Culture & Conversation Maternity and Birthing

I Had Postpartum Depression. But Because I Was Breastfeeding, I Couldn’t Access the Care I Needed.

Meredith Alston

After years of hearing about the importance of seeking help and accepting treatment for postpartum depression, it never occurred to me that a doctor would be more concerned about the level of antidepressants in my milk. 

When I found out I was pregnant, the first thing I did was call my OB-GYN to find out if I could stay on my antidepressants.

I was taking a Category C medication—meaning there aren’t enough well-controlled studies in humans to categorize it as a safe medication during pregnancy, but the potential benefits may warrant use of the drug despite the risks. My OB-GYN and I agreed that given my history of depression and anxiety, and the lack of evidence that my norepinephrine and dopamine reuptake inhibitor (NRDI) would produce negative fetal outcomes, my best option was to stay on it.

This was my second pregnancy. During my first I had decided to stop taking all medications, even the selective serotonin-reuptake inhibitor (SSRI) Zoloft, which is generally considered safe for pregnant and lactating women. It was a mistake: I’d experienced dramatic mood swings and panic attacks. I knew I had made the right decision this time this time around by staying on my antidepressants.

When my daughter was born, everything changed.

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I had a traumatic labor and delivery; then, my daughter was diagnosed with a life-threatening airway disorder when she was only a few days old. I was under constant stress because of her illness, and it began taking a physical and mental toll on me.

Four weeks after giving birth, I went to my primary care physician to get help for postpartum depression. I had run out of the antidepressants I had taken my entire pregnancy, and I thought it would be a short, straightforward appointment for her to refill my medication. But when she saw the medication I needed, she referred me to my OB-GYN for a refill. Her concern was that my daughter would be exposed to the antidepressant through my breast milk.

After years of hearing about the importance of seeking help and accepting treatment for postpartum depression, it never occurred to me that a doctor would be more concerned about the level of antidepressants in my milk.

Two weeks later, at my six-week postpartum appointment, my OB-GYN told me she wasn’t comfortable prescribing it either. She justified prescribing it throughout my pregnancy because of my history of severe depression and anxiety. Now that I was no longer pregnant, she wanted me to see a psychiatrist who could, she felt, better determine if my depression was severe enough to warrant the use of the medication while nursing. The psychiatrist I saw cited the same concerns: She didn’t know how this antidepressant would affect my milk supply or the baby. She asked me if I could just “hang in there” until I finished breastfeeding. I left the office empty-handed.

I returned to my primary care doctor and saw a nurse practitioner. I begged her to refill my medication, eight weeks after I’d first asked for help, and she finally agreed to write a one-month prescription if my daughter’s pediatrician approved it. The pediatrician called her office, and together they decided it wasn’t worth the risk of exposing my daughter to the medication through my milk.

None of my doctors could explain to me why there was a concern about a medication that was already present in my bloodstream during my pregnancy now being present in my milk. Perhaps my OB had simply made a mistake by allowing me to stay on my antidepressant throughout my pregnancy. Regardless, I had now been unmedicated for two months, desperately searching for help.

My depression made it hard for me to enjoy my children. Taking care of an infant is exhausting, repetitive, and mundane. My depressed mood only added to the sense of monotony. It took away from what makes me a great mother: being attentive, patient, and fiercely loving. I felt dull, disconnected, and exhausted to my core. The worst part was knowing that I didn’t feel like this when I was properly medicated. I knew there was a better way.

Finally, I went to an urgent care facility where I got a one-month prescription. But urgent care providers are meant for just that: urgent concerns. They’ve become integral to reducing the burden on emergency rooms because they’re able to treat an array of conditions, and they can provide diagnostic services such as X-rays and laboratory tests. Urgent care providers can bridge the gap for patients who can’t wait for their primary care physician to see them. None of these situations applied to me: I needed a provider who specializes in mental health, specifically in treating postpartum depression. None of those providers, though, were willing to give me the care I need. I go back to that same clinic each month for a refill, rather than seeing a psychiatrist, primary care doctor, or OB-GYN.

With each physician visit, I knew my chances of receiving help decreased exponentially, because each encounter added another layer of doubt in my mind: Did I really need help this badly? Was it worth paying all these co-pays? My saving grace was that I work in behavioral health, and I know that maternal health is the foundation for a healthy child. I knew that the potential harmful effects of postpartum depression, aside from making me miserable, would impact the health, well-being, and development of my baby.

As with any other medication, health-care providers must mak ean individual risk-benefit assessment before prescribing antidepressants to a breastfeeding woman. But there isn’t a universal safety scale or index available to help them determine how best to treat postpartum depression in nursing women. While the safety and efficacy of certain antidepressants—particularly SSRIs like Zoloft—has been well studied in both pregnant and nursing women, these medications aren’t always the best line of treatment for all mental health disorders. For instance, I respond better to NDRIs, but they are woefully under-studied in the treatment of postpartum depression.

When I asked my OB-GYN for a refill at my six-week postpartum appointment, she consulted a huge textbook. She found the medication name in the index, and flipped to that page; there were two paragraphs written, concluding that there wasn’t enough research to support the safety of prescribing the medication to nursing women. I wondered when the textbook had last been updated: What if there was new research? What if something had changed? Sitting in her office, surrounded by advanced technological medical equipment, I thought consulting a textbook for information seemed positively antiquated. Providers need access to the most current studies and research to treat postpartum depression.  The barriers to treating postpartum depression in nursing women are not insurmountable; they can be overcome through education and strategic dissemination of existing research to women’s health-care providers.

As a society, we demand that women breastfeed, then deny them access to the medication they need to carry on. We implore them to seek help when they experience postpartum depression, then when they finally find the courage to do so, they face nothing but obstacles. Without proper treatment, postpartum depression can last for months, years even, interfering with the health and well-being of both mother and child. We need to focus on treating postpartum women with the same level of care, empathy, and compassion as we treat their newborns.

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