus to be exposed to anti-depressants in utero? No. But it's better than the mother committing suicide or going on a nine-month drinking binge. So for mild or moderate depression that responds well to non-drug interventions, and for mothers and families who have the access and inclination to use those interventions, then drug therapy can be avoided, and I think that makes sense as a goal.

But that model doesn't fit everyone, and it's shortsighted to pretend it does.

Occhiblu, you think it's a good idea to mix antidepressants with people who are on a 9 month drinking binge?

DGuller, now I am beginning to understand the arguments that someone made in another thread about you always needing to have the last word. You also are acting like your truth is the only truth regarding what Dr. Raison said.

I feel he was subtly implying that a manic reaction to BP meds means the person is BP. No, he didn't say it directly but that is the sense I had.

Just because you're a psychiatrist, doesn't mean your opinion is the right one and I am wrong. What you just did goes on in psychiatry constantly and that is why people are mad as heck.

Please don't insult me by telling me how to argue or what to say. I was too tired to frankly deal with your post and decided to keep it short and sweet. But you still had to have the last word, didn't you?

In present times, the trend is to avoid all non-biological chemical influence on the fetus. Yet, we are finding that plenty of women have one caffeinated beverage a day or one glass of wine a day and their children turn out fine. On the other hand, we are finding out just how damaging stress can be to a mother and her fetus. A U of MI study suggests that elevated cortisol (stress hormone) signficantly increases the likelihood of early pregnancy loss. Also, a new mother who has been off her meds is at much greater risk of post-partum depression, which can effect an infant's brain development, ability to bond with its mother, and ability to feed. You really do have to weigh the pros and cons. For example, a family with two strong parents and a night nurse might decide that they have enough support to deal with post-partum depression and they can't live with any birth defect that may in any way be related to meds.

On the other hand, we have some clear documentation of pysiological problems in fetuses caused by some meds. For example, Lamictal carries a warning that it can increase the risk of cleft pallette. Yet, if a mother is desperately mentally ill and needs Lamictal, I wouldn't fault her for staying on it during pregnancy. Cleft pallette can be fixed surgically, but there is no fix for a mother or mother-to-be who commits suicide.

Any mental health issue and the decision to take meds is a very personal risk-benefit analysis. Any woman prone toward mental illness should make her family plans with a psychiatrist as well as a ob-gyn. And any woman under treatment for depression needs to be deliberate and careful about birth control. I'm glad that a TV doctor is not offering "yes" or "no" answer for what could literally be a life or death issue.

CB in DC, you said, "Also, a new mother who has been off her meds is at much greater risk of post-partum depression, which can effect an infant's brain development, ability to bond with its mother, and ability to feed. You really do have to weigh the pros and cons."

Actually, it sounds like you are confusing withdrawal for a relapse which is sadly very common in psychiatry. Many women are coming to Paxil Progress Boards being tapered way too fast off of meds due to being pregnant which of course leads to withdrawal symptoms confused as a return of the illness.

I will take a look at the study you mentioned. Is it free access?

Also, comparing taking Prozac to caffeine is like comparing candy to apples. And yes, I am deliberately playing with the expression to make a point.