Antidepressants are being prescribed by obstetricians to women who have experienced a miscarriage or stillbirth. Several of my clients have left the hospital with a prescription for an antidepressant and a few have questioned why. I have been scolded for my stance on this and told that prescribing antidepressants is very productive and should be a standard of care for all women.
I realize this can be a controversial topic and by no means is this post meant to offend women who were prescribed and took an antidepressant following their miscarriage or stillbirth. Many of my clients take antidepressants and some feel better doing so. This post is meant to bring awareness to why this may not be the best idea and why prescribing antidepressants for pregnancy loss should not be a standard of care.
When talking with some of my peers, some believe that women need an antidepressant for grief, that the loss of a baby requires medication. But why? Why would an antidepressant be needed for something that is considered normal? It’s a stigma and one that needs to be broken.
Let’s talk about what an antidepressant does. Antidepressants affect the neurotransmitters in the brain. Basically, the brain chemicals may be out of balances and an antidepressant can assist with balancing those chemicals. It changes the mood in the person but grief is not a chemical imbalance. Grief is a reaction, most commonly occurring from the death of a loved one. So if grief is not a chemical imbalance, why prescribe a medication that modifies the chemicals in the brain? Grief symptoms can mimic depression but this is where the psychotherapist or psychiatrist comes in.
- Are antidepressants appropriate for grief alone?
I did some research on this topic to include talking to local therapists who specialize in pregnancy loss. Antidepressants should be utilized in conjunction with psychotherapy and should only be prescribed for depressive reactions to bereavement. This article at GLOWM states, “When medications are required, there is often prior major depression, serious personality disorder, or a history of trauma rather than solely a severe reaction to perinatal loss.” 1DSM-V states that ordinary grief is not a disorder and does not require professional treatment (therapy). 2 “Furthermore, contrary to insistent cries of alarm by some, “treatment” of post-bereavement depression need not involve antidepressant medication, except in the most severe cases.” So even the DSM-V does not believe that grief alone should be treated with antidepressants. The DSM-V allows access to treatment options even with a recent loss but that does not mean everyone should be treated with therapy or antidepressants. In fact, the article at GLOWM by Leon, I., states “The majority of couples appear to adapt within two years without psychotherapy, indicating that recommending extended counseling for all couples experiencing perinatal loss is unwarranted183 and may be detrimental based on findings challenging the universal benefits of grief counseling.70, 87“
- Should the obstetrician prescribe antidepressants for pregnancy loss? The consensus among some local psychotherapists who specialize in treating patients experiencing pregnancy loss is NO. Psychiatrist should manage and monitor a patients antidepressants as they are the experts or rather, the specialty for mental health, not the obstetrician. A patient who is prescribed an antidepressant for grief alone may not be monitored appropriately and according to the articles above, patients should be receiving psychotherapy when they are taking antidepressants. This is because antidepressants alone cannot “fix” the grief or depression. Antidepressants and therapy should be used together.
So the question remains, how should grief for pregnancy loss be treated? With compassion and empathy. The grief journey is one that needs to be experienced in order to get through it. It should not be suppressed. We know that grief is normal and it is even healthy. The family enduring the grief should find a supportive and empathetic bond, free from the boundaries that society places on how long they feel the family should grieve.
There is no timeline on grief. It changes and morphs. Families will learn to live with the pain but it may never disappear; their child will never be replaced by another child and they will not forget. Friends and family can be extremely helpful on the grief journey by providing support (meals, childcare, taking care of chores, etc) and not imposing their beliefs on the family. Helping the family know what to expect is also important and this can be achieved by hiring a bereavement doula or loss doula.
Am I saying that antidepressants should never be prescribed following pregnancy loss? Absolutely not. For grief alone, the consensus is that antidepressants should not be prescribed at time of discharge. Without proper follow-up and monitoring, there is no way to know if the medication needs to be adjusted or stopped altogether. If the obstetrician believes that there is an underlying condition or mental health disorder which requires an antidepressant, the patient should be referred to a psychiatrist and begin therapy. Referral to the proper medical profession is imperative.
1. Leon, I, Glob. libr. women’s med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10418
2. Pies, R.W., Bereavement and the DSM-V, One Last Time., December 11, 2012