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"​Seaneen Molloy was excited to discover she was expecting her second baby during lockdown. With a history of mental illness, she carefully planned the pregnancy, but when her baby arrived she experienced the "terrifyingly rapid" onset of a crisis which left her unable to hold baby Jack."

"Having a baby is supposed to be a joyful experience, and for lots of women it is. However, up to 20% experience mental ill health during pregnancy and the year after birth. Tragically, suicide is the leading cause of death in new mothers.
Women who already have a mental illness are at a high risk of relapse during pregnancy - that's women like me.

I have a diagnosis of bipolar disorder and an anxiety disorder. This meant that pretty much from the moment I became pregnant, the perinatal mental health team were involved.

This includes specialist midwives, psychiatrists, nurses and social workers whose goal is to support women to stay well, and intervene quickly if they don't.

Normally, I manage my mental health by being careful with my sleep and leading a pretty boring life away from overwork and alcohol, but pregnancy chucks in a host of factors you have no control over.

Hormones rage through your body, wreaking havoc upon your mood, your energy levels and your ability to keep your lunch down. You either can't stay awake or are awake for hours - peeing a thousand times and being hoofed by tiny feet.
I had managed to stay well, and off medication, for years, but in the run-up to birth antipsychotic medication was introduced to prevent postpartum psychosis. This can cause women to develop delusions and lose touch with reality.
It's the one I was most at risk of developing due to my history of bipolar disorder, but in the end, I experienced postnatal anxiety.

My mental health had been largely OK during my pregnancy and my labour and after-care were carefully planned.
I had a calm elective Caesarean section due to a traumatic first birth, a room of my own and the baby was whisked away on his inaugural night so that I could get some all-important sleep (this bit was hard - it went against every natural instinct). A procession of midwives, doctors and social workers visited to see how I was doing.

Although I found it intrusive, it helped me feel safe. When I was discharged from hospital with my baby, Jack, I felt swaddled in care and confident everything would be OK.

It was a complete shock that I did get ill.

In the chaos of newborn-life I forgot a dose of my anti-clotting medication which is given to mothers after C-sections.
And this one tiny event broke my brain.

I went from mildly chiding the home treatment team for their postnatal visits, because I was fine, to a full-blown mental health crisis within about 12 hours. It was terrifyingly rapid - which is why perinatal mental illness can be so deadly.

My mild anxiety exploded into an all-consuming panic that I was going to die imminently from a blood clot in my lung. I couldn't think of anything else but the black terror of certain death that was coming for me - how I was going to leave my children, how I'd brought a new child into the world never to know me.

I called out-of-hours GPs describing symptoms I was convinced I had, sobbed, screamed and couldn't breathe. I terrified my husband and myself.
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Then we hit the emergency button.

The psychiatrist came over with the home treatment team. They took my fears seriously, which I appreciated, and gave me a physical examination and the missed dose of medication. My antipsychotic medication was increased to the maximum dose and benzodiazepines - a type of sedative - prescribed, to try and calm me down.

I wasn't allowed to be left alone and the mental health team were to visit me every day where I tried to articulate my terror to their masked faces.

At first I resented their visits, but they became a 30-minute space where I could let down the exhausting facade and share how I was really feeling.

My anxiety then transformed into an obsession that Jack was going to die. I was afraid to leave the room and rested my hand on his chest all night.

If my husband took him out to the shops with his brother, I cried and paced about, imagining they had all been hit by a car. I texted him incessantly.

Everyone was saying I needed "rest", so he tried to give me space. But after the second or third breakdown, he agreed to keep his phone on loud and to answer quickly. The home treatment team also advised he give me clear timescales so I knew when to expect them home.

​But the medication also caused intense restlessness. I couldn't sit still. I couldn't get comfortable enough to hold my baby for more than a minute."

"This is a question we often hear.  One of the challenges in answering this question is the interpretation of the word “best”.  On one hand, the best antidepressant is the one that is the most likely to be effective.  On the other hand, the best antidepressant is the one that carries the least risk when used during pregnancy. What this means is that there is no single answer.  Each situation is different, and our recommendations are based on a careful assessment of the patient’s course of illness, treatment history, past medication trials, and the most up-to-date information on reproductive safety. Added to this calculation is the understanding that untreated depression also carries some risk in terms of maternal well-being and has been associated with worse pregnancy outcomes.  

Stay with the Same Treatment or Switch?
We often meet with women who have switched to a different antidepressant medication in preparation for pregnancy.  Other women make a switch when they discover they are pregnant.  These switches are motivated by the belief that there is a “safer” medication to be used during pregnancy.  The reality is that most of the antidepressants taken by women today are relatively safe and carry a very low risk to the developing fetus.  What separates one antidepressant from another is that some medications have more data to support their reproductive safety than others.  But even this distinction is disappearing; we have data to support the use of most SSRIs (with less data on fluvoxamine or Luvox), the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor), and bupropion (Wellbutrin). Tricyclic antidepressants, although not commonly used today, also have data to support their reproductive safety.  

MAO Inhibitors: 
We have very little data on the reproductive safety of the MAO inhibitors. In addition, MAO inhibitors may have serious interactions with other medications frequency used during pregnancy and labor and delivery, specifically medications used to manage pain, such as nalbuphine (Nubain) and meperidine (Demerol).  In women taking these medications, we are likely to suggest switching to another antidepressant with a better reproductive safety profile.  

Mirtazapine (Remeron):  
At this point, we have less data on the use of the newer antidepressants. There is some data on mirtazapine, with the most recent study including 334 cases of neonates with prenatal exposure to mirtazapine.  While these data are reassuring and there is no indication that mirtazapine carries significant teratogenic risk, the number of mirtazapine exposures remains small.  Ideally we would like to have data from 600-700 exposures to get a better estimate of risk.  Making decisions regarding safety on studies with small sample sizes can lead to miscalculations of risk in either direction.

Other Antidepressants: 
The data is even more limited with regard to the use of vortioxetine (Trintellix), vilazodone (Viibryd), levomilnacipran (Fetzima). If there are effective alternatives, we typically recommend switching to another antidepressant.  
In settings where we have limited data regarding the reproductive safety of a particular antidepressant, we may consider switching to an antidepressant with a better characterized reproductive safety profile.  It is important, however, to carefully consider the benefits and risks of making this switch. With any switch, there is the risk of relapse when making a change in the maintenance treatment. Thus, there are situations where we recommend continuing an antidepressant with limited reproductive safety information because there are no effective alternatives and the risk of relapse is significant.  

What About Zoloft? Isn’t Zoloft the Safest?
At some point in the early 2000s, there emerged the belief that sertraline (Zoloft) was the safest antidepressant to use during pregnancy, and many women taking other antidepressants were encouraged to switch to sertraline during pregnancy.  It is somewhat unclear where this opinion came from — maybe one paper suggesting lower placental passage of sertraline compared to other antidepressants; however, there is and never was any solid data to support the assertion that sertraline is safer or the safest antidepressant.  Reflexively switching women to sertraline puts women at risk for recurrent illness.  

While sertraline is effective for the treatment of depression and anxiety and is a reasonable choice for many women, one problem with sertraline is that it tends to be under-dosed. The typical starting dose is 50 mg; however, many individuals will need 150 mg to 200 mg to effectively manage their symptoms.  Especially when sertraline treatment is initiated in the primary care setting, we often see women whose dose is too low to effectively manage their symptoms.   

What About Paxil? Doesn’t It Cause Heart Defects?
The most current data regarding the use of paroxetine (Paxil) during pregnancy does not indicate an association between the use of paroxetine during pregnancy and risk for cardiovascular malformations.  However, in 2006, GlaxoSmithKline (GSK) elected to change product label warnings for the antidepressant paroxetine (Paxil), advising against the use of this drug by women who are pregnant. This decision was based on two preliminary studies which suggested a small increase in the risk of cardiovascular malformations among infants exposed to paroxetine in utero. For many years, this concern regarding risk of heart defects resulted in recommendations that women taking paroxetine should either stop paroxetine or to switch to a different antidepressant during pregnancy.

However, in 2008, a study from the Motherisk Program in Toronto reported on the outcomes of over 3000 paroxetine-exposed infants and found no association between the use of paroxetine during pregnancy and increased risk of cardiovascular malformations.  Nonetheless, some women and their treaters continue to feel uncomfortable with the use of paroxetine during pregnancy. Furthermore, many websites (including reputable sites like the Mayo Clinic) continue to urge women to avoid paroxetine during pregnancy because of the risk of malformations. 

At this point, we typically do not recommend switching from paroxetine to another antidepressant for pregnancy. Although paroxetine is an SSRI, there are definitely situations where an individual may respond better to paroxetine than to other SSRIs. Thus, switching to a different antidepressant may increase risk for relapse. 

What About Lexapro? And Pristiq?
There are some newer antidepressants that are derived from older parent antidepressants.  For example, citalopram (Celexa) is a racemic mixture, composed of R- and S-enantiomers (or mirror images) of citalopram.  While the S-enantiomer is clinically active, the R-enantiomer is not.  Escitalopram or Lexapro contains only the active S-enantiomer.  Because the S-enantiomer is contained in the original citalopram formulation, we can infer that the reproductive safety of escitalopram (Lexapro) is the same as that of citalopram (Celexa).
Another example is desvenlafaxine or Pristiq.  For venlafaxine to be effective as an antidepressant, it must first be metabolized by the body to desvenlafaxine.  Pristiq contains only the active metabolite desvenlafaxine.   Because desvenlafaxine is a metabolic byproduct of the original venlafaxine formulation, we can infer that the reproductive safety of desvenlafaxine (Pristiq) is the same as that of venlafaxine (Effexor).

The Bottom Line
No two situations are identical; thus, we must carefully consider each woman’s clinical history and preferences in order to select a treatment plan that makes sense.  Ideally this discussion should occur long before a woman is pregnant, so that there is ample time to consider the various options and to make changes, if necessary.  

When we meet with women to discuss the use of antidepressant medications during pregnancy, we typically consider a number of issues:

1. Determine the risk of recurrent illness: Has she had one episode of depression or does she have recurrent depression? If she has attempted to discontinue antidepressants in the past, how long was she able to remain well without medication? If she has had prior pregnancies, what happened to her mood during pregnancy and the postpartum period?
2. Assess the severity of previous episodes of depression: Did the depression contribute to missed days of school or work? Psychiatric hospitalization? Suicidal ideation? Self-harm? Suicide attempt?
3. Review past medication trials: What antidepressants have been effective in the past? Which antidepressants have been ineffective? Assess dose and duration of treatment to determine if the trial was adequate.  
4. Identify factors that may mitigate risk: Has psychotherapy been helpful? Is this an option for decreasing risk for relapse? What about other non-pharmacologic interventions: mindfulness, meditation, yoga, acupuncture, exercise?
5. Discuss options for pharmacologic treatment during pregnancy: What are the antidepressants most likely to maintain stable mood during pregnancy? What is the medication with the best characterized reproductive safety profile? Does it make sense to maintain or to switch to a different antidepressant? Even if the woman ultimately decides that she would like to avoid medications during pregnancy, it is important to discuss options for treatment, in case she relapses during pregnancy and would like to resume treatment. 

We now have data to support the reproductive safety of a large number of antidepressants.  
The perinatal psychiatry consultation should be viewed as a collaborative venture, where provider and patient decide together what is the best option for treatment during pregnancy."

-​Ruta Nonacs, MD PhD

By: Love Amy Michelle | October 28, 2017

"Love Amy Michelle is a space for you to reconnect with yourself + to find some peace amidst the chaos."

​By MGH Center for Women's Mental Health | May 18th, 2021

​By MGH Center for Women's Mental Health | May 6th, 2021

"While we have relatively limited information regarding the prevalence of obsessive-compulsive disorder (OC) during pregnancy and the postpartum period. Previous studies have indicated that women may be more vulnerable to the onset of OCD during the postpartum period. Other studies indicate that women with OCD  may experience worsening of OCD symptoms during pregnancy and the postpartum period. 

A recent study published in the Journal of Clinical Psychiatry looks at the prevalence of OCD symptoms during pregnancy and the postpartum period. They speculate that using standardized instruments for the diagnosis of OCD may fail to capture perinatal OCD, and their study incorporates a detailed assessment of obsessions of infant-related harm and corresponding compulsions.  

In this study, 763 English-speaking women living in the Canadian province of British Columbia were recruited into this longitudinal study following women from the third  trimester of pregnancy until 9 months postpartum.  The Structured Clinical Interview for DSM-5 (SCID-5) was used to confirm DSM-5 diagnoses of OCD.

The weighted prevalence of OCD during pregnancy was 7.8%, and the weighted prevalence increased to 16.9% across the postpartum period.  The estimated point prevalence of OCD diagnosis was 2.6% during pregnancy (6 weeks prior to delivery) and increased to 8.7% at 8 weeks postpartum. The point prevalence of OCD remained high (6.1%) at 20 weeks postpartum.

The incidence of new OCD cases was estimated to be 4.7 new cases per 1000 women each week during the postpartum period.  By six months postpartum, the cumulative incidence of new cases of OCD was  9.0%.  Most cases emerged during the first 10 weeks postpartum.  

In total, the researchers observed that 100 women reported symptoms consistent with a diagnosis of OCD at some point during pregnancy or the postpartum period.  In this group, 60 of the women reported onset of OCD symptoms during pregnancy or the postpartum period.  The remaining 40 women reported that their OCD symptoms preceded the pregnancy.  

High Prevalence of OCD During Pregnancy and the Postpartum Period
The lifetime prevalence rate of obsessive-compulsive disorder (OCD) has been consistently estimated to be 2%-3% in the general adult population in the United States.  The current study indicates that the weighted prevalence of OCD during pregnancy was 7.8% and increased to 16.9% across the postpartum period. Consistent with previous studies, Fairbrother and colleagues conclude that pregnancy and the postpartum period is a time of increased vulnerability to OCD.  In addition, new onset of OCD is relatively common  during pregnancy and the postpartum period, with 9% of women reporting postpartum onset of OCD in this study.  

These estimates of prevalence are higher than those reported in previous studies, a finding that the researchers attribute to using a more comprehensive evaluation of perinatal-specific OC symptoms, including intrusive thoughts of infant-related harm.  However, the authors note that some women joined the study after childbirth and may have been attracted to the study because of their experience of postpartum intrusive thoughts.  Nonetheless, this is one of the largest studies we have regarding the incidence of OCD during pregnancy and the postpartum period and is noteworthy in that it used the SCID to confirm OCD diagnoses.

Current guidelines for screening perinatal women do not specifically recommend screening for OCD.  This study indicates that perinatal OCD is relatively common and the authors recommend more careful screening for perinatal-specific OC symptoms.  They note that standardized assessments for OCD include questions about obsessions involving dirt, germs, arranging and ordering; however, perinatal OCD is more often characterized by intrusive thoughts related to harming the infant (e.g., unwanted thoughts or images of harming the infant on purpose, harm to the infant stemming from parental distraction or neglect, being sexually inappropriate with the infant).  Furthermore, given the shameful and horrifying nature of these thoughts, many women are hesitant to share these thoughts with others."

​-Ruta Nonacs, MD PhD​

By MGH Center for Women's Mental Health | May 5, 2021

By: Becky Vieira

"Dear Husband-I see you. Then and now. You might not think I did. 

I try to imagine what you endured. The pain, fear. While the primary focus was on me, my health and recovery, I know you were suffering also. Silently. Never saying a word of complaint.

I recognize all you did to get me where I am today. To get us here.

We thought we’d just be tired. That exhaustion would be the biggest of our problems once our son was born. Neither of us expected that I’d be gripped – no, controlled – by my postpartum depression. It was supposed to be the happiest time of our lives, not the living nightmare it soon became.

It started slowly, do you remember? We thought I was tired. That my hormones were adjusting yet again. But before we knew it I was underwater. The progression from healthy to dangerous transpired within days once that beast took hold of me.

How did you do it? We had a newborn. No idea what to do with him. You carried that aspirator in your back pocket at all times “just in case.” And while we watched him sleep for fear something would happen if one of us closed our eyes, I began losing my fight.

Yet you continued on.

I started to slip away. I wanted to leave, convinced you both would be better off without me. You held me when I needed it. Let me run into the street to scream, then greeted me at the door with a warm blanket and tea when I returned. Researched treatment. Medications. Called my doctor and hid my car keys when things got dark.

You also got up every morning and went to work. Held things together for us financially. All while receiving frantic calls from me. Coming home between meetings, at lunch. To check on us.

There was no guidebook for you. No one you could call to ask questions on how to handle the situation. I was wrapped in the support I found online from other mom’s with postpartum depression. But what did you have? No men on social media were presenting themselves as the husbands of women with PPD. You had nowhere to turn.

There are resources for PPD. Help. But no one can really tell you how to live through it. It felt as if we were thrust into a new universe, one that spoke an entirely different language. My mind started lying to me and my will to live was faltering. Our coping skills were stripped away and we had to find a way to survive. I needed to be healthy again.

You kept going, for all of us. Trusted your instincts and did the best you could. Yes, there were moments when I was angry over the things you said or did. But today I see that it was in my best interest. You always tried to help.
Even when I screamed at you and said horrible things. Threatened to walk out of your life because I was convinced you deserved better than a sick wife. You never gave up.

You should be proud of yourself and recognize all you did. I’m proud of you. And grateful you stayed by my side. I’ll never forget sitting on the kitchen floor, crying to you as I said, “I’m crazy.” You kissed me and said, “then I guess I’m crazy, too.” Our tears turned to laughter and I knew I’d never be alone.

We survived and our marriage is actually stronger today because of all we endured. You held it together so that I could fall apart safely. And then build myself back up again.

Yes, I spoke up. Got help. Worked on myself, started taking medication. But it would have been much harder without you by my side.

I know you suffered. Were scared. And probably angry, frustrated and hopeless at times. But I never saw that. I only felt loved and supported.
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Thank you for everything. I see you and what you did for me and our family. And I’ll never forget."

​"If you think you may be suffering from postpartum depression, don’t wonder. Speak up. Talk to you doctor, partner, family and friends. If you are scared or worried about the stigma (I get it… we shouldn’t be concerned about that but of course we often are) and would rather talk to someone outside of your circle, you can call Postpartum Support International at 1.800.944.4773. If you just need a fellow mom to validate you and listen to your fears, find me on Instagram and reach out.
Anxious, overwhelmed, unhappy, or scared by how you feel? If you’re struggling emotionally, you could be depressed. Take this 10-question quiz to find out."

By: Melissa Willets

"If you're like me, your answer to the question: "Should I have another baby?" changes by the hour. I gaze at my sleeping, angelic children, snug in their beds at night, and think, YES! Definitely, the sooner the better, NOW. Then my kids are screaming, fighting over a single, blue crayon, and it's, NO! NO! NO! No more kids, ever.So how do you cut through those everyday moments of indecision, to get to the real answer of whether you should have another baby? Try asking yourself these six things:

1. How do you feel when you get your period?
Is it, relief or sadness? Last month my period was a welcome relief. I have a 10-month-old baby, a three-year-old, and an almost six-year-old. We've got enough going on! But this month it was different. I felt a little sad, and began to think, what if? What if our family is not quite complete yet? What if we had another baby?

2. How do you feel when you see a newborn?
Do you feel love sick, or just sick? I see an infant, and my heart swells. An involuntary, "aww," escapes my lips. I can't help it! I love how a newborn smells, I love her soft, delicious skin. Babies are heaven, pure and simple. And having another one is starting to feel like the greatest idea ever!

3. What do you picture your life to be like with another child?
Is life overwhelmingly hectic or charmingly challenging? I don't picture a scenario replete with loud crashes, screaming children, me trembling, gripping a too-full glass of wine, crying in frustration, as little people slowly take over my house, and my life. Instead, I see happiness. I picture smiles, hugs, cuddles, love and giggles. Oh, there's craziness too, believe you me. But mainly I hear The Beatles' song "All You Need Is Love," playing in my head when I imagine being a mom to four kids.

4. What would life be like if you didn't have another baby?
Arrow straight through the heart. Ouch. No, the truth is I've felt conflicted about having another baby for a while. Life is great the way it is. Life is full. We are parents to three, beautiful, funny, silly, smart, wonderful girls. Why mess with what is working pretty darn well for us? When I think this way, another baby seems like a bad idea...

5. What is your biggest reason for wanting another baby?
Is something still missing? Or, is it just hard to imagine closing that door yet? There are so many reasons I want another baby. I still long to feel a baby kick inside of me. I yearn to hold a newborn in my arms, knowing that I did that; I made that. I have also loved, loved seeing how my children love, and care about each other. Being witness to their sisterly bond has been the greatest privilege of my life. I know that adding to our family would just bring more love, and joy.
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6. What is your biggest fear about having another baby?
I worry about tempting fate if we have another baby. Can I really be lucky enough to bring four healthy babies into the world? No one could be that lucky; it just isn't fair. Right? Sigh. I don't know."
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