Treatment for Depression in Mothers

I have been a mother struggling more or less with depression now for 2 years (I had to work that out several times because it feels like 20). In that time I’ve done quite a lot to help myself which has made the biggest difference; I’ve also reached out to the NHS who have not helped much at all- and I’ve done enough research to know that the care I’ve received from them has been at best short term and superficial (medication) and at worst erroneous and dangerous. So I’ve wanted for quite a while to write an article imparting what I’ve learnt to other other women in the same position- because, for me, a mother could not be a higher priority case but (as you probably know if you are a mother with depression)- GP’s seem to care very little. Note: I am really sorry for the generalisation to any conscientious GP’s out there doing great work, I’m talking from personal experience and a mass of anecdotal evidence about what does seem to be the unfortunate norm. I’m finding this difficult to write because it makes me feel utterly defenceless consciously accepting my lack of professional support. I successfully suppress this knowledge most of the time but I had to see a GP today and my experience was so awful that from relative stability it’s triggered the worst down I’ve had for a while so- while I can’t feel much worse- I want to tackle this goal and hopefully help someone.

Let’s do the obligatory ‘look you’re not alone statistics’:
* Around 10% of women are believed to be experiencing depression in the UK at any given time- that’s pre-natal, post-natal or outside of the perinatal period altogether (although post-natal depression is associated with greater severity and incidence of psychosis and suicide).
* 1 in 3 women will be prescribed antidepressants in their lifetime (most commonly in their reproductive years).
* Up to 4% of pregnant women are taking antidepressants.
* Interestingly, 18% of women keep their medication secret from their family, 10% do not even tell their partner.

If you think you may be depressed you should seek professional help but if you feel the need to tick some boxes before you can make that leap there is a ‘depression test’ that GP’s routinely administer and is available at http://www.nhs.uk/Tools/Pages/depression.aspx. Here is a plain text version of it:

Could you be depressed?

There are many symptoms of depression, including low mood, feelings of hopelessness, low self-esteem, lack of energy and problems with sleep. The more symptoms someone has, the more likely they are to be depressed.

This test will help you to assess whether you could be suffering from depression.

Answer the questions based on how you’ve been feeling during the last two weeks.

1.Have you found little pleasure or interest in doing things?

No, not at all (0 points)

On some days (1 point)

On more than half the days (2 points)

Nearly every day (3 points)

2.Have you found yourself feeling down, depressed or hopeless?

No, not at all (0 points)

On some days (1 points)

On more than half the days (2 points)

Nearly every day (3 points)

3.Have you had trouble falling or staying asleep, or sleeping too much?

No, not at all (0 point)

On some days (1 points)

On more than half the days (2 points)

Nearly every day (3 points)

4.Have you been feeling tired or had little energy?

No, not at all (0 points)

On some days (1 point)

On more than half the days (2 points)

Nearly every day (3 points)

5.Have you had a poor appetite or been overeating?

No, not at all (0 points)

On some days (1 point)

On more than half the days (2 points)

Nearly every day (3 points)

6.Have you felt that you’re a failure or let yourself or your family down?

No, not at all (0 points)

On some days (1 point)

On more than half the days (2 points)

Nearly every day (3 points)

7.Have you had some trouble concentrating on things like reading the paper or watching TV?

No, not at all (0 points)

On some days (1 point)

On more than half the days (2 points)

Nearly every day (3 points)

8.Have you been moving or speaking slowly, or very fidgety, so that other people could notice?

No, not at all (0 points)

On some days (1 point)

On more than half the days (2 points)

Nearly every day (3 points)

9.Have you thought that you’d be better off dead or hurting yourself in some way?

No, not at all (0 points)

On some days (1 point)

On more than half the days (2 points)

Nearly every day (3 points)

More on suicidal thoughts

If you have had thoughts of self-harming or are feeling suicidal contact someone immediately.
• See your GP or the out-of-hours GP service. If you have already taken an overdose or cut yourself badly, dial 999.
• There are helplines with specially trained volunteers who’ll listen to you, understand what you’re going through, and help you through the immediate crisis.
• Or contact a friend, family or someone you trust.

The Samaritans operate a service open 24 hours a day, 365 days a year, for people who want to talk in confidence. Call 08457 909090.

RESULTS

0-10 points

Based on your responses today it’s unlikely you’re suffering from depression.

While it’s unlikely that you have depression, if you have any concerns about your health, or mood, please call NHS Direct on 0845 4647 or arrange to speak to your GP.

More information on depression, and its causes, can be found by following the link at the bottom of this tool.

10-27 points

Based on your responses today it’s very likely that you could be suffering from some form of depression but only an experienced health professional can tell for sure.

You should make an appointment to see your GP as soon as possible or call NHS Direct on 0845 4647. They will be able to help you and offer some form of treatment.

Most people with depression improve with good care, which may include changes you can make to your life, talk therapy and medication.

This is for information only and is not intended to replace a consultation with a GP. The PHQ was developed by Drs Robert L Spitzer, Janet BW Williams, Kurt Kroenka and colleagues with a grant from Pfizer Inc. Reproduced with permission.

NHS Choices 2013

Once you have confirmed some kind of diagnosis of depression is where things start to get very tricky for a woman of child bearing age being treated by her GP. Professor Howard (head of Women’s Mental Health section at the Institute of Psychiatry, Kings College) attests that “the risk of taking most antidepressants is very, very small” but also advises avoiding them if possible at child bearing age (half of pregnancies are unplanned), looking instead to psychological therapies as the first line of defence. Advice from the Royal College of Psychiatry suggests that GP’s should always refer depressed patients to a psychiatrist for the prescription of antidepressants. I am yet to meet any woman whose GP spoke to them about their medication in relation to pregnancy (regardless of their situation and whether they were likely to become pregnant in the near future) unless they were literally pregnant at the time. Evaluation from a trained psychiatrist is incredibly rare, and generally must be fought for by the patient. What should be a detailed risk/benefit analysis conducted by the patient and those caring for her to minimise exposure both to the illness and treatment is all too often a stab in the dark by someone of limited expertise with little choice or explanation given about the chosen medication. The elephant in the room is likely to be Professor Howard’s ‘psychological therapies’, far from being ‘first line of defence’, they are nigh-on impossible to obtain from the NHS (though many people find this kind of assistance, for free, from the charity MIND, who are always highly commended).

Pregnancy is a critical point in a woman’s life to achieve this balance of minimising exposure to illness and treatment unfortunately knowledge is limited making choices very difficult to make. Companies do not recruit pregnant women for tests on antidepressants for ethical reasons and this leaves massive holes in our knowledge both of the drugs effects on unborn babies and of what the physiological changes in the pregnant woman does to the functioning of the drugs. Even the effects of untreated mental illness are relatively less documented than say poor diet/ smoking/ drinking or drug use in pregnancy. But what is known is that the presence of high levels of cortisol in the womb (as there is in untreated or unsuccessfully treated depressed mothers-to-be) are linked to: miscarriage, low birthweight/ preterm birth, increased use of pain relief in labour and worse obstetric outcome, impaired attachment in the postnatal period, poor growth and impaired development in children, behavioural disturbances, family breakup and predisposition to stress, anxiety and depression (attempted and completed suicide) in adulthood. No decision is risk free, advice for all medications is to take as little as possible especially during the first and last 3 months of pregnancy, but mental health complications outweigh the dangers of responsible pharmacotherapy. Pregnancy can mask symptoms of depression such as fatigue, insomnia and appetite changes so psychological symptoms (see NHS questionnaire above) are more reliable in pregnancy- and, despite the difficulties, just so worth investigating as part of your commitment to parenting your coming child.

There are four main types of antidepressant: Tricyclics, MAOIs (Monoamine oxidase inhibitors), SSRIs (Selective Serotonin Uptake Inhibitors) and SNRIs (Serotonin and Noradrenaline Reuptake Inhibitors). There is no research into MAOIs therefore they are not advised during pregnancy. In the ‘Summary of Product Characteristics’ of SSRIs and SNRIs you should find that they are not recommended for pregnant or nursing mothers. This is a legal statement and is due to insufficient evidence for licensing for mothers caused by the ethical constraints in testing. However there is a lot of evidence out there suggesting their safety so it is at the discretion of the prescribing doctor and they do seem to have fewer side-effects than Tricyclics which have been in use for such a long time that their use by pregnant women is regarded as fairly safe (though still not licensed). In fact the only antidepressant that is licensed for use by pregnant women is Fluoxetine and this is as a result of the length of time it’s been in use and the sheer quantity of data that has been collected on it- but this does not mean it is the best medication for any given pregnant woman and a really knowledgable health practitioner may be able to recommend to their patients more suitable options off-license.

Breastfeeding with antidepressant use is another complex issue with even less controlled or systematic research. What evidence there is is from small case series and single case reports. These confirm that antidepressants are excreted into breast milk at varying rates. They also show that infants have a decreased capacity for drug metabolism (compared to adults) until the 3rd week of life then it gradually increases till by the 8th to 12th week the rate is several times faster than an adults. At the moment although there is not enough evidence to support categorical guidelines there are no conclusive contraindications against the use of Tricyclics, SSRIs or SNRIs whilst breastfeeding. Furthermore, the physical touching in breastfeeding promotes attachment and better mental health and the abnormal brain function apparent in one month olds whose mothers were depressed in pregnancy inexplicably disappears if the baby is breastfed.

It is of course a fantastic idea to pursue holistic methods of managing depression, including the myriad of psychological therapies available, relaxation techniques, social interaction and support groups (all of which you will likely have to access without the help of the NHS I’m afraid). Counter-intuitively though, the martyrs road of rejecting pharmaceuticals whilst pregnant or breastfeeding may not be in your child’s best interests (though this is adverse to the advice most GPs dole out). It is an unfair burden on an ill mother but you must do your own research, pressure your GP unrelentingly for what you think you need from them and discover the changes and practices you need to implement for long-term health on your own. Welcome to parenthood!

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