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THE NEGATIVE EFFECT ON THE USE OF MEDICATION IN THE PERINATAL
PERIOD THAT SO CALLED; “EVIDENCE BASED MEDICINE” PRODUCES
Ralph Wittenberg M.D
I'm happy to help out as I think this is exactly the negative effect that so called; “evidence based medicine” produces. Basically the risk benefit ratio is reversed. While there may be some slight risk involved with the use of medication it does not begin to compare with what we know are the devastating effects that lack of treatment produces, especially on the newborn infant. The most disturbing problem is that of persistent perinatal pulmonary hypertension. There has been only one study of about 350 women. The effect is noted only in women who start taking medicine after the twentieth week of gestation. Women who start antidepressants earlier do not have this happen to their babies. The study revealed that the number of cases in association with medication was 13 while the control group was a little over 6 cases. This may not even be statistically significant. It does not consider other factors that operate in the same time frame. If a mother is not treated for a serious depression towards the end of pregnancy we know that it has specific adverse effects on the baby. These children a born with a hyper-reactivity to stimulation. They are hyperactive. Mothers who are seriously depressed have high levels of cortisol in their blood which crosses the placental barrier. This is the body's hormonal emergency system. While is it a reaction to chronic stress, its presence for a fetus is traumatic. A depressed mother cannot respond to their babies on an emotional level. These babies are more difficult than the average baby. To the extent that a large part of the development of postpartum depression has to do with tremendous disillusionment with the visions of happiness and perfection that associated with childbirth, a difficult child is just another nail in the coffin.
Women were taken off all medications when they became pregnant. If antidepressants were being taken and stopped these patients had 5 times the relapse rate of women who remained on them. This is even more dramatic in bi-polar disorder where a relapse is of tragic proportions that might require hospitalization.
Much of the so called scientific literature is misleading because they do not quote massive sources of data which suggest that there is not difference in the likelihood of a malformed baby in the presence of medication as without it.
The classic risk benefit ratio should read that the only time that fetuses are at risk during pregnancy is the first three weeks, when the neural tube is being formed. The rate of malformations with SSRIs is indistinguishable from normal, which is about 1 baby per thousand live births.
A mother who does not get treated for depression during pregnancy goes on to have an even more serious version after delivery. Her illness has a profound effect on herself, squally making her non functional, her relationship to her spouse who interprets her inadequate function as intentional and infuriates him, prevent emotional bonding with the new born infant and is like having a family destroyed for the other children. This condition lasts for over a year for 50% of untreated.
Many of the reactions that are described as caused by the medication
are really side-effects. All these medicines require two to three
weeks before they start working. Any symptoms or changes before
that are either a placebo effect or side-effect. Side-effects are
usually dose dependent and transitory. That is they usually wear
off fairly quickly or will do so if the dose is reduced. Most psychiatric
medicines seem to be made in standard doses. Unfortunately, one
size does not fit all. But if you are aware of that simple adjustments
can be made.
All antidepressants are equally effective. What distinguishes them
is their side-effect profile. Some side effects are transient, others
are more long lasting, such as loss of sexual enjoyment for a variety
of reasons. Fortunately there are antidepressants that have minimal
sexual side effect. This is something most doctors don’t discuss
with their patients as that is the farthest from the patient's mind
when they are totally miserable. The doctor should inform the patient
of her options and include the various problems that may be present
various medications, which differ from one to another.
All of this should be part of the training of any health professional using these drugs. it is not difficult but requires at least an hour of the professionals time. Not dealing with what are almost universal fears of patients, such as “will I be addicted” and being aware that only about 2/3 of patients will respond to any one medicine makes it easier to accept the necessity of trying another after a sufficient time has elapsed. The patient can then be reassured that their success rate will be well over 90%.
If a medicine works the patient will feel tremendously improved by 6 to 8 weeks. Almost every one will say to themselves. “why stay on the medicine?” A very large percentage stop. I inform patients that if they stop their medication they have a great chance of having a relapse. I also tell them if they are getting their symptoms back they can continue the medicine and they will go away.
When patients try this test and prove to themselves that they do need the medicine there are no further problems.
This is so common a phenomenon that it is called by a special name, “patient non-compliance” which is considered the most serious reason that antidepressant treatment fails.
Health care professionals are not paid to talk to patients. You are rewarded far more financially if you perform procedures. Insurance companies do not usually pay for the kind of counseling that is essential to the success of drug treatment.
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