Can the term "adoption" cause depression in a mother & her baby?
It seems to me that adoptees from the Closed Era of Adoption are more likely to suffer from depressive and anxiety disorders than our non-adopted brethren. In fact, animal studies have proven over and over how Stress effects pregnancy health.
I found the following article, and I cannot help but ask the burning question: How many of our mothers were stressed-out and depressed during pregnancy because they were told they couldn't keep their baby?
Think Adoption doesn't alter our brain development? Read how maternal feelings affect her unborn baby, and how the threat of loss can translate itself into a family history of depression.
WHICH IS MORE TOXIC TO A FETUS— ANTIDEPRESSANTS OR MATERNAL DEPRESSION?
NEW ORLEANS—Although clinicians routinely weigh the benefits of a given medication or treatment against its potential adverse effects, this clinical balancing act is rarely more difficult than it is when a patient is pregnant or breastfeeding. In such cases, of course, the complex web of benefits and risks involves not only the patient but the fetus or child as well.
Historically, many psychiatrists and patients have considered avoidance of medication to be the safest choice, at least for the child. But during the past decade studies have cast doubt on this view, suggesting instead that untreated maternal depression may actually have a more adverse effect on fetal well-being than antidepressant drugs do. “Depression is not a benign state,” said Katherine L. Wisner, MD, MS, Associate Professor of Psychiatry at Case Western Reserve University School of Medicine in Cleveland, at the annual meeting of the American Psychiatric Association (APA). “I think of depression itself as a kind of toxic exposure.”
Other experts echoed this view. “I have spent the last 10 years of my career worrying about the impact of medications,” said Zachary N. Stowe, MD, Associate Professor of Psychiatry and Behavioral Sciences, and Director of the Pregnancy and Postpartum Mood Disorders Program, at Emory University in Atlanta. “I’ve been wrong. I should have been worrying more about the impact of illness.”
THE HIDDEN RISKS
Numerous studies have documented that maternal depression has adverse effects on fetal and infant well-being. Untreated depression during pregnancy is associated with premature labor and low birth weight, and depressed mothers-to-be are more likely than their nondepressed peers to use alcohol, nicotine, and illegal drugs, all of which can have adverse effects on the fetus. Depressed women also have higher levels of stress, a concern because animal studies have documented that the offspring of mothers subjected to high levels of stress during pregnancy show abnormal growth and impaired learning as adults. And a study presented at the APA meeting by Dr. Stowe’s group revealed that 6-month-old infants whose mothers had been depressed during pregnancy show a higher than normal cortisol response when subjected to stress (eg, loud noises). It remains unclear, however, whether untreated maternal depression during pregnancy—or, for that matter, antidepressant use during that period—has long-term effects on child behavior and development in humans.
Maternal depression is also a danger to the child during the postpartum and early childhood periods. For example, recent data indicate that maternal depression is a major predictor of negative parenting behaviors (eg, yelling, spanking) and that each additional depressive symptom increases the likelihood that the mother will exhibit low levels of positive parenting behaviors, such as reading or playing with the child.
YES, THE FETUS IS EXPOSED…
The data examining the impact of maternal depression on the child are dwarfed, however, by the number of studies looking at the safety of antidepressant use during pregnancy and breastfeeding. “Our fear of psychiatric medications has generated an enormous amount of data in the last five years,” said Dr. Stowe, noting that the number of cases in the literature regarding the safety of antidepressant drug use during breastfeeding has risen seven-fold since 1996.
Two major themes run through the clinical and preclinical literature. One—a message that patients often would rather not hear—is that women using antidepressants during pregnancy are exposing their infants to medication. Not only do antidepressants pass through the umbilical cord, but the medication that the fetus excretes into the amniotic fluid is reabsorbed by the respiratory and gastrointestinal tracts. In the case of fluoxetine, the latter routes of exposure alone can add up to a dosage of 3 mg/d, according to Dr. Stowe.
How much of this medicine reaches the brain? Given the obvious impediments to obtaining fetal brain samples in humans, Dr. Stowe and colleagues investigated this issue in a rat model; the findings indicated that the concentration of fluoxetine in the fetal brain is roughly three quarters of that in the mother’s brain. Assuming that the same holds true for humans, Dr. Stowe said, the implications are clear: “If you give a woman an antidepressant during pregnancy, you’re probably giving the child a therapeutic dose of that medicine.”
…BUT DOES IT MATTER?
Fortunately, the second theme running through the literature is that nearly all the studies to date have failed to detect significant adverse effects from fetal exposure to antidepressants. Thus far, researchers have reported outcomes for more than 400 prenatal exposures to tricyclic antidepressants; these data have not shown any evidence of an increased risk for major malformations. The literature for selective serotonin reuptake inhibitors (SSRIs) is even larger—more than 3,000 exposures, most of them with fluoxetine—and there has been no evidence that these medications increase the risk of miscarriage, premature birth, or major birth malformations.
Not every study has concluded that the SSRIs are safe for the fetus, however. The major exception—one that continues to concern many patients and physicians—is a 1996 New England Journal of Medicine article in which Christina Chambers, MD, and colleagues at the University of California, San Diego, reported that infants whose mothers used fluoxetine while pregnant were more than twice as likely as control infants to have three or more “minor anomalies” at birth. They also had an 8.7 relative risk of poor neonatal adaptation (eg, respiratory difficulty, jitteriness) and a 2.6 relative risk of being admitted to a special care nursery.
Because these findings didn’t match his clinical experience, Lee S. Cohen, MD, Director of the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital in Boston and Associate Professor of Psychiatry at Harvard Medical School, performed a study using the same design as Chambers et al. To their surprise, the findings, published in Biological Psychiatry last November, were “very consistent” with those of the San Diego group, showing an increased rate of special care admissions associated with prenatal fluoxetine exposure. Dr. Cohen noted, however, that the reasons for infant admission—anomalies such as left facial droop or a skin lesion on the arm—were not problems one would typically attribute to fluoxetine exposure. Moreover, the duration of special care stay was quite short: Nearly all of the infants left the hospital with their mothers.
These findings have been replicated yet again by Dr. Cohen’s group, this time for SSRIs other than fluoxetine, in a retrospective study presented at the APA meeting by Kimberly H. Pearson, MD. Compared to neonates without antidepressant exposure, those whose mothers used SSRIs during pregnancy were more likely to receive a special care admission, even though there were no differences between the groups in Apgar scores or in the rate of readily apparent adverse events. Moreover, the special care stays were much shorter than those of the control group, mirroring earlier studies.
What these data suggest, Dr. Cohen said, is that the special care admissions associated with SSRI use may reveal less about the medicine’s effects than about clinicians’ assumptions. Specifically, he suspects that many doctors consider a brief visit to the special care unit to be a reasonable precaution for an infant exposed to antidepressants. “We have come to believe that the threshold to send a child with SSRI exposure to a special care nursery for observation is extremely low—and has very little long-term predictive value,” he said.
Still, it is possible, Dr. Wisner pointed out, that the minor malformations observed in these studies are a marker for some more subtle central nervous system anomaly that might not become apparent until later in development. Thus far, only one study has examined long-term behavioral outcomes in this setting; the researchers followed children for 16 to 86 months after birth and found no evidence that prenatal exposure to fluoxetine or tricyclics increased the risk of behavioral problems. But more such studies are clearly needed, Dr. Wisner said.
A final concern is neonatal toxicity. Dr. Stowe noted that there have been several reports of possible withdrawal effects, such as tremor, sedation, and decreased muscle tone, in infants with prenatal antidepressant exposure. But these symptoms resolve within 72 hours.
BREASTFEEDING: MORE REASSURANCES
Infant exposure to antidepressants is also a common concern during the postnatal period: Estimates suggest that as many as a quarter of a million breastfeeding women develop postpartum depression each year. Unfortunately, as with treatment during pregnancy, women hoping that their breast-fed infant will not ingest any drug are destined for disappointment. “Without a doubt, baby will be exposed,” Dr. Stowe said.
For women who used antidepressants during pregnancy, the good news is that the amount of additional medication that the infant will receive in breast milk is not substantial. “A woman would have to breastfeed for four and a half years to equal the exposure of one month of pregnancy,” Dr. Stowe said. “So if she took an antidepressant in pregnancy and you’re worried about exposure [during breastfeeding], you’re worrying a bit late.” Put another way, he said, a baby’s annual dose of sertraline or fluoxetine is, at most, only about twice the mother’s daily dose.
The bottom line? “We have no evidence to date that psychiatric medicines during breastfeeding produce any adverse effects to the child,” Dr. Stowe said.
IS PROPHYLAXIS WARRANTED?
Given the apparent safety of antidepressants and the possible adverse effects of untreated depression, is prophylactic treatment warranted during pregnancy and the postpartum period? For women with a significant history of depression, the answer may be yes. In a pilot study, Dr. Cohen and colleagues prospectively followed a group of women whose depression was in remission and who discontinued antidepressant use about two months before conception. “By the end of pregnancy, about 75% of those women relapsed,” most of them in the first trimester, Dr. Cohen reported.
Similarly, the incidence of postpartum depression is about 50% for women with a history of postpartum depression and about 33% for women with a history of depression during pregnancy, according to Victoria Hendrick, MD, Director of the UCLA Pregnancy and Postpartum Mood Disorders Program. Women with high levels of stress, family difficulties, or infant health problems have an especially great risk, she said. In contrast, only 2% to 5% of women without a history of depression develop postpartum depression.
Several common-sense guidelines apply to prophylactic therapy. First, said Dr. Stowe, clinicians should prescribe the antidepressant that has worked for the patient in the past and avoid those that haven’t. Moreover, he said, “monotherapy at any dose is preferable to two medicines. Two medicines is the world of the unknown” with regard to infant outcomes. In addition, Dr. Stowe said he is more likely to recommend prophylaxis if the mother has other young children.
The increases in a woman’s body weight, plasma volume, body fat, and renal function that occur during pregnancy (especially in the final trimester) may necessitate higher medication doses to maintain therapeutic levels. In extreme cases, a threefold increase may be appropriate. This precaution is by no means overkill, Dr. Stowe said; if the mother becomes symptomatic because the dose was not increased, then the fetus has been exposed not only to medication but to the physiologic effects of depression. However, Dr. Cohen noted that he does not change a patient’s dose during pregnancy unless she becomes symptomatic.
Currently there is little controlled data supporting the efficacy of postpartum prophylactic therapy. In a study published in the February Journal of Clinical Psychiatry, Dr. Wisner and colleagues randomized 51 women to nortriptyline or placebo in an attempt to ward off postpartum depression. Though the researchers were able to begin treatment within 24 hours of birth, nortriptyline proved to be no better than placebo at preventing postpartum depression, a fact highlighted by the survival curve that Dr. Wisner displayed during her presentation. “If I wanted to construct a graph that showed no difference [between two treatments] better than this, I would have a hard time,” she lamented, adding that the researchers are now testing whether sertraline offers any prophylactic benefits.
Still, Dr. Hendrick said, “in my experience prophylactic interventions do tend to work, and I recommend them for women with a history of postpartum depression, especially those who experienced depressive symptoms during pregnancy or who are experiencing significant stress during the postpartum period.”
IS PSYCHOTHERAPY APPROPRIATE?
Thus far, two randomized controlled trials have examined the benefits of psychotherapy during the postpartum period. In a 1997 University of Manchester study, six sessions of cognitive therapy during a 12-week period produced a statistically and clinically significant reduction in depressive symptoms. The same was true of a recent University of Iowa study utilizing interpersonal psychotherapy: Scores on the Beck Depression Inventory fell by an average of 12.6 points, compared to a 3.8-point drop among wait-listed controls. Moreover, women in the active treatment group were three times more likely to achieve remission.
Given these findings, should patients consider bypassing pharmacotherapy in favor of psychotherapy? “Our clinical experience has been that for patients with more mild depression, that may actually be fine,” Dr. Cohen said. “Where we have not had success—though we don’t have data on it—is for patients who have much more serious illness. If we can avoid medicines and use psychotherapy, that would be wonderful, but in patients who are severely and recurrently ill, I don’t think we have that luxury.”
A PERSONAL CHOICE
Ultimately, the experts agreed, a woman’s decision to use antidepressants while pregnant or breastfeeding is an extremely personal one. It depends not only on her medical status but on her values and risk perception. Dr. Wisner noted that some patients will say, even after extensive counseling, “I don’t care how much you tell me about what is known about these drugs, I just cannot put a drug in my mouth during pregnancy. I’d rather take the risk of depression.” In such cases, it is important not to pressure patients into unwanted therapy. “We’ve always viewed our role as not to drive the car, but to inform patients in a systematic way,” Dr. Cohen said. “What we tell patients is that there is no perfect decision, and no decision is risk free. Patients need to know about the risk of exposure, and they need to know about the risk of untreated disease.”
—Peter Doskoch
Suggested Reading
Wisner KL, Zarin DA, Holmboe ES, et al. Risk-benefit decision making for treatment of depression during pregnancy. Am J Psychiatry. 2000;157:1933-1940.http://www.neuropsychiatryreviews.com/jun01/npr_jun01_antidepressants.html