I treat very anxious patients. Many are afraid of germs. They avoid sick people, and they wash their hands innumerable times over the course of a day. Their children are not allowed to play with children who have been sick recently. They will not use public toilets. Some avoid touching doorknobs, especially in public bathrooms. Many of them consider these precautions to be common-sense. Worry about germs is, in fact, common even among people who are not patients.
I remember a judge who came to Jacobi Hospital to commit mentally ill patients for a longer stay. I remember him particularly because he mocked the patients in open court. Although he held the patients in contempt, he, himself, refused to touch any of the doorknobs in the hospital. An aide had to open all the doors for him.
Similarly, I have patients who worry about food additives, drug side effects, radiation, and other poisons. These fears are part of a health anxiety, a subset of obsessive-compulsive disorder. Naturally, I find myself arguing against taking unnecessary precautions against largely imaginary dangers. Avoidance behaviors tend to make the underlying fears worse. But there is a situation when it is appropriate to be especially nervous: during pregnancy.
Certain medications and infections are known to have an adverse effect on the fetus. These drugs are given a certain designation for that reason. However, in most cases, it is not known to any degree of certainty whether or not exposure to most substances, or infections, or drugs will affect the fetus. The effects, if there are any, may appear directly after birth but possibly only years later. We tend to presume that a baby who does well initially is okay, but it may not be so. I hesitate to mention studies on this subject because they are hard to replicate and may not be valid; but I think they give reason to be wary about a variety of exposures during pregnancy. For instance, there is a study that suggests that infection, or maybe simply a high fever, may cause a higher than usual incidence of schizophrenia, which may not show up until the child is grown. For this reason, some of the unwarranted concerns of the health worrier are very much a realistic concern for the pregnant woman. I usually give the following advice to pregnant women (These are my suggestions and are not necessarily the view of all physicians.)
1. Avoid all drugs that are not absolutely necessary. Your physician is the best guide to deciding this. Do not take any drugs or herbs that he has not approved. Take vitamins only to the extent that they are prescribed.
2. Do not go on any new or extreme diet. Do not diet aggressively while pregnant.
3. It is okay to exercise moderately.
4. Stay away from sick people. There have been a number of studies suggesting that nursery school teachers have a higher than normal rate of miscarriage, almost certainly due to catching more than the usual number of infectious conditions from the children.
5. Do not take alcohol is any amount. Do not smoke, and avoid smoke-filled rooms.
Psychoactive drugs:
1. I think the minor tranquilizers, the benzodiazepines, should be avoided during a pregnancy. Initial studies showed an elevated risk of cleft palate and other neurological defects. Later studies have thrown doubt on this finding. But these drugs are never necessary, so I think they should be avoided.
2. The anti-depressants. Conventional wisdom states that the benefit of these drugs should be weighed against the possible negative effects on the fetus. This is easy to say, but hard to decide, because the negative effects are not really known. There were reports that the Prozac-family of drugs, given in the last trimester, caused the baby to be born at a somewhat lower than average weight. This was not considered significant; and these drugs are not listed as dangerous for a pregnancy, as many other drugs are. More recently, there have been hints of subtle effects that may extend much longer into the life of the child.
Before giving my specific advice about these drugs, I would like to make a general comment. Every physician, no matter how experienced, has not seen as many patients as would be examined in a well-designed study. Conventional medical wisdom grows out of such studies. So, every sensible physician hesitates to practice in a manner counter to the prevailing conventional medical opinion. The conventional wisdom is that there are occasions when these drugs are appropriate for use in pregnant women. Still, having said that, I am affected also by my experience with a number of depressed patients who at some point became pregnant. Some of these women were chronically depressed. There were a few whom I had previously tried to withdraw from anti-depressants without success. Nevertheless, when they got pregnant, they no longer needed to be on these drugs. There may be some hormonal effects of pregnancy that prevent depression. The effect, if there is such an effect, lasts only through the pregnancy. One woman became so depressed after delivering, that I had to re-start the medications before she left the hospital. There was another patient who had a history of depression who seemed to get depressed again in the middle of her pregnancy, and I thought she would be the exception to this rule, but I waited a week, which I might not otherwise have done, and all the signs of the depression lifted.
I cannot give advice for a patient I have not seen and who might have all sorts of complicating illnesses or circumstances. So, I do not want to encourage a patient to quarrel with her physician. But I have told my patients to stop these drugs when they get pregnant and wait a little while to see if they really need them. This seems to me a reasonable strategy and safe if the patient is being supervised closely. So far, they have not needed them until the pregnancy was over.