The ability to cope
Many women who ultimately decided to take antidepressants during pregnancy described high symptom burden and struggling to look after themselves, and in turn their babies, when making their decisions:
‘When I’m not on my medication I have … well I call them episodes … where I’m very anxious or the other end I’m very depressed, I can’t really function very well on a day-to-day basis and obviously that’s not — you’re not in the best place to look after yourself let alone if you’ve got a baby.’ (P3)
Many women described challenges that were related to being pregnant, including difficult emotional responses (negative feelings towards the pregnancy, anxiety about fetal wellbeing) and physical stressors (nausea and vomiting, tiredness, physical discomfort). These caused additional stress on top of existing challenges, including those related to work, relationships, and caring for existing children, leading to a reduced sense of coping:
‘So moving to a new [work] site with a terribly sick teacher who can’t get a decent night’s sleep, whose daughter isn’t sleeping a hundred per cent all the time anyway … you can imagine it was a toxic combination, absolutely toxic … it got to the point in the January I ended up in floods of tears ’cos I was just being sick most days.’ (P4)
In some cases, the trigger for starting antidepressants during pregnancy was a crisis, for example, a strong negative reaction to a gender scan or experiencing suicidal ideation:
‘I said “this isn’t normal, I’m a mum, I shouldn’t feel this thing that I’m feeling. I feel awful and evil and I should be caring and nurturing and yet I just want him gone” … then I thought do you know what, I’m just going to crash my car, it’ll be easy … So I braked at the last moment, missed by, don’t know, wholly surprised I missed it but I did and then the doctor — I went and saw the GP, they put me on sertraline.’ (P12)
Three women who initially stopped their antidepressants shortly before or in the early stages of pregnancy said their depressive symptoms re-emerged in the second or third trimester:
‘A tidal wave on the horizon.’ (P2)
They attributed this resurgence of symptoms to the discontinuation of antidepressants at a time of increased physical or emotional stress and decided to re-start their antidepressants.
Some women believed that antenatal antidepressant treatment might mitigate the risk of developing postnatal depression. This was particularly the case for women who had suffered previously from postnatal depression, often with distressing and disruptive sequelae:
‘It was a really big fallout if I became really, really unwell, you know, the impact on my other children … With my first baby I was in hospital for three months with her … if I had to go into hospital again with my other babies I’m leaving my other children behind … missing out on them … they’re missing out and a big horrible, ugly mess basically.’ (P7)
Other women described coping well while taking their antidepressant and not wanting to risk disruption resulting from discontinuation. In some cases, any potential adverse effects of antidepressants were perceived to be outweighed by the possible effect of depression itself. Conversely, some women who described coping well with their symptoms and day-to-day life felt that the potential risks outweighed the benefits and opted to stop their antidepressants in anticipation of, or shortly following, conception:
‘Things had been fine for quite a long time so I wasn’t particularly anxious and I wasn’t experiencing a great deal of stress at the time … I just decided [continuing antidepressants] wasn’t a risk that I needed to take.’ (P17)
Concerns about antidepressant use
Almost all women in the sample expressed concerns about the risk of adverse fetal effects. These were sometimes non-specific, but many women did cite specific concerns including effects on brain chemistry, risk of cardiac abnormalities, neonatal addiction/withdrawal, and neonatal respiratory distress. Two women who decided not to take antidepressants both had a previous history of miscarriage and expressed concerns about possible pregnancy loss. For one woman, this concern prevented her from seeking professional help:
‘’Cos of the history of miscarriage and because of this whole I’m so lucky to be pregnant, I didn’t want to do anything that would compromise it … I think as well that was a factor of me not admitting my mental health problems because I think they would have prompted me to have treatment and in my head that would have been straightaway medication and I know I wouldn’t have taken it.’ (P9)
Only one woman described having no concerns about fetal wellbeing. She reported feeling emotionally detached from her pregnancy. Her concerns about taking antidepressants were centred more around the potential for her to experience adverse effects, and about the potential effects on her existing child.
Some women considered that safety in breastfeeding was also an important factor, especially those who had had previous (positive or negative) experience of breastfeeding.
A number of women described their intolerance to fetal risks, even when they perceived them as minimal. These women also described high levels of anxiety relating to fetal health, fear of experiencing guilt, and anticipation of self-blame in the event of an adverse outcome:
‘I think if he ended up having any, I don’t know, having difficulties or even mental health problems himself, I didn’t want to feel like I might have contributed to it by doing something during pregnancy.’ (P19)
Many women referenced the idea of the sanctity of the pregnant body, the reluctance to introduce ‘unnatural’ substances, and a preoccupation with healthy living. Some women described a sense of fear and uncertainty about taking any medication at all during pregnancy.
‘I didn’t take paracetamol, I didn’t take ibuprofen, I didn’t really take any kind of drugs when I was pregnant. I struggled coming to terms with getting — to having Gaviscon with my heartburn (laughs).’ (P7)
Several women described making their decisions within the context of the perceived societal expectations placed on pregnant women: to feel joyful, and to nurture the pregnant body. This was described by P17 as the ‘surveillance’ of pregnant women. Women described the stigma associated with being mentally unwell or taking antidepressants during pregnancy:
‘I just felt that if I said “oh I’m on medication for my mind”, that might be seen as a selfish thing to do, you know, the equivalent I guess of maybe tucking away a bottle of wine a night or something by people.’ (P2, who initially stopped her antidepressant and then re-started during pregnancy)
Two women (P9 and P18) who worked in the mental health field described feeling particularly ashamed and vulnerable to criticism. Both women decided not to take antidepressants.
For some women, the desire to avoid medication during pregnancy was rooted in the context of their personal experiences. Following an overdose early in her pregnancy, P5 reported feelings of guilt and tried to avoid any medication for the rest of her pregnancy, but later re-started her antidepressants during an inpatient psychiatric admission. P10 reported that her drink was ‘spiked’ shortly before becoming pregnant, leading her to fear taking any medication. Another woman described a neighbour with mental health problems as someone she feared she would become like if she took antidepressants:
‘I was just so frightened of becoming like her, so dependent on [antidepressants] and if she’s running low towards the end of her pack she gets jittery and “oh my God, is this normal?” It’s like she’s a drug addict.’ (P12)
Due to their concerns about taking antidepressants during pregnancy, most women said they preferred to try non- pharmacological strategies before, or instead of, antidepressants. Many women described antidepressants as an adjunct to non-pharmacological strategies:
‘A buffer.’ (P7)
‘A hand to hold … a boost up.’ (P10)
‘A crutch.’ (P2)
Most women reported seeking non-pharmacological strategies: most commonly counselling (often private), help from charities or local support groups, and exercise. However, women reported a range of barriers to accessing these strategies, including long waiting lists for talking therapies and difficulty accessing perinatal mental health services. Such barriers, alongside the time-limited nature of pregnancy itself, contributed to some women’s decisions to start antidepressants:
‘[My GP] said by the time they get referred to you, you will have had the little one so she said you might need something before that ’cos you’re not coping … it did make sense and I appreciated her saying it so I could get treatment there and then.’ (P15)
