Differing Views On Antidepressants During Pregnancy

The question of taking antidepressants during pregnancy is extremely intimate and complicated. Research studies evaluating the risks and benefits are mixed. There are documented harms, like an elevated risk of pre-term birth. But there are also the documented harms of untreated depression. In other words, it’s a deeply personal health decision that requires judgement based on a body of data that offers no easy answers.

The latest on this fraught debate comes from Andrew Solomon who wrote a long piece published in last Sunday’s New York Times Magazine, “The Secret Sadness,” with this basic message: “Pregnant women who are depressed often fear taking the medication they rely on. But not treating their depression can be just as dangerous.”

Solomon, whose own depression is well documented in his powerful book, “The Noonday Demon: An Atlas of Depression,” (The Times piece will be added as a new chapter in the book) begins the magazine article with an anecdote about Mary Guest, “a lively, accomplished 37-year-old woman” who “fell in love, became pregnant and married after a short courtship.”

Struggling with depression for much of her life, Mary took various antidepressant and anti-anxiety drugs, Solomon writes, but decided to discontinue the meds during pregnancy. But Mary’s mood and behavior “spiraled downward” so, “near the end of her fifth month of pregnancy, she finally, reluctantly, resumed taking an antidepressant,” he writes.

Then, at six-and-a-half months pregnant, and convinced that something was wrong with her fetus, Mary “went to the 16th floor of the building where her parents lived and jumped to her death.” Solomon quotes Mary’s mother saying: “We feel, rightly or wrongly, that if Mary had stayed on her medications, or even gone back on them sooner, it’s possible she would have survived.”

It’s an intense, moving story.

But Dr. Adam Urato, an assistant professor at Tufts University School of Medicine in Boston and a maternal-fetal medicine physician at Tufts Medical Center and MetroWest Medical Center in Framingham, says he’s got an important story to tell too: that antidepressants can also cause harm. Urato writes and lectures on this topic frequently, and says he feels that Solomon’s piece didn’t offer the complete picture. (Here’s Urato’s full rebuttal to Solomon’s article on the website Mad In America, published by journalist Robert Whitaker.

Solomon quotes Urato in the Times story (in fact, some of the quotes come from a post Urato wrote for CommonHealth). But Urato says his views weren’t fully reflected. Here, edited are a few of Urato’s points:

1. Anecdotes Have Limitations

No one wants a pregnant woman to kill herself. An article in which pregnant women stop their medications and kill themselves while others continue on their meds and have happy outcomes is sure to push readers in an obvious direction. However, such anecdotes are limited.

For example, the author could have told stories of women who stayed on their medications, weren’t counseled regarding the risks, and had severely impaired babies. Continue reading

Appreciating The Nature In Your Medicine Cabinet

By James Morris
Guest contributor

One of the the most exciting aspects of the recent discovery of the new antibiotic teixobactic was the way scientists discovered it — and where.

The antibiotic comes from a bacterium that was found in a sample of soil from Maine. To uncover it, scientists used a new technique that allowed them to screen bacteria for antibiotics without growing them in culture, opening the door to finding newer, more potent and less resistant antibiotics in the future.

It’s worth noting that teixobactic is not the only antibiotic that comes from a bacterium. In fact, many of our antibiotics come from bacteria and other microbes, and many of our medicines come from nature. It’s one of the benefits of biodiversity.

Recently, I was teaching a class on biodiversity to college students. To get them thinking about how we benefit from species richness, I asked the class to name a couple of medicines that derive from nature.

I thought this would be an easy question. To my surprise, the class (of 250 students) was silent. This was unusual — I usually have more trouble keeping them quiet. Finally, after maybe 20 seconds (a long time in a large lecture hall), a hand shot up. “Marijuana!” one student proudly exclaimed.

I was taken aback. Not because weed was mentioned in a college classroom. And not because the student was incorrect — she was of course correct. Marijuana comes from the plant Cannabis and it has some useful medicinal properties, for example to treat nausea caused by cancer chemotherapy, and fatigue, appetite loss and pain associated with AIDS. There is continued debate over its use, but that’s not the point.

The point is that while the class was hard-pressed to come up with more than one medicine derived from nature, the reality is just the opposite: It’s difficult to think of a medicine that doesn’t ultimately come from nature.

If apples and carrots are nature’s toothbrush, grapes are nature’s jellybeans, and raisins are nature’s candy, then certainly plants, animals, fungi, and microbes are nature’s medicine cabinet.

Perhaps the most famous example is penicillin. Continue reading

Pregnancy Woes: Why Did The Price Of My Progesterone Skyrocket?

(Photo: Rekha Murthy)

(Photo: Rekha Murthy)

By Rekha Murthy
Guest Contributor

Update: KV Pharmaceutical changed its name to Lumara Health, two days after this post was published.

I’m 34 weeks pregnant and working hard to keep this baby inside me for as long as possible. As with my last pregnancy, there’s a real risk that the baby could come too early. But we’re both holding on so far, thanks to a combination of luck, modified bed rest and medical science.

The science is my biggest concern right now. I will spare you much of it because, man or woman, you will instinctively cringe and close your legs. However, one critical medical intervention that has been proven to work for countless women and babies is again under threat, and I must speak up.

Every week, my husband injects me with 250 mg (1 ml) of 17 alpha-hydroxyprogesterone caproate (“progesterone” for short). Leaving aside what this does to an otherwise tender and loving marriage, these injections have been found to significantly lower the risk of preterm birth.

Two weeks ago, my insurance co-pay for progesterone went from $5.50 per dose to $70 per dose. Just like that. For those without insurance (or with a deductible), the medication went from $32.50 per dose, according to my local compounding pharmacy, to…wait for it…$833 per dose, according to the new pharmacy my insurer is now requiring me to use.

$833. Per. Dose.

Pricing varies somewhat across pharmacies and insurers, but not enough to make this price change any less breathtaking. In fact, the drug’s list price is $690 per dose.

The 12-fold leap in my co-pay sent an epic shock through my (natural and synthetic) hormone-laden system. I immediately called both pharmacies, my insurer, and my doctor, and started digging around online. I soon learned that the price increase came from a new requirement to buy expensive brand-name progesterone, instead of the affordable compounded version I had been getting. A disturbing picture came into focus. Continue reading

Study: Drug Ad Side-Effect Warnings May Actually Boost Sales

“Side effects may include dry-mouth, insomnia, sexual side effects, diarrhea, nausea and sleepiness,” warns the Zoloft ad above. And those aren’t even particularly dire side-effect warnings, as drug ads go — some warn of possible blindness, even organ failure or death.

If you’ve ever wondered why pharmaceutical companies haven’t resisted these daunting end-of-ad warnings more, here’s a possible piece of an explanation: A new study in this month’s issue of the journal Psychological Science finds that the fear sparked by such warnings fades very quickly over time, and may even end up morphing into trust and boosting sales. From the press release:

“We were struck by just how detailed, clear, and scary many warnings had become with regard to potential negative side-effects of products,” says [psychological scientist Ziv Carmon of INSEAD in Singapore.] “It then occurred to us that such warnings might perversely boost rather than detract from the appeal of the risky product.”

Carmon and colleagues tested their hypothesis in four experiments. In one experiment, for example, smokers saw an ad for a brand of cigarettes: one version of the ad included a warning that smoking causes lung cancer, heart disease, and emphysema, while another version did not include the warning.

Predictably, participants who had the opportunity to purchase the cigarettes soon after seeing the ad bought less if the ad they saw included the warning.

In contrast, participants who were given the opportunity to purchase the cigarettes a few days later bought more if the ad included the warning. The same outcome emerged when the researchers ran a similar experiment with ads for artificial sweeteners. Continue reading

Seniors On Drugs: Report Finds Many Taking ‘Risky’ Meds

Are we unnecessarily drugging our seniors?

That’s the subtext of an analysis by public health researchers at Brown University which found that more than 1 in five seniors with Medicare Advantage plans got a prescription for a “potentially harmful high risk medication,” a.k.a. “Drugs To Avoid In The Elderly,” during 2009.

Researchers report that 21.4 percent of the patients — more than 1.3 million people — “received at least one high-risk medication, for which there is often a safer substitute.”

medicationGetting a prescription for a “risky” medication (among a list of 110 drugs agreed upon by a group of clinicians and other experts) was more common in the Southeast, among women and people living in relatively poor areas, the study found. In terms of geography, it was least prevalent in New England; indeed, Worcester, Mass. had “the best rate of single and multiple high-risk prescription use, respectively,” researchers report.

Amal N. Trivedi, an associate professor of Health Services Policy and Practice at Brown said one of the key take-home messages is that patients should regularly “review their medication lists with pharmacists and their health care providers.”

(According to the report, high-risk medicines in the elderly are broadly defined as “medications that should be avoided among patients 65 years of age or older because the associated adverse effects outweigh potential benefits or because safer alternatives are available.) Continue reading

May Cause Confusion: A Poem Composed From Pill Bottles

Peggy GIrshman's pill bottles (Courtesy of PG)

Peggy GIrshman’s pill bottles (Courtesy of PG)

Peggy Girshman is the executive editor of Kaiser Health News, a nonprofit news service that is a major new player in health journalism, widely valued for its reporting on health care policy and politics. These days, she’s also a patient, being treated for amyloidosis, which she describes below as “a rare, weird disease related to blood cancers.”


Peggy Girshman (KHN)

Though she has covered health care for more than 25 years, Peggy says, she has never before been moved to poetry. But here, she shares a late-night inspiration: A poem composed entirely of instructions from her pill bottles.

May Cause Confusion

Follow the instructions very closely
Take before first food. Stay fully upright
Smoking should be avoided
Take this medication by mouth with or without food
Drink plenty of fluids, unless your doctor directs you otherwise
Do not split, crush or chew the medication. Doing so may destroy the drug
Take by mouth at least 1 hour before or 2 hours after a meal
If the tablet falls out before using, throw it away
Avoid exposure to sunlight
Take with full glass of water
Take with food or after a meal
Take on an empty stomach
Must agree to use 2 different forms of effective birth control at the same time
This product may contain inactive ingredients, which may cause allergies Continue reading

Doc: ‘Distorted’ Report May Hurt Hypertension Patient Compliance

By Dr. Daniel E. Forman
Guest Contributor

A recent news article on blood pressure medications and the elderly is stirring up controversy among cardiologists and physicians who treat older patients.

The article, published in The New York Times earlier this month, analyzes a medical study in which researchers looked at the utility of a walking test to identify patients who may not benefit from anti-hypertensive therapy. But the Times piece misrepresents the study, in my opinion, and will likely exacerbate non-compliance for an already notorious problem: the undertreatment of high blood pressure.

Here’s the back story:

The medical study led by Michelle Odden and published online in the journal Archives of Internal Medicine on July 16, was primarily an epidemiologic assessment of a database — not a controlled clinical trial. The study falls far short of an evidence-based randomized trial about hypertension and doesn’t have the rigor of anything that justifies a major therapeutic impact. But The New York Times account on August 8 by Paula Span, described the study as a potential indictment against routine treatment of blood pressure in older adults. Furthermore, the premise of the study, as reported in the NYT, is distorted and the reporter’s characterization of the data exaggerated. (For instance, the study doesn’t clearly refute value of anti-hypertensive medications — it is primarily a trial about treatment stratification.) It does not match other blood pressure trials in rigor and substantive clinical method and it simplifies very complex issues regarding frailty/risk stratification/and even old age. On the basis of the NYT article many patients are likely to become more skeptical about the use of their blood pressure meds.

Odden focused on novel steps to stratify care for older adults with hypertension, i.e., assessing the utility of walking speed to identify subgroups of adults aged 65 years and older who are less likely to benefit from standard therapeutic strategies. The concern is that so-called “evidence-based standards” were derived using data from younger adults and/or particularly healthy trial-eligible older adults and that these treatment parameters may not benefit real-world frail older adults. Continue reading

Supreme Court Strikes Down VT Prescription Privacy Law

The Supreme Court has just struck down Vermont’s prescription privacy law, reports Kevin Outterson, associate professor at Boston University and blogger at The Incidental Economist.

The Associated Press:

WASHINGTON (AP) – The Supreme Court has struck down a Vermont law that forbids drug manufacturers from using information about the prescription drugs doctors prescribe to tailor their sales pitches to physicians.

In a 6-3 ruling Thursday, the court ruled in favor of the data mining companies that compile the information and sell it to pharmaceutical companies.

Justice Anthony Kennedy said in his majority opinion that the Vermont law violates the speech rights of the companies.

Kevin Outterson’s bottom line, in his post here: “Vermont can fix this, but this case spells trouble for any federal or state regulation of data or information.”

The full Supreme Court decision is here, and a previous blog post — in which Kevin makes clear that he serves as counsel on the case to doctors’ groups — is here.

More from Kevin’s analysis: Continue reading

Many More Pregnant Women Taking Prescription Drugs

Prescription drug use jumped dramatically among pregnant women

In a startling new analysis, researchers at Boston University’s Slone Epidemiology Center, in collaboration with the Centers for Disease Control and Prevention and Harvard School of Public Health, report a vast increase in the numbers of pregnant women taking prescription drugs.

Over the last 30 years, for instance:

• First trimester use of prescription medications increased by more than 60 percent
Use of 4 or more medications during the first trimester tripled
Antidepressant use during the first trimester increased dramatically.

The study, published online in the American Journal of Obstetrics and Gynecology, also found that medication use varied by socioeconomic status, maternal age, race/ethnicity and state of residence.

In recent years, a debate has raged in women’s health and maternity care circles about the safety and usefulness of pregnant women taking medications, particularly those to treat depression and other mood disorders. Purists argued that pretty much all drugs during pregnancy are bad. Others said that having a depressed or otherwise mentally ill mother might be worse than the potential risks of taking an antidepressant while pregnant. Still others grappled to find an appropriate balance.

This study, which analyzed interviews from more than 30,000 women, didn’t get into the pros and cons of taking drugs (including prescription and over the counter brands). But it did note that the first trimester is when there is most concern about fetal development and potential birth defects, and that many of the medications pregnant women are taking have not yet been tested for safety.

The study’s lead author, Allen A. Mitchell, MD, director of BU’s Slone Epidemiology Center, said such testing is critical.

“These data identify prescription medications that are currently most commonly used and therefore urgently require research on their risks and safety; they also reinforce the need for ongoing surveillance regarding medication use in pregnancy and its consequences,” he said by email. “Not only is it critical to identify how many OTC and prescription medications are taken by pregnant women and what those specific medications are, but it is also important to know how use of medications changes over time.”

Here are some more of the findings:

–During the first trimester of pregnancy 70-80 percent of women reported taking at least one medication
–Medication use increased with a woman’s age and education level
–Use was higher among non-Hispanic white women compared with women of other races or ethnicities that were studied
–Use during pregnancy varied by state of residence.