Postpartum psychiatric illness or a drug cascade gone wrong?
Andrea Yates (see part one of this article), who is still in a mental hospital years after killing her five children while in the grip of psychosis, was treated with sedatives and antipsychotics to deal with her delusional thoughts. Her psychiatrist seems to have lacked knowledge of the dangers of abrupt withdrawal from such strong medication, insisting that she stop taking the antipsychotics even though Andrea’s husband warned him that she wasn’t doing well without them.
A few days later, Andrea’s children were dead.
Andrea was failed multiple times over the years, starting from when she first experienced deep depression after her third child was born. She was clearly under tremendous pressure from homeschooling all her children as well as caring for her elderly father who had dementia. It is not clear from accounts of her life whether she had any emotional support or household help, or whether she was offered anything other than drugs to treat her symptoms.
By contrast, Nadine (not her real name) did have some support from her family, as well as only one child to take care of, when she experienced emotional difficulties after her baby was born. Unlike Andrea, her story is one that could be considered a success — that is, if taking an antidepressant, a benzodiazepine, and also an antipsychotic, can be called a successful outcome.
Drugs ‘as needed’ — were they really what she needed?
Nadine is 30 years old, and her case was recently featured in the New England Journal of Medicine (NEJM), one of the most prestigious medical journals in the world. The article starts with the author telling us that her pregnancy had been “uncomplicated.”
Only much later do we learn that while pregnant she took nifedipine (to treat high blood pressure), as well as sertraline (better known as Zoloft), an antidepressant of the SSRI class, as well as a benzodiazepine, “lorazepam, as needed for anxiety.” Despite being on two strong psychiatric drugs, the author states that she had not undergone “psychiatric treatment” prior to the birth of her child.
Nadine’s son was born in the Massachusetts General Hospital. Everything seemed fine at first. Nadine was breastfeeding her baby, seemed to be bonding well, and went home four days later.
A few days after that, she started to experience difficulty in feeding the baby and called the hospital for advice. She added that she was “having difficulty sleeping and feeling anxious and nervous.” She was advised to pump milk in addition to feeding, and it was at this point that “treatment with sertraline was initiated.”
Drug cascade begins...
Sertraline has a long list of common side effects, and another long list of rarer adverse events. From the case study, it is not clear whether Nadine was given informed consent regarding what sertraline might do to her (or whether it was safe for her baby to breastfeed while she was taking it). Possibly, whoever prescribed the drug relied on her previous apparently uneventful experience using it, although this seems doubtful given that the drug is described as being “initiated” rather than “reinitiated,” indicating that the prescriber was unaware that she had previously taken Zoloft.
At any rate, Nadine did experience side effects, although there is no indication in the case study that they were interpreted as resulting from the drug. Her blood pressure shot up, she had “insomnia” (as opposed to just “difficulty sleeping”), and she was tense and anxious, with a pulse rate of 107 beats per minute.
Treatment with nifedipine was initiated for hypertension, along with lorazepam as needed for anxiety. Sertraline therapy was continued.
... and things only get worse
Things did not improve.
The next day, the patient awoke and told her husband, “I can’t go on like this. I can’t do this anymore. I can’t wake up feeling like this again.”
Nadine headed back to the hospital, describing herself as “exhausted” and “emotionally numb,” both common side effects from taking an SSRI antidepressant. She was also feeling confused, saying that sometimes, she couldn’t remember if she had recently fed the baby. She had stopped nursing him by now, due to the physical pain it caused her.
She described feeling lonely, isolated, distressed, and unable to engage in most child care duties.
In fact, Nadine wasn’t lonely, isolated, or incapable. Her mother had been visiting her to help out, and her husband was helping out too. Nonetheless, she felt overwhelmed by her new responsibilities, and told hospital staff that she would “awaken frequently during the night when the infant made noises.” Even when the baby was sleeping, she had “racing thoughts,” reflecting her doubts over her new role as a mother:
The idea of being this baby’s mother for the rest of my life is too much for me to handle. I don’t want to do this now or for the rest of my life.
Numb to herself, numb to her baby
Although Nadine was clearly distressed, there was nothing actually abnormal about the way she was feeling — waking up frequently with worries about a new baby is very normal, as are trouble sleeping, feelings of inadequacy, and even doubts about having brought a new life into the world. Her dulled thoughts, however, certainly contributed to feeling somewhat out of control, and the emotional numbness, most likely brought on by the sertraline, deprived her of a normal new mother’s elation with her child, all the natural and desirable feelings of delight at having a healthy baby to look after and bring up.
Sertraline, like all other SSRI antidepressants, has a boxed warning, alerting users that it can cause suicidal ideation. Nadine wasn’t actively suicidal — that is, she had no concrete plans to do away with herself — but now she started to say that sometimes, “I wish I were dead.”
Again, at no point is it mentioned that what she was feeling could simply be the adverse effects of one of the drugs she had been prescribed. And now things got even worse:
On evaluation, the patient stated that she did not want to hurt the infant or other people; however, she described intrusive thoughts of stabbing the infant and had visual hallucinations of herself holding a knife. She noted that the thoughts had started after delivery and had become increasingly vivid and frequent. They caused distress and anxiety and led to episodes of intense crying, rapid breathing, and feeling shaky. She avoided the kitchen because knives were present, and she had stopped cooking — an activity that she had previously enjoyed.
Am I a bad mother?
The author does not clarify what “after delivery” means with regard to the onset of intrusive thoughts. At any rate, they are described for the first time at this point only. Prior to her readmission to the hospital, Nadine had been feeding her baby and trying to look after him, so presumably the thoughts of harming him had not been overwhelming then.
So now, Nadine is in the hospital, bottle-feeding the baby, and still tense and anxious despite the fact that she is taking an antidepressant and an anti-anxiety drug. Her anxiety is in fact so extreme that she does not “feel comfortable holding or feeding the infant because of the unwanted, intrusive thoughts.” Instead of benefiting from the hormonal effects of holding her baby close — floods of oxytocin that promote calm and bonding — she is actually “avoiding physical contact” with the baby.
Instead of being reassured that she’s doing the best she can and that she’ll soon get the hang of being a mother, she “frequently asks her husband whether the infant is OK,” and “repeatedly searches on the internet looking for reassurance that ... she is not a 'bad mother.'”
Just what is ‘normal’?
At this point, the diagnosis is made: postpartum OCD. Should Nadine feel relieved?
The author writes,
It is crucial to distinguish the symptoms of OCD from normal worries that parents have about their child’s well-being; such thoughts occur in the majority of mothers (34 to 65%) after delivery. Having worries about a child’s safety is thought to be adaptive and to help protect the baby. These concerns are usually temporary and do not affect the mother’s normal functioning, nor do they interfere with appropriate caretaking of the child...
What the author doesn’t add is that it is also crucial to distinguish between the normal feelings and concerns of a new mother, and the side effects of antidepressant and anti-anxiety medication.
Why not? Because when psychiatric symptoms emerge in the postpartum period, the tendency of psychiatrists is to attribute them not to the normal stresses that accompany a momentous transition in life, but rather to an “underlying disease” that has been “triggered” by childbirth. And so,
The peripartum period, in particular, has been associated with an increased risk of worsening of existing OCD and new-onset symptoms of OCD...
The incidence of new-onset OCD in pregnancy ranges from 2 to 22% and is similar to that in the postpartum period (2 to 24%). It is common for patients with existing OCD to have worsening of symptoms in the peripartum period.
A new mother’s natural concerns for her baby, especially when it is her first baby, can thus be interpreted as “obsessions that occur during the postpartum period [which] are likely to be focused on preventing infant harm, with compulsions to check the infant.”
OCD, depressed, drugged, and still miserable
Nadine escaped being diagnosed with postpartum psychosis because her thoughts were “egodystonic” — that is, she realized that it wasn’t natural for her to have such thoughts, and she rejected their validity.
But she didn’t escape being diagnosed with “psychiatric illness,” with the NEJM author noting that the causes of this “illness” might include “blood loss–induced anemia, hypertension, infection, or a thyroid or other endocrinologic disorder.” That said, Nadine was not screened for any of these (other than hypertension, which she did have).
Aside from being diagnosed with postpartum OCD, Nadine was also diagnosed with “coexisting major depressive disorder, with onset in the postpartum period.” No reason for this diagnosis is presented in the article other than her vague statements that sometimes she wanted to die and that she had episodes of “intense crying.”
As for the intrusive thoughts, the NEJM author admits that CBT plus exposure and response prevention therapy have proven effective in treating OCD, but concludes that therapy alone would be unsuitable in Nadine’s case, as she clearly needs swift relief from the distress the thoughts are causing her, and therapy would likely take between “12 and 16 weekly sessions to attain a clinically significant abatement of symptoms.”
No informed consent, no monitoring
Over the next few weeks, Nadine stopped taking sertraline due to the stomach upset it was causing her — she was switched to fluoxetine (Prozac) instead. The case study stresses that,
Since data supporting the superiority of one SSRI over another in the management of OCD are lacking, close monitoring for the occurrence of side effects associated with the use of particular SSRIs should be prioritized.
Was Nadine monitored? The author only notes that “it is unclear whether a system was in place to monitor the patient’s response.”
Furthermore, the author adds that Nadine was not screened for bipolar disorder prior to being started on an SSRI, even though “the postpartum period is a particularly high-risk time for an incident diagnosis of bipolar disorder, and SSRI treatment without an adequate assessment for previous bipolar disorder symptoms can lead to mania or psychosis.”
Still no good? Add another drug
Nadine’s story as recorded in the NEJM ends with her continuing to be treated in the hospital’s peripartum psychiatry clinic, receiving “extensive psychoeducation about OCD,” and “reading news articles about postpartum mental illness.” She is taking Prozac as well as lorazepam “as needed.”
Nadine is also being seen by a therapist and attending group therapy sessions for “patients with peripartum OCD.” Notwithstanding what is described as “intensive, daily outpatient psychiatric care,” however, Nadine was clearly still not doing well, and so she has been started on yet another drug, this time an antipsychotic (olanzapine—Zyprexa). Only then did she finally experience a “decrease in anxiety and insomnia,” not surprisingly, given the intense sedating effects of this drug.
Nadine by this point is no longer breastfeeding and in any case that would have been ruled out due to the drugs in her system. But she is, apparently, content with her situation, reporting at a follow-up visit that the intrusive thoughts are now “infrequent, fleeting, and only minimally distressing.”
The compulsive behaviors have resolved, and she described an improved mood and better sleep. She is bonding well with her new baby and has been feeling more confident in motherhood. She resigned from her job to become a stay-at-home mother.
The article concludes with an appeal for greater “recognition of mental health as an important component of comprehensive reproductive healthcare,” as well as clarification that “prescribing psychiatric medication for depression or anxiety is within the scope of the obstetrical clinician’s practice.”
The article does not conclude with any appeal for:
- Greater awareness of the effects of taking psychiatric medication during pregnancy (on the baby as well as the mother)
- Recognition of the possible effects of withdrawal from psychiatric drugs prior to giving birth
- Recognition of the side effects of antidepressants on a new mother, specifically the numbing effect which occurs in the vast majority of those who take these drugs, and the likely effect this will have on the new mother’s feelings toward her baby
- Caution with the use of strong medication which precludes the possibility of breastfeeding with its uncontested benefits for both mother and baby
- Awareness of the long-term side effects of taking psychiatric medication, or the caution that must be exercised when withdrawing
- More support, both emotional and physical, for new mothers in a fast-paced society that places sometimes intolerable stress on postpartum women
In the final part of this series, The Gold Report will examine alternative approaches to the postpartum period, the role of hormones, and how the pharmaceutical industry is attempting to portray the natural fluctuation of these hormones as an obstacle to health and healing.
Disclaimer: The information contained in this article is for educational and informational purposes only and is not intended as health, medical, financial, or legal advice. Always consult a physician, lawyer, or other qualified professional regarding any questions you may have about a medical condition, health objectives, or legal or financial issues. If you are struggling with suicidal thoughts, you can call a qualified free mental health helpline or seek help from a qualified therapist.
