For the first month of her pregnancy, Beth and her husband, John, were ecstatic. Conception had been hard-won after a year of attempts by natural means and a second year of difficult, expensive infertility treatment.
But by the second month, Beth knew something was wrong beyond the vomiting.
"I felt like I was having a heart attack," she says. Her obstetrician, baffled by her symptoms, did not know where to refer her.
"It was a complete, 24-hour panic," recalls Beth, a Los Angeles preschool teacher. "One Sunday, in the middle of the night, my husband called the hospital to tell them I was having a heart attack. They said it sounded psychological and that they couldn't help me. . . . I didn't know what was wrong with me."
Beth was suffering from panic disorder, a psychiatric condition that affects a small percentage of pregnant women. She was also depressed, a condition that affects at least 10% of pregnant women--some of whom are so severely depressed that they must be treated by a psychiatrist or be hospitalized.
Psychiatric disorders in pregnant women is a phenomenon that only a handful of psychiatrists have specialized in over the last decade. There is a dearth of knowledge in psychiatry and obstetrics about pregnant women afflicted with psychiatric disorders, says Dr. Vivien Burt, founder and director of the Women's Life Center, a branch of UCLA Medical Center's Neuropsychiatric Institute, which specializes in treating psychiatric conditions that afflict women from menstruation through post-menopause. (Mostly, what has been written about pregnancy and depression concerns postpartum depression.)
Although American women experience depression or anxiety disorders twice as frequently as men--with the greatest number of cases during childbearing years--Burt says many pregnant women are misdiagnosed or mistreated. The result can be protracted suffering for the mother, danger for the baby and a higher risk of postpartum depression or postpartum psychosis.
"I don't think we're as tuned into it as we should be," says Dr. Johanna Abernathy, a member of the American College of Obstetricians and Gynecologists.
"It's difficult for many of us to recognize whether or not (symptoms are) a real problem or if it's just related to a lot of things that occur during pregnancy, such as anxiety, irritability and high emotions," she says.
Historically, pregnancy has been thought of as a salutary time, says Dr. Lee S. Cohen, director of Massachusetts General Hospital's perinatal psychiatry clinical research program. But evidence suggesting that rates of depression or anxiety disorders are lower for women during pregnancy may have been gathered using inferior methods, says Cohen, a pioneer in perinatal psychiatry. Moreover, diagnosis is difficult because some women may be unwilling to tell their doctors how bad they feel.
"The idea that a pregnant woman could be depressed is very much anathema to the myth that we perpetuate about pregnancy, which includes the Madonna, and being at peace, and even Demi Moore pregnant and naked on the cover of Vanity Fair as this image of, 'I'm this whole, beautiful, ecstatic state,' " says Maryellen Handel, psychologist and co-author with Dr. Roberta Apfel of "Madness and the Loss of Motherhood" (American Psychiatric Press, 1993).
Compounding the problem is a lack of knowledge among obstetricians about depression and anxiety disorders, says Burt, who founded the Women's Life Center a year ago. Pregnant women are most likely to relate their symptoms to their obstetricians or gynecologists, who are not trained to make psychiatric diagnoses. While many obstetricians take psychological histories on their patients in a quest for a general patient profile, they often don't know what to do with the information, Burt says.
In addition, the risk for misdiagnosis in pregnant women is heightened in part because there is very little information about pregnancy-related psychiatric disorders and because symptoms may be confused with a number of pregnancy-related problems.
Beth, who asked that her last name not be used, had symptoms of panic attacks, which included an overwhelming sense of doom, sleepless nights, shivering, shaking and sweating. She reported the feelings to her obstetrician to no avail.
"I told him twice because I knew it wasn't his specialty," says Beth, 33, who added that a psychologist she was already seeing did not refer her to a psychiatrist.
At the end of her fourth month, Beth had lost 14 pounds. She had become so dehydrated that she had to be given intravenous fluids. After she endured three days of nonstop panic attacks without sleep, her husband called the emergency room when he thought she was having a heart attack. Hospital physicians referred Beth to a psychiatrist, who in turn recommended Burt.
"She looked about as sick as anybody I've ever seen," Burt recalls. "She had to be treated because she had lost so much weight. . . . She couldn't stand without support. She was hyperventilating. She was at risk."
Burt prescribed a low therapeutic dose of the antidepressant nortriptyline, and monitored Beth's blood and fluids to make sure that she was eliminating the drug properly. The course of medication, combined with therapy for Beth and her husband, was immediately effective.
"It didn't soothe me 100% because you can't increase the medication," Beth says. "I still have anxiety, but I learned to enjoy the two hours a night I did sleep."
Little is known about the causes of pregnancy-related depression and anxiety disorders, except that women with a history of psychiatric problems appear to be at greater risk for recurrence, especially when they are taken off medication prescribed to arrest their symptoms.
For some women like Beth, conditions worsen after conception. But it was only after becoming pregnant that Beth developed full-blown panic disorder. Other women experience the symptoms of anxiety disorder or depression for the first time while pregnant, but experts say the condition may not be caused by their pregnancy.
"We know very little about the causes," says Dr. Nada Stotland, a psychiatrist and associate professor at the University of Chicago Medical School. "But it seems they are multifactorial . . . family stresses, finances, a history of psychiatric illness or domestic violence. There are clearly some hormonal triggers, but nobody can say there is a specific level of pregnancy-related hormone associated with psychiatric conditions during pregnancy.
"No one wants to mess with pregnant women. . . . Understandably, scientists are reluctant to get involved in treating pregnant women because there is little known about how pregnant physiology effects drug dosages."
Half of all the patients who come to the Women's Life Center are pregnant women suffering from severe psychiatric conditions, with equal numbers suffering from depression and anxiety disorders.
Burt speculates that the number of pregnant women who are depressed or suffering from anxiety disorders will likely increase as women continue getting pregnant later in life. She bases her theory on figures that show that more older women than younger women have psychiatric problems. (According to Census Bureau findings, the number of women 35 and older giving birth for the first time has quadrupled in the past decade.) And any woman who has had severe psychiatric disorders stands a greater chance of recurrence during pregnancy and postpartum.
"We have a lot of women who come to us who want to get pregnant, but are afraid to because of a history of depression and a fear of recurrence if they go off their medication," says Burt, who directs the center's two psychiatrists and five medical residents in training.
Once depression or anxiety disorders are diagnosed in a pregnant woman, the psychiatrist and patient are presented with a difficult therapeutic problem.
Whenever possible, drug-free therapies such as psychotherapy, interpersonal and behavioral therapy are primary choices. But in cases in which those approaches aren't effective and the well-being of the woman and her baby is compromised, the risks and benefits of medication, hospitalization and electroconvulsive therapy (ECT) are weighed.
"There is very little data that guides us for treating women who are pregnant," says Dr. Susan Blumenthal, psychiatrist and director of the U.S. Public Health Services Office on Women's Health, noting that the Food and Drug Administration is just beginning to investigate the affect and use of drugs during pregnancy. "We now have a new national focus on women's health, so many of those questions will be faced head-on."
Indeed, the issue is under active discussion at the FDA, which held a two-day conference in November and addressed how drugs work in pregnant women, whose physiological changes during pregnancy can alter a drug's effectiveness.
The American Psychiatric Assn.'s 1993 guidelines on treating psychiatric disorders in pregnant women advises great caution when using antidepressants, stating that although there is no proof of malformations in humans exposed to the drug in utero, "the issue remains open." (Also unknown is the neurobehavioral affects on children born to these mothers.)
When medication is unsuitable, the guidelines advise the use of ECT, which consists of a brief jolt from a specifically designed machine that induces an epileptic-style seizure that lasts 30 to 60 seconds.
"ECT is for the severest of cases," Burt says, adding that while there have been no clinical studies on the long-term effects of ECT on children who have been exposed in utero, anecdotal cases suggest that there are no adverse effects. "For someone who can't tolerate medication, ECT is really the choice," she says.
Burt and Cohen say they refrain from prescribing medication in the first trimester of pregnancy whenever possible, the time when a baby's organs are formed. But in the most extreme cases, in which a woman is suicidal or has delusions about hurting the fetus, medication during those three months is not ruled out.
"What we do is carefully review the risks and benefits of using a particular medication during pregnancy based on published case reports," Burt says. "It is done very carefully with obstetrical and psychiatric teams. I don't aim for perfection; I just want to make sure the patient is treated with the lowest dose possible to get her through the pregnancy." Burt adds that on occasion, she uses newer drugs such as Prozac to treat dire cases.
Other psychiatrists who specialize in perinatal psychiatry feel less confident with the newer drugs, which don't have the track record that older drugs do.
"If we can, we use a drug that has been around for 50 years," says Dr. Leslie Hartley Gise, associate clinical professor in the departments of psychiatry and obstetrics, gynecology and obstetrics at the Mt. Sinai School of Medicine at New York.
There are no scientific studies on whether psychotropic drugs can cause miscarriage, or malformation or other problems in children exposed to the drugs in utero, and giving pregnant women the drugs solely for a rigorous scientific study would be unethical, Burt says. But case reports on women who have taken psychotropic drugs unaware that they were pregnant show that there is no higher risk of fetal malformation compared with the general population of women--2% to 3%.
Beth plans to continue taking her antidepressant medication to avert postpartum depression--something a new mother with a history of psychiatric disorders stands a 20% to 40% chance of getting. She does not breast-feed at Burt's urging, something the psychiatrist recommends to all her patients on medication.
"It was really a tough nine months," says Beth during a telephone interview, with the tiny bird-like cries of her healthy 2-month-old daughter in the background. "I couldn't have gotten through it without the medication . . . and I don't know how fine the baby would be if I hadn't been on medication. It's really a happy ending."