Rethinking Medication and Pregnancy

I want to see what medication-free life is like for a while. –Me.

Psychiatrist: Is that goal separate from having a baby? Do you think you’d still want to “live ‘medication-free'” at this time if you didn’t also want to have

Sorry for the generic photo. But this is what I wake up to every day. This orange bottle that is my savior one day and my albatross the next.

a baby?

WHOA. That is a good question. I did not see that question coming.

It was one of those moments where my brain creaks with effort. Quick! Adjust to an entirely new perspective, right now! Like when you suddenly see the other image in one of those old lady/young lady with a hat optical illusions. It was one of those moments that makes me so proud to have asked for professional help. Because this guy? He knows stuff. Here’s why he asked:

I can’t separate them. I want to get off all medication because pregnant women take vitamins, not prescription drugs. Because there is a warning label on my medication about taking it while pregnant. Because I should. And that information really matters if my doctor is going to do his job properly.

If going off my prescription medication, all of it, were a life goal (a goal separate from anything else), then I could do it with a lot of effort and a lot of time and a lot of patience. I do have a lot of patience. I have the patience to carefully decrease my daily dose of Klonopin, a medication classified as a benzodiazepine–I have been doing this for years. When I met my husband over three years ago, I took two milligrams of this stuff morning, noon and night, for a total of six each day. As of this morning, I take one milligram of Klonopin, once a day. These last few milligrams and half-milligrams are the hardest. The dosage has decreased and increased and decreased again. We’re months from being done. I have patience. But that’s exactly why this is such a great question for the doctor to ask–going off Klonopin was a life goal long before I felt any immediate desire to be pregnant. Which is not true for Effexor, the SNRI I take to help me manage anxiety and depression. Before I wanted a baby, I was just fine with the idea of taking an antidepressant every day for the rest of my life. I have been smart about coming off of Klonopin. I’ve gone slowly and I’ve been patient with myself (mostly) and I’ve been honest with my doctors. Because I don’t feel the same way about the antidepressant–I just want to stop taking it for the sake of a hypothetical fetus–I will not be happy to wait as long as it takes to do so safely. I will be pissed. I will be stomping my feet and hating myself for not being able to do it faster, which will cause more anxiety and slow down the whole process. Not a fun cycle.

And here’s what I knew but did not fully understand until my doctor articulated the idea: it may be safer for the fetus (hypothetical though it is) and for me if I stay take antidepressants during pregnancy. Yes. Taking a prescription drug with a warning label on it might be safer.

How do we figure out if it is safer to take the meds or to not take the meds? A cost-benefit analysis. “Cost-benefit analysis” is an economic term for something we do all the time–weigh the pros and cons and choose the option that costs least. The textbook example (at least in my textbook) was going to college (vs. not going at all). It costs time and money, including the cost of the money you’re not making at a job because you’re in school. You benefit by getting a better job and earning more money in the future. Is anyone else with a fancy college degree and loans to pay wondering about that particular benefit? I liked econ. class. But I also read about applying this concept to life in a great book called Spousonomics: Using Economics to Master Love, Marriage and Dirty Dishes.

It sounds really simple, right? Pros and cons lists are easy! Except that in study after study, we find that human beings are generally bad at being honest about pros and cons. We do things like count “the label is nice” as a “pro” when choosing a brand-name pain-killer over the generic we know has exactly the same ingredients and costs two dollars less. We are famously susceptible to ads featuring beautiful people. We order something at a restaurant because it “looks good” in the picture on the menu even when we know that whatever is in that photograph is probably not even real food. Getting people to do accurate cost-benefit analyses is darn near impossible.

But I can get a lot of help making my list from people who know more about this than I do and have a tiny bit more perspective on the issue. Here’s what I know so far:

  • There is evidence that links benzodiazepines to birth defects. There’s a link, but it’s not fate. If I take Klonopin while pregnant, it is more likely that the fetus will have a birth defect. (To the friend who could not stop taking her Klonopin when she found herself pregnant–you are brave and doing so well, even though things get really hard. Your girls are lucky to have a mom like you!)
  • The research we have has not found a link between most antidepressants and birth defects.
  • Some antidepressants do show an increased risk of birth defects.
  • There is a giant body of research that links untreated/unsuccessfully treated depression in pregnant women with harm to the baby. These babies cry more and sleep less than babies born to women without depression or whose depression has been treated successfully. This is true in the first 48 hours and, as a matter of fact, even after many months, the children whose mothers were depressed during pregnancy tend to be more sensitive and less resilient than other kids. Bottom line: out-of-control depression and anxiety during pregnancy is bad for a fetus.
  • Both Effexor and Klonopin are habit-forming. (The baby could go through withdrawal after birth if enough of the drugs get through the placenta and into the fetus’s blood stream. I have no idea how likely this is, but I’m throwing it in here because I freaking hate what my body does if I don’t take my meds.)
  •  SSRIs and SNRIs have been around for a long time, and many women have safely taken them while pregnant.
  • No cognitive technique I could possibly use to stop an anxiety attack would counteract the effects of a high “baseline” level of anxiety. This could have already done serious damage by the time I recognized the problem and got help. In other words, going off the SNRI only to go back on it while pregnant is not a pretty scenario. And my “baseline” is high. If you knew me before I was medicated/in therapy, you might remember that I was, well, on edge and a bit moody.

Sometimes, the chemicals our bodies make are worse for a fetus than something artificial. If I can safely stop taking Klonopin, that’s really a good idea. But I do not know if it’s a good idea to try going off of everything, altogether. In this case, “natural” is not necessarily the best.

I might feel overwhelmed by this if I didn’t have an ace up my sleeve. Ready? Drumroll please

The Columbia University Center for Women’s Mental Health Center

My psychiatrist recommends these people very highly. He says that both Nathan and I can go together for a consultation in which people who specialize in the mental health of pregnant women give us information and advice to help us make decisions. He says that he doesn’t know enough about treating a pregnant woman to comfortably give me the advice I want; so he’s sending me to people who do know.

No matter what I choose, I’m going to be giving up something I have grown really attached to: either I wait to get pregnant or I give up the idea of a prescription drug-free pregnancy. I don’t want to wait. I don’t feel comfortable exposing a fetus to antidepressants. Remember what I said about people being bad a cost-benefit analysis? Here’s another example. A big part of me whispers that if I just threw out the drugs, I’d be fine. Eventually. That part of me is stupid. I feel like utter crap if I skip Effexor for just one day. Toughing it out is not an option.

A therapist once told me that I draw too many “lines in the sand,” meaning that I give myself rules and deadlines that are impossible to follow/meet and then beat myself up for failing. Our current plan is to make a decision about trying for a baby next spring. Which means that I want to start trying for a baby next spring, dammit, and have gotten my hopes up! This is not a line in the sand, though, it’s a safe space. We decided to set a date (March 1, 2012) for making this decision so that we didn’t have to talk about it constantly or wonder what the other person was thinking. But it could easily become a line in the sand if I start thinking that I must come off my medication by March. I have already said things like “I’ll be off Klonopin by December, and then we’ll immediately decrease the dose of Effexor!” I see it now–that’s absurdly difficult. Nathan’s concern about that plan? Valid. Holding myself to a schedule like that could put my health in serious danger.

Another stupid part of me is whispering you are already a bad mother, too impatient to make the healthiest choice. (For the record, this is not an actual voice.) It’s important to articulate that thought. Because you know what? If I decide to wait until my un-medicated baseline level of anxiety is comparable to what I feel now, I might wait forever. So here’s my new world: I might never be comfortable without medication. That is a possibility. I am trying my very hardest to accept that without throwing around the word “Failure.” Like a diabetic who takes insulin during her pregnancy, I might have to take medicine that helps me fight anxiety and depression during my pregnancy. I’d be doing it for me and for the baby.

One picture has been stuck in my mind since last night’s session–it’s a printout from a monitor recording mirror image heart-rates for fetus and mother. It comes from a woman who is suffering from depression and her unborn baby. In a study done at Columbia University, fetal heart rates stayed relatively constant, even when the mother was under stress. When a woman with untreated depression experienced anxiety, her heart rate rose, and her baby’s rose with her. We know that babies born to these women are highly sensitive to their environments; this could be one clue about why that is. But let me tell you–the idea of that tiny, new heart beating too fast and a fetus feeling anxiety keeps my mind open. Whatever the cost of taking medication, it’s hard to imagine that cost outweighing the benefit of keeping our fetus safe from that awful stress.


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