Treatment for Motherhood Blues Poses Dilemmas for Patients

Days away from delivering her second child, Amy Van Sickel felt unnerved by a sense of foreboding.

Even now, two years later, she can recall that fear: “Somehow, emotionally, I wasn’t going to be able to handle the birth.”

Indeed, after the birth, Van Sickel wanted to die. Minutes felt like days, days like months. “I went home, and I didn’t sleep for six days straight,” she recounts now.

The emotional pain was also unspeakable: “as deep as any gouging wound.”

She tried herbs, acupuncture, hypnotherapy, cranial massage, a diet recommended by a homeopathic doctor. Nothing worked.

Desperate, struggling to care for her children, she turned to a psychiatrist. The diagnosis? A classic case of postpartum depression that a prescription could help.

Van Sickel, a 36-year-old massage therapist from Santa Monica, is typical of women conditioned to believe that drugs would harm a fetus or nursing baby. A woman who rarely took even aspirin, she suddenly found herself among thousands of women wrestling with the risks of taking medication for depression while pregnant or nursing.

An explosion in prescriptions for the new generation of antidepressants--including Prozac, Paxil, Zoloft and Luvox--makes the dilemma real, as does the fact that more women are postponing childbirth until their 30s and 40s, when statistically they are more likely to get depressed.

They face many options: Take medication or do without. Try psychotherapy. Or, in severe cases, try electroshock, a treatment believed safe for the fetus.

With women’s health a major concern of the decade, more mental health professionals are tackling the special needs of these depressed women.

Van Sickel’s psychiatrist, Dr. Victoria C. Hendrick of UCLA, prescribed one of the longer established antidepressants, nortriptyline, which had the lowest known risk for her breast-feeding daughter.

When that proved inadequate, Van Sickel agreed to combine it with Zoloft, a newer antidepressant with fewer side effects for her but more unknowns for her infant.

“The minute I started taking it, I felt better,” she says.

Not all antidepressants work so quickly. Many require two to four weeks to reach peak effect.

Today, Van Sickel is off medication. But her experience convinced her that drugs can help some women face a problem that pregnancy triggers or exacerbates.

Psychiatrists say depression affects about 10% of pregnant women and those who have recently given birth; it’s more frequent among women with a history of depression.

After delivery, the chances of becoming depressed triple for women who experienced depression earlier. For unclear reasons, stress and marital discord may also contribute to postpartum depression, as do dramatic hormonal changes after giving birth.

Such depression often is untreated. Many obstetricians and their patients confuse postpartum depression with the “baby blues,” a mild depression that passes after about 10 days. But unlike those “blues,” postpartum depression lingers and may lead to neglect of the newborn.

At the root of the problem is the misguided perception that pregnancy should be “a wonderful, blissful experience in which people glow and everybody is happy,” says Dr. Zachary Stowe. He directs a program at Atlanta’s Emory University that explores pregnancy and postpartum mood disorders.

During 40 weeks of waiting, expectations clash with discomforts. Then, delivery may be painful and breast-feeding difficult.

Dr. Liza Gold, a psychiatrist from McLean, Va., who specializes in women’s issues, calls the postpartum period “a time of very high biological stress,” with only women “80 and ill” more likely to be depressed. “The shifts in body chemistry around delivery are vast, plus now they’ve got all the stress of having a new baby,” she says.

A woman so depressed that she neglects her own health and nutrition may deny the baby a healthy start, but Stowe says there is not enough hard data to prove that the illness actually harms the unborn.

Research does show that babies of depressed mothers tend to be more withdrawn and irritable and more likely to suffer depression as children.

Because women must weigh the risks of medications versus untreated depression, Stowe voices the practitioner’s caution: “We cannot say any medicine, I don’t care what it is, is safe.”

Some studies do show promise, documenting the well-being of children up to four years after they were born to women who took Prozac or one of the better-studied antidepressants that have been on the market for decades. But doctors do not yet have the long-term data to say if medications will affect a child’s IQ or motor skills, says Dr. Lori Altschuler, a psychiatrist who directs mood disorders research at UCLA.

A recent Canadian study in the Journal of the American Medical Assn. found no greater incidence of birth defects among children of 267 women taking any of three newer antidepressants than among children of 267 women who were not exposed to anything thought to cause birth defects.

Dr. Richard Schwarz, an ob-gyn at New York Methodist Hospital in Brooklyn, is among critics who say the study group is too small to conclude that the drugs are “perfectly safe during pregnancy.”

Schwarz, a consultant to the March of Dimes Birth Defects Foundation, worries about babies exposed to antidepressants during the first three critical months of development in the womb. He’s especially concerned about unplanned pregnancies where mothers may have inadvertently exposed fetuses.

At the same time, he doesn’t want women taking antidepressants for serious depression to “suddenly stop, commit suicide.”

“What we’re talking about,” he says, “is weigh the need against what is at the moment an indefinite, unknown kind of risk.”

Researchers at Emory, UCLA and Harvard are measuring antidepressant levels in breast milk to help mothers minimize medication passed to babies. They suggest that mothers discard milk at those times of day when concentrations are highest, or, to be 100% safe, bottle-feed.

Dr. Lawrence Gartner, a neonatologist at the University of Chicago, favors breast-feeding. Babies, he says, rarely experience more than sleepiness from milk of mothers who use antidepressants.

“The benefits of breast-feeding far outweigh the very minimal risk of any of these drugs’ effects--all of which are reversible,” says Gartner, who chairs an American Academy of Pediatrics group that studies breast-feeding.

Severely depressed pregnant women with long histories of the illness face some of the toughest decisions.

When she became pregnant at 41, Candy Greene of Redondo Beach was terrified of halting her lifeline of medication. She struggled through the first three months of pregnancy without drugs, “and amazingly, the depression lifted.” But depression returned after her daughter’s birth, and she resumed antidepressants.

Pregnant again at 46, the public relations consultant began a “long, slow slide” when she stopped the medication in her second trimester.

“I didn’t much care about the baby at all,” she recalls. “I was too depressed to care.”

Back on Zoloft, Greene delivered a healthy boy in November. “The idea there’s something that will allow you to be OK and [does] not hurt your child really makes a normal life possible,” she says.

Dr. Katherine Wisner, a professor of psychiatry and reproductive medicine at Case Western Reserve School of Medicine in Cleveland, studies medications and alternatives. As more is known about medications, and risks appear “less and less,” she says she and her patients are more comfortable in selecting them.

Although often overlooked, psychotherapy can provide an effective alternative. But UCLA’s Hendrick says “it gets dismissed so quickly these days because of cost-containment pressures to treat quickly.”

Dr. Margaret Spinelli, director of the maternal mental health program at the New York State Psychiatric Institute, is following up on a pilot study of short-term talk therapy during pregnancy.

Interpersonal psychotherapy targets specific events, including the transition to motherhood, with the therapist helping the patient modify relationships or change expectations. “When I first started doing it, I really thought it was hocus-pocus,” Spinelli says. But good results in her pregnant patients made her a believer.

Michael O’Hara, psychology chairman at the University of Iowa, has federal funding to study the same therapy in new mothers. “This is particularly appropriate for women who have mild or moderate levels of depression,” O’Hara says. He’s convinced it works as well as medication.

Another option, light therapy, is in the experimental stage at three medical centers. Wisner, Spinelli and Yale researchers place depressed pregnant women in front of light boxes similar to those used to treat “winter blues,” seasonal affective disorder. Both Wisner and Spinelli have recorded successes in private practice.

Hendrick also encourages patients to read books and join support groups, like Postpartum Support International, based in Santa Barbara. Their goal, like hers, she says, is “to help them recognize there are a lot of other women like them who experience postpartum depression and recover.”