Chapter 8

Counteracting a Chemical Cause: Medical Treatments

In This Chapter

Understanding the benefits of medication

Consulting with a psychiatrist

Dealing with worries about medications

Discovering the many medical treatments and their side effects

Deciding the best time to begin treatment

When it comes to treatment for PPD, antidepressant medications are some of the most commonly prescribed medications. They’re frequently used to treat depression, anxiety disorders, pain, and sometimes other conditions as well. Just as in the case with any medication you would take for any physical disorder, medications for depression can have both risks and benefits. Because of these risks, many women are confused or have mixed feelings about medication. However, other women feel more afraid of antidepressants because of the perceived stigma about needing to take this type of medication. If you’re nervous about beginning an antidepressant, please note that they aren’t meant to change you — they’re meant to help you recover from depression and anxiety. They’re meant to help you be you.

This chapter starts off by considering the many benefits of medication and then covers some of the typical concerns that new moms with PPD (and their partners and families) may have. I also pay special attention throughout this chapter to the issue of nursing while taking medication and emphasize the importance of having the new mom’s thyroid evaluated (a thyroid imbalance can cause depression or anxiety). Finally, I round out this chapter with the six major categories of medical treatment (five types of medication plus electroconvulsive therapy). I cover these one by one, including who they’re for, when they’re best used, and what side effects are possible.

Recognizing the Benefits of Medication on Depression

There’s no doubt that prescribed, pharmaceutical grade medication can have substantial benefits for a new mom with PPD. Whether it’s antidepressants, antianxiety medications, sleep aids, mood stabilizers, or antipsychotics, each of these groups of medications is targeted at helping a different kind of problem or disorder. And, in combination with other types of treatment, these medicines can rapidly propel a new mom with PPD into a much healthier place and put her well along the road to complete recovery.

A mom with PPD doesn’t always need medication in order to recover, though — sometimes all she needs is support, education, and psychotherapy. But when her particular symptoms or situation warrant the use of it, medication can be a blessing. A woman doesn’t have to be feeling horrible to be prescribed and to take medication. As a matter of fact, catching and stopping PPD before the woman feels horrible is the goal. Often the mom worries that if the doctor or therapist thinks she needs medication, then she must be pretty far gone, so to speak. Not so at all. The doctor will prescribe medication if he believes that the symptoms may respond well to medication, not based on how severe the symptoms are. Some of the symptoms of PPD that often respond well to medication include the following:

Anger

Anxiety

Depression

Hopelessness

Insomnia

Loss of appetite

Scary thoughts (see Chapter 3)

Moms also worry that if they start taking a medication then they’ll always need it. This isn’t true either. Often my clients take an antidepressant (and possibly an antianxiety or other medication as well) temporarily to help them get back on track, and then they’re slowly weaned off and they go on with their happy lives medication-free. It depends on each particular woman’s history, reasons for the depression, and a host of other factors. I discuss this in more detail later in this chapter.

Who You Gonna Call? A Psychiatrist, That’s Who

When medication is suggested to you, the professional that you should consult if at all possible is a psychiatrist. If you’re worried about stigma, remember that if you broke your arm or needed a cavity filled you’d see the properly trained professionals for those ailments. For this ailment, optimally you should see a psychiatrist — in this section, I give you the full scoop on why.

Understanding why a psychiatrist is essential

Ultimately, psychological meds make up a detailed and specialized scientific area, and because of the great amount of detail, even your regular medical doctor isn’t always fully up-to-date and informed for purposes of PPD (unless, of course, she’s specifically following the literature on antidepressants, antianxiety, and other medications as they relate to new moms suffering from PPD). So, if you need or otherwise are seriously considering prescribed medication, work with a psychiatrist, especially one familiar with PPD, if at all possible.

The confusing world of pharmaceuticals

Even though prescribed medication can be enormously beneficial, it can also be a confusing area to understand because you have to take many factors into consideration. For example, you have to consider the following questions:

Which medication is the right one?

What should the dosage be?

How do you best use the medication?

What side effects should you look out for?

Unless you’ve taken a medication earlier in your life that’s worked well for you, you’ll be doing some trial and error when starting a medication for the first time. Most often, though, the first medication prescribed will work well with your body chemistry, because the psychiatrist is trained to make an educated guess regarding what may work well for you, based on your symptoms and family history.

What makes this confusion even worse is the fact that PPD is a scientific area that’s constantly changing. It seems that every time medical science declares a particular medication safe for breastfeeding, another report comes out a few weeks, months, or years later that raises a question. Or as soon as the best scientific evidence shows that a particular medication is just fine for a depressed woman to take during her third trimester, new research comes out that implies a possible risk to the developing baby. This so-called “research” may not be good research at all, but in the meantime it causes alarm among moms trying to make the decision about whether or not to take the medicine. Also, sometimes research findings are blown out of proportion by members of the media, who like to shock readers and viewers.

As one example, the media announced a study reporting that taking an antidepressant in the third trimester causes symptoms in the newborn, and it scared women into not taking badly needed medication. The researchers and practitioners I know and trust who devote their professional careers to studying this specialized area continue to prescribe in the third trimester, because they don’t believe that these “symptoms” in the newborn are damaging — they’re transient and mild. In the meantime, these children have mothers who are enjoying them and can care for them.

Not only is research and evidence on existing medications constantly changing and evolving, but the medications themselves keep changing. New medications keep hitting the market, and as time goes on you can expect new substances to emerge that may be more effective and that have fewer side effects than anything available right now.

Two great benefits of working with a psychiatrist

Working with a psychiatrist has advantages in addition to the wealth of trustworthy information you’ll receive:

Psychiatrists are best at — and best trained at — prescribing the right medication, including the right starting and follow-up dosages. To help determine these dosages, they’re trained to think about certain patient background information and to ask questions that elicit other relevant information.

Compared to most general practice MDs or even MDs who are OB/GYNs, a psychiatrist is likely to inquire about any blood relatives of the new mom (or the new mom herself) who have previously and successfully taken any antidepressants. Knowing about past successes may help determine which medication should be tried first. Similarly, a psychiatrist is far more likely to inquire into whether there’s any bipolar illness anywhere in the new mom’s family history, which demands a specific medicine combination.

Psychiatrists are best at monitoring your progress and following up with you. As wonderful as many MDs are, very few are as conscientious as psychiatrists about follow-up on the impact of prescribed medications. This lack of follow-up is mainly because they don’t have the background and training to know how — they’re excellent at performing the tasks pertaining to their own specialties.

Knowing where to go if you can’t get to a psychiatrist

If you feel you need (or might need) medication and no psychiatrist is available, do whatever you can to find one anyway — even if you have to travel to go see one. If there’s absolutely no way for you to get to a psychiatrist, see another MD or nurse practitioner who can prescribe medications. Try to find one who either specializes in or has substantial experience with PPD.

Don’t underestimate the knowledge of PhD psychologists or other psycho-therapists if they have experience in PPD. As one of those psychologists, I can tell you that frequently I receive calls from obstetricians and other medical professionals who ask my opinion on what to prescribe for various patients and at what dose. They know that I follow this highly specialized area and know the data well. Psychologists can’t give you medical advice or prescribe, but if they’re specialists in the area of PPD, they can educate you (and your doctor) about what the research says.

Addressing Concerns about Taking Prescribed Meds

The potential benefits of taking prescription medications, especially when they’re properly prescribed, dosed, used, and followed-up on, are clear. But there are also some concerns that should be considered, some of which can rightly be dismissed, and some of which have to be cautiously watched for and monitored.

The most common general worries

Many people, from new moms with PPD to ordinary folks encountering depression for the first time, are wary about taking prescribed medication for their condition. I address a few of the most common worries in the following sections.

“Taking meds means I’m a weak person”

Never buy into the self-reliant myth that says you should be able to pull yourself out of your PPD on your own without any outside help. Admittedly, given the backwards thinking about PPD that’s still far too common, there may be some stigma attached to seeing a doctor (especially a psychiatrist) and receiving prescribed medication as a result. But here’s what I have to say about that: So what? It would be sad to let other people’s ignorance stop you from being placed firmly on the road to recovery.

“I’ll become dependent on or addicted to the drugs”

It never fails to amaze me how often women with PPD refer to prescribed medication as a “crutch.” When someone with a broken leg ambles past you on crutches, you don’t say, “Look at that sad excuse for a human being — I can’t believe that she has stooped to relying on crutches.” If you need crutches to help you get stronger until you don’t need the crutches any longer, then so be it. And if you need prescribed medication to give you a boost until you’re well enough to wean off, do it.

Unfortunately, women with PPD also have the fear that if they start using antidepressants, they’ll become dependent on them. Well, just as crutches are used as a temporary support until you no longer need them, the medication that you’re prescribed is meant to restore the normal functioning of your brain chemistry so that you no longer need the medication. When you have felt like yourself again for a few months — the length of time will differ depending on your history and other factors — the psychiatrist or other MD will make sure that you successfully begin the process of weaning off of the medication. And if it turns out that you need to stay on the medication longer, try to count your lucky stars that there’s something you can take to help you enjoy your life.

Never stop a medication, especially an antidepressant, cold turkey because your body will have gotten used to it (not addicted to it, just used to it). Typically, if you abruptly stop taking an antidepressant you can experience bad side effects, sometimes amounting to severe dizziness and queasiness for a number of days. These side effects are other reasons why you want an experienced doctor in your corner — one who knows how to gently and steadily decrease your dosage until you’re medication free.

Even when you wean appropriately off the antidepressant, you still may experience some unpleasant effects as your body gets used to continuing without the medication. Or, at the very least, you may experience a bit of a bumpy ride. Often, though, there are little to no negative effects.

“I’ll suffer horrible and long-lasting side effects”

Mild side effects are common, and I cover them in some detail in the section “Side Effects: You Can’t Always Get Just What You Want” later in this chapter. The important things to note about medications are that

Side effects, if any, are usually mild and of short duration — they generally subside after a few days to a week or two of beginning the med therapy.

If you experience a really uncomfortable side effect, your doctor won’t continue prescribing that particular medication. But, if the side effects are mild, weigh them against the benefits. Most women decide to stick it out, because some temporary stomach upset is better than feeling hopeless and withdrawn.

“Is taking meds while nursing safe?”

For the mom who isn’t pumping or breastfeeding her baby, her body is hers alone, and the entire psychiatric treatment arsenal is open to her without any reservations whatsoever. However, for those who are breastfeeding or pumping, a sensible worry is whether taking medications will affect their babies.

The growing modern consensus is that the benefits of breastfeeding seem to far outweigh any risk of harm to a baby when their moms take medication. For many years the research emphasis has been on whether there might possibly be any harm to the baby from a nursing mother who’s taking medication. Over time, however, the research (especially with respect to antidepressants, the most important category of medication for PPD) has consistently shown no harmful effects. Researchers and practitioners agree that it’s time to change the general way this issue is framed — from one that emphasizes potential harm to the baby to one that emphasizes the great deal of overall good that comes to new moms (and therefore to their babies) when they take the appropriate medication.

Most antidepressants are virtually undetectable in a baby’s system. Sometimes tiny amounts are detected, but without exception, the infants and children whose moms were taking medication while they were nursing have, to date, been completely normal across all tested behavioral and developmental parameters.

It’s worth repeating, however, that if you have PPD and you’re pumping your milk or breastfeeding your baby, you have no reason (with respect to your child’s health) to not take advantage of the medication that your doctor feels is right for you. Pediatricians are becoming more and more aware of the literature regarding the safety of antidepressants and breastfeeding, so it’s becoming less confusing to women in need.

Ironically, often a breastfeeding mother who’s anxious about taking medication while she’s breastfeeding finds that as soon as she starts on the medication, she calms down completely with respect to this issue. Her anxiety may be an indication that she’ll benefit from the very medication she’s anxious about taking.

If you’re that concerned about taking an antidepressant when you’re breastfeeding, though, talk to the psychiatrist about “pumping and dumping.” In this tactic, you pump and discard the feeding that follows the time that the particular medication peaks in your system. Instead, you can use a bottle of previously pumped milk or formula for that feeding.

“How do I know I’m not dealing with a thyroid problem?”

At least 10 percent of women, after delivering a baby, develop some kind of postpartum thyroid disorder or thyroiditis (inflammation of the thyroid gland). And many times, these types of disorders mimic PPD.

If a new mom is depressed and has a problem with her thyroid — which will typically be an underactive thyroid, or hypothyroidism — then all the antidepressants in the world won’t make her feel completely well.

It’s important, then, that the thyroid be treated if there are any signs that it isn’t functioning well, including unusual tiredness, lack of energy, inability to get warm, ongoing sore throats, weight gain, dry skin, low sex drive, constipation, anxiety, and, not surprisingly, depression.

Because many of these symptoms are also symptoms of PPD, you probably want to know how you can determine whether they’re just due to the PPD or are also in part due to a thyroid disorder of some kind. Not surprisingly, you really can’t tell and really can’t rule out a thyroid problem without seeing a medical doctor who can perform a blood test to check your thyroid. If I had my way, all postpartum women would be screened and tested for potential thyroid disorders. If you do have a thyroid problem, it can usually be addressed fairly quickly, either with thyroid supplements or through natural remedies. The optimum time to test your thyroid postpartum is two to three months after delivery.

If you have a personal or family history of thyroid imbalance, usually the MD will make sure you get tested. If not, you may need to convince him that you want to rule out a thyroid problem before starting on an antidepressant. Subclinical hypothyroidism (meaning that it doesn’t show up on the thyroid test because it’s so slight) can make PPD worse. So, many doctors will give a woman a bit of thyroid medication to boost the antidepressant if it’s not working 100 percent. Sometimes this addition is all the woman needs to confirm that a thyroid imbalance was lurking.

Specific Types of Medical Treatments for PPD

After you decide to try a medication to recover from your PPD, you and your doc have another decision to make: What medicine is best for you? The six major types of medical treatments available for women with PPD — five of which are prescription medications — are shown one by one in this section.

Antidepressants

A woman suffering from PPD is, by definition, depressed, so it makes sense that the first line of treatment for PPD is an antidepressant. There are two main types of antidepressants used for PPD:

Tricyclics: Tricyclics (TCAs) have been available since 1958 and, although they’re generally less popular today than they used to be (because they have more side effects than the newer group of meds), they’re still useful for many women and for particular symptoms. Tricyclics work by beefing up the brain’s supply of norepinephrine and serotonin — two important brain chemicals affecting mood if they’re low. Some of the more commonly used tricyclics are amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Pamelor), and imipramine (Tofranil). Some psychiatrists like to prescribe these meds during pregnancy and breastfeeding because they’re considered to be tried and true, having been around for so long. These meds are also prescribed for women who don’t respond well to the newer antidepressants, SSRIs (see the next bullet).

Selective serotonin reuptake inhibitors (SSRIs): These substances work the brain’s serotonin levels, and have become increasingly more popular since the original SSRI, Prozac, was introduced in the late 1980s. Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine (Luvox) and other SSRIs are the first line of treatment for most women with PPD.

A mom with PPD commonly worries that an antidepressant will change who she is or will alter her in some way. If this is you, remember that the PPD has already altered you — you’re already changed by the illness. The antidepressant simply helps you get your real self back. So, in fact, you better hope it changes you — back to you!

A woman with a personal or family history of bipolar disorder should be monitored very carefully if she’s given any amount of an SSRI, because an antidepressant may increase the risk of a manic episode in moms whose depression may actually be part of a bipolar disorder (jump to Chapter 3 for a description of a manic episode). Usually these moms are prescribed a mood stabilizer as well, (if they’re accurately diagnosed), which I discuss later in this chapter.

Antianxiety meds

Anxiety is a frequent and major symptom of PPD (see Chapter 2 for a list of all the other symptoms). Sometimes women who have PPD identify more with anxiety than with depression. To address anxiety and to help the new mom gain control over the wheels in her mind that are constantly spinning, a psychiatrist will often prescribe antianxiety medications (also called benzodiazepines ) such as lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin), and alprazolam (Xanax).

To make matters confusing, though, some of the best medications that treat anxiety are the same medications that treat depression (see the preceding section). But sometimes an antianxiety medication is needed temporarily just until the antidepressant kicks in. You don’t necessarily need to take these meds every day (unlike antidepressants). They help you come down a couple of notches so you can relax enough to remember to breathe, affirm yourself positively, and take the other steps you’re working on in therapy.

One common result of anxiety is insomnia. It’s not that the new mom isn’t tired or that she needs something to sedate her, it’s that she has so much anxiety that she can’t settle her mind and stop it from racing. The benzodiazepines are also very helpful for insomnia.

Antianxiety medications are also prescribed to stop or, better yet, prevent the onset of panic. Generally speaking, you want to prevent your body from going into a full-blown state of panic whenever possible because with a panic disorder, the more often you enter into a state of panic, the easier it becomes for your body to return to that panicked state. So, you want to do everything you can to prevent yourself from getting there in the first place.

Antianxiety medications, therefore, can either be taken on an “as needed” basis — when the new mom with PPD feels a panic attack potentially coming on — or on an ongoing basis (as long as the potential for panic remains). An antianxiety medication like alprazolam or lorazepam is often prescribed to be taken on an “as needed” basis. The longer-acting antianxiety medication called clonazepam (Klonopin) is frequently used if the mom has more persistent anxiety that lasts night and day.

Often, women with a history of substance abuse are extra wary of taking a potentially addictive medication such as the benzodiazepines. It’s important to mention that sometimes these meds are abused, even by women with PPD, and the biggest risk factor for someone abusing them is a history of substance abuse. If you’ve ever had a problem with alcohol, illicit drugs, or prescription medication abuse, make certain you tell your doctor — this information is crucial for your medical care! Make sure that you stick to the regimen as prescribed by your doctor.

Doctors, trying hard to be responsible, sometimes prescribe only a few of these antianxiety pills at a time, and ironically, a mom starts obsessing about running out, which only adds to her anxiety. The psychiatrists I work the closest with have no problem extending the prescription of antianxiety medication as long as they know the moms are taking them responsibly.

Sleep aids

Needless to say, sleep is a huge issue for new moms with PPD. Nothing is more frustrating for a new mom than working with her support system to set aside the time to sleep (as described in Chapter 12), and then being unable to actually take advantage of it. Imagine lying there for hours thinking “I should be sleeping. I should be sleeping. I should be sleeping. The baby will be up soon and it will be my turn.” To get over this particular hump, a sleep aid can prove very useful.

Sleep aids, including medications such as zolpidem (Ambien), trazodone (Desyrel), and many of the benzodiazepine medications, help new moms with PPD obtain the good rest that they so desperately need. However, a woman often needs a separate medication for sleep only until her main antidepressant kicks in.

Tricyclic antidepressants with sedative effects, such as nortriptyline (Pamelor) or amitriptyline (Elavil), are frequently prescribed as sleep aids as well.

Mood stabilizers

Mood stabilizers are used mainly for women with bipolar illness, so that both their “high highs” and their “low lows” are moderated. Quite often, mood stabilizers are used to boost the effect of an antidepressant — even for women who aren’t bipolar. So, if your MD or psychiatrist recommends a mood stabilizer, don’t necessarily take this as a sign that you’re also bipolar.

Atypical antipsychotic medications, despite the name, are some of the most frequently used mood stabilizers. But, again, just because a doctor prescribes one doesn’t mean that a patient has a psychotic disorder. Two of the mood stabilizers, valproate (Depakote) and carbamazepine (Tegretol), are anticonvulsants, and both of them are approved by the American Academy of Pediatrics for breastfeeding mothers. Lithium, another mood stabilizer, however, is not recommended for breastfeeding mothers but is the mood stabilizer of choice during pregnancy.

Antipsychotic meds

The most important use for antipsychotics is for women who have postpartum psychosis (PPP). PPP isn’t just a really bad case of PPD, but rather, is an entirely different kind of animal (see Chapter 3 for more on the distinctions). PPP can have tragic results, as in the infamous case of Andrea Yates, the Texas women who drowned her five children in 2001. About two out of a thousand new moms are thought to suffer from PPP. For new moms who want to continue breastfeeding, certain high-potency antipsychotics, such as haloperidol (Haldol), are often recommended.

Antipsychotics can also be used in other ways. For example, because it tends to really knock people out, the antipsychotic medication olanzapine (Zyprexa) is occasionally used for powerful insomnia that isn’t responding to any of the other sleep medications.

Electroconvulsive therapy

Often used when psychotherapy and medication are ineffective with an individual, electroconvulsive therapy (ECT) is in some ways similar to rebooting a computer that has started to malfunction, because it temporarily alters some of the brain’s electrochemical processes. ECT, also known as “shock therapy,” has proven to be an effective treatment for severe PPD and postpartum psychosis and can be used safely by nursing mothers. It’s also useful in treating postpartum bipolar illness. ECT is also used during pregnancy to treat severe depression and psychosis. It isn’t, however, an appropriate treatment for anxiety, panic, or obsessive-compulsive disorder. Interestingly, sometimes an antidepressant that didn’t work before suddenly starts working after the woman has had one or more ECT sessions. It’s also suggested when a mom is on the verge of committing suicide, since ECT works much quicker than antidepressants.

Unfortunately, this kind of treatment has an undeserved negative reputation that often prevents the effective deployment of ECT. This is in part because whenever ECT is brought up, the Ken Kesey book One Flew Over the Cuckoo’s Nest (or the 1975 movie of the same title) is what people often picture. In this book and movie, ECT was presented as a terrible type of therapy akin to torture, and so people tend to believe ECT is associated with screaming people holding on for dear life.

This view of ECT is a truly antiquated and distorted version of what goes on with ECT. As a clinical psychologist, I accompanied a client of mine as she received ECT. I saw the entire process from start to finish, and I can unequivocally say that this is an extremely humane process that isn’t scary or painful at all. In fact, a short-duration general anesthesia is given to the patient, and the treatment itself takes only seconds.

In the United States, because of the prevailing negative view towards ECT, it’s usually considered the treatment of last resort. In other countries, however, depending on their history, ECT is often the first line of treatment for some depressed new moms. Healthcare providers in these other countries wonder why women in the U.S. are so cruelly deprived of ECT, and why they’re allowed to continue to suffer, going from one medication to another, instead of receiving something that only takes a few seconds and often provides relief even after the first treatment is given (sometimes women undergo a series of treatments).

Understanding the Fact that Finding the Right Med(s) Is a Process

Quite frequently, after a mom with PPD has made up her mind that she may benefit from medical treatment and wants to try it, she’ll ask, “So, what’s the right type of medical treatment for me?” Unfortunately, there’s no one right treatment for all women because every woman is unique. So, a doctor may present various options and may discuss them with the woman before the two make a decision. This discussion usually happens in one office visit, but the woman may want to think about the options and discuss them with her partner or other supports. Different factors go into this important decision-making process, and I outline them in this section.

Identifying the important health-related differences among women

Although this decision is usually left up to the doctor’s expert opinion, you can and should still have a say in the matter — after all, it’s your body. When you’re weighing out the information your doctor is giving you regarding different medication options, remember that you’re unique in so many different ways — from your emotions and situations all the way up to your physical makeup. For example, not only do you have a unique medical history, but you also have your own special body chemistry that works better with some medications than others. For one thing, each woman metabolizes medications differently, and in most cases both the correct diagnosis and the correct dosage can only be approximated at first.

In short, the answer to “What’s the best medical treatment for me?” can’t be determined until you do the following:

Meet with a competent psychiatrist or other medical doctor.

Have your symptoms brought to light and your history taken.

Have a blood test administered if your doctor needs information about your thyroid or other hormone levels.

After these steps are taken and the tests are returned, an assessment is made and one or more prescriptions are given. When you’ve finally received a prescription from your doctor, don’t play what I call “the milligram game.” Remember that each person metabolizes medication differently. A higher dosage doesn’t mean that you’re more ill than the next mom who’s taking a lower dosage (and it wouldn’t be shameful if you were). A few women with the same level of depression may be given the exact same dosage of the exact same medicine, and each may respond differently. So, take whatever you need to reach the therapeutic dosage that’s right for you.

Keep in mind the fact that the first prescription may not be the best or the last one you try. Medicine is an art, and you may go through a succession of treatments — or dosage changes — based on how you respond. Usually the first medication chosen will be a good one for you, but not always. Think of it this way: Prescribing medicines for PPD is an educated trial and error system.

Staying the course after you receive a prescription

It’s crucial for you to stay on your prescription until your doctor tells you to stop. Undertreating can lead to chronic illness and to an increased chance of relapse. “Treat to wellness,” therefore, is the mantra that you need to follow here. Never, ever quit cold turkey because you think the medicine isn’t working right or because you’re experiencing side effects. Your opinion counts, however, so certainly bring up the topic and discuss the possibility of stopping the medication if you’re thinking about it. This is your health, and your opinion is important, but trust that the psychiatrist has knowledge that you don’t, so her reasoning about your staying on the medication should be taken seriously. If you want to get a second opinion, do so.

Many women say, “I stopped taking my medication because I felt better.” Most psychiatrists would recommend a period of wellness, so that a woman feels like her normal self for at least a few months before stopping the medication, to decrease the risk of the depression returning. Also, don’t forget that the reason (at least a big part of it) that you felt better is because of the medication. The last thing you want to do at that point is stop what’s working.

Because your body quickly adapts to and gets used to the substance being there, even if it’s the wrong medication for you, you’re far better off (in most cases) if you gradually wean yourself off of it with your doctor’s help. The opposite is also true: If you need more of a substance, you need to gradually increase the amount you’re taking — but only with your doctor’s guidance. The bottom line is this: Dose up slowly, dose down slowly, and make changes only when your doctor or psychiatrist says you should.

Needless to say, after you receive a prescription medication, you need to take it exactly in the manner that has been prescribed for you. Take your meds regularly, and don’t skip a dose. If you forget to take it (forgetfulness is a symptom of PPD, as you probably know), ask your doctor how to proceed. You may want to come up with a simple system for yourself, such as marking a calendar after you’ve taken your pill or getting a pill holder with the days of the week imprinted on it.

To make staying the course a bit easier, remember not to be shy with your doctor. If you feel like you’re having an adverse reaction to a medication, you need to let your doctor know pronto. It’s her job to listen to what you have to say and evaluate your situation. If you think you may need a different medicine, it’s up to you to make sure you get that across. And the same goes if you feel you need to increase your medication — talk to your prescribing doctor and see if it’s time to take more.

Side Effects: You Can’t Always Get Just What You Want

All of the medical treatments listed in this chapter can have side effects, which are, of course, unintended (and generally unwanted) symptoms that can be experienced physically or psychologically. As you know, the thigh bone is connected to the knee bone, and as soon as you start adjusting one part, system, or biochemical process in the body, it can easily have unexpected and unintended consequences on other parts, systems, and biochemical processes that are related to it.

The good news is that most side effects are mild, and few tend to persist after the patient stops using the treatment. In some cases, though, if you have a severe side effect, you may want to stop using the treatment in question and try something else. But, this should only be done in consultation with your psychiatrist or other prescribing MD.

Table 8-1 shows the most common side effects for the various types of medicine (and ECT) discussed in this chapter. More detailed information on the side effects of the particular medications you’re prescribed can be found on the labels and inserts that come with the medication. But, if you’re anxious, please don’t read those — they’ll only make you more anxious. Ask the pharmacist to throw the labels and inserts away before giving you the medication (I’m not kidding).

Table 8-1 Common Side Effects of Medicine and ECT

Type of Treatment	Side Effects
Antidepressants	Different categories of antidepressants can have
	different side effects.
	SSRIs can cause gastrointestinal problems (most
	common are nausea and diarrhea) and a lowering of
	libido (the main one that doesn’t go away with time).
	It can also make you feel jittery or either tired or
	wired. Some individuals gain clarity, while others
	get “fogged out.”
	Tricyclics can cause weight gain, dry mouth, constipa
	tion, dizziness, or heart palpitations. (The better tolerabil
	ity of SSRIs explains why they’re more commonly used.)
Antianxiety meds	Benzodiazepines can be habit-forming or addictive and
	can make patients lethargic (proper dosing is critical here).
Sleep aids	These aids can be habit-forming and can leave patients
	feeling a bit “drugged” in the morning if the substance
	hasn’t been thoroughly “slept off.”
Mood stabilizers	Mood stabilizers often increase appetite and slow
	metabolism, so weight gain can result. Some individuals
	with bipolar disorder (or tendencies of bipolar) miss the
	“high” side of their unmedicated cycle, which they con
	sider to be a negative side effect. Some are sedating
	(and can help with sleep if taken at bedtime).
Antipsychotic meds	These meds have a very sedative effect, which can be
	helpful for sleep purposes but can also make patients
	feel “drugged.”
Electroconvulsive	ECT is often accompanied by memory loss, which is
therapy (ECT)	usually short-term in nature (for example, the patient may
	not remember the day she came to the hospital for treat
	ment). Her short-term memory generally comes back
	after a few weeks or a couple of months.

Knowing When to Begin Med Therapy

If your particular situation clearly suggests that you should at least seriously consider taking prescribed medications, you want to get on it right away. This decision may depend on a few factors:

The reasons for your depression: Causes of depression are quite individual. If, for instance, your therapist evaluates you in the initial assessment and discovers that you’re totally isolated, you’re up every night for hours with a screaming baby, and you were just diagnosed with a low thyroid for which you’ll be receiving treatment, it may make sense to wait and see what happens with your depression in the next few weeks after you start your new plan of action with social support, sleep, and thyroid treatment. If, on the other hand, your support system and sleep are in place, but you have a history of depression and an antidepressant has helped you before, you should probably start your treatment immediately (and use the medication that’s helped you in the past).

Your level of functioning and level of depression: If you’re suicidal, your doctor will want you to take medication right away (and possibly have you hospitalized if you’re in imminent danger of harming yourself). If you’re having really scary obsessive-compulsive thoughts (see Chapter 3), you probably want to begin medication right away.

How you feel about your treatment: If you have mild to moderate depression and prefer not to take medicine, if at all possible, waiting a few weeks (assuming you don’t get worse during that period) is an appropriate option. Sometimes psychological treatment, increased support, and better self-care are all you need.

The whole point of medical treatment is for you to get well as quickly as possible. Getting well sooner rather than later is far better for you, your entire family, and your future prognosis. In general, the longer PPD hangs around, the longer it’s likely to stay with you and the more difficult it is to get rid of.

Some therapists and MDs believe that every woman with PPD should start medication as soon as possible. That’s not my opinion. I believe it’s an individual choice — some women should definitely use it right away, others don’t need it at all, and many fall in the gray area (“It could help but it may not be necessary”).