Medical Examiner

Should Pregnant Women Take Anti-Anxiety Medication? Some Have No Choice.

The relentless focus on fetal purity was one of the hardest things I faced during my already tough pregnancy.

A pregnant woman holds a pill in one hand and a glass of water in the other.
Photo illustration by Slate. Photo by Getty Images Plus.

The doctor said his name was Lipton, “like the tea.” He pantomimed drinking, pinky up, as I laid back on the hospital bed. It was a Saturday morning. I was six weeks pregnant. My eyes were completely glazed over, and I vacillated between feeling fascinated by my numbness and wondering how much longer I would live.

Two weeks earlier, I had found out I was pregnant for the fourth time. My previous three pregnancies had ended in miscarriage, all within one particularly brutal nine-month period. At first, I had felt excited, if tentative. Then the nausea hit, a driving, urgent queasiness reminiscent of my first pregnancy, which had relegated me to bed for weeks before it ended at three months. Terrified by the similarity, I had gone back on my anxiety medication a week before, 20 milligrams of Celexa, which had seemed to help with my generalized anxiety disorder in the past. But two days later, my panic was at an all-time high—physical, visceral, heart-pounding terror. I took a Benadryl but didn’t sleep a wink. My breathing grew shallower. I saw spots at the corner of my eyes. After another sleepless night, my husband and my mom took me to the closest emergency room. The nurses handed me warm blankets from what appeared to be an oversize silver refrigerator, and I shivered under them while Dr.
Lipton’s assistant inserted an IV and slowly pushed two milligrams of Ativan into my bloodstream. The relief was almost instant. A dayslong panic attack subsided, and I felt better than I had in weeks. That night, I left the house for the first time in days. I saw a movie! I fell asleep sure that the worst of it was over.

I woke up at 1:30 a.m. to heart-pounding terror. My breathing was shallow, and I saw silvery stars in the dark. The panic hadn’t actually gone away. It simply had been masked, for a time, by the anxiolytic effects of the Ativan. If it was possible to feel even lower than I had the night before, that’s where I was. I wondered if it would be worthwhile to wake up in the morning. But I made myself take one pill from the small prescription I had been given, letting it dissolve between my lower teeth and my cheek. Then I fell back asleep for another five hours. Thus began my monthslong relationship to Ativan, for which I became entirely grateful—and incredibly ashamed.

Women who also deal with anxiety or depression are asked to make a terrible choice during pregnancy: take a pill that helps you but could hurt your child, or suffer without medication but keep the “purity” of your baby intact. Pregnancy in America is essentially an endless pursuit of fetal purity. From my perch as a patient, I often felt that doctors practiced “maternal fetal medicine” in name only—the overriding concern is for the fetus, often at the expense of the mother, who is reduced to mere vessel for a baby.

This is how women have been treated during pregnancy for most of human history, says Catherine Medici-Thiemann, professor of women’s and gender studies at the University of Nebraska. People used to believe, for example, that if a pregnant woman saw a rabbit, their baby would be born with a harelip—what we now know as a cleft palate. Relying on fear and superstition rather than fact “continues that trend of putting the responsibility for the perfection of the baby on the mother,” says Medici-Thiemann. Society—and, often, the medical establishment—already scares pregnant women away from caffeine, alcohol, and deli meats, all for reasons that have more to do with the interest in keeping the womb free of imagined threats than in dealing with facts. Given the tenor of the conversation, is it any wonder so many women are ashamed to talk about their decisions to take medication during pregnancy?

Ativan is not a medication that most nonpregnant people would take without caution.
The brand name version of a drug called lorazepam, it’s a benzodiazepine, meaning it works by inhibiting the fight-or-flight response in the brain (that’s why it’s especially effective during a panic attack). It can be habit-forming and may harm long-term memory. But people take it, and they do so because the other option—not taking it—is much worse. The same exact calculation applies during pregnancy. There is no one who wants to be so wrought with panic during this time that one of her only lifelines is a poorly understood drug that is known to have some intense side effects. And yet, there are some pregnant people who suffer so severely from panic that the regular use of the lowest possible dose of benzodiazepine is vital—perhaps even necessary.

There have been attempts to understand the effects of benzos in pregnancy, but they’re muddied. You can’t set up an ethical traditional controlled experiment, because you wouldn’t want to give the drug to anyone if it’s not necessary, and you also wouldn’t want to refrain from giving the drug to women who need it. But then you are left with observational studies, which don’t give concrete answers. A 1992 study found 80 pregnancies in which the fetus was exposed to benzodiazepines, but it concluded that it was impossible to isolate the effect of benzodiazepines, due to “frequent alcohol and substance abuse, and other disorders” observed in the women. An early study that suggested a possible link between benzodiazepine use in pregnancy and cleft palates actually saw a difference of only 1 child in 10,000 between those who were exposed to benzodiazepines in utero and those who were not—hardly a note of statistical significance. Later studies have found that that benzodiazepines do not have an effect on fetuses who have in utero exposure but also discovered a correlation between benzodiazepine use and cleft palate.

Many women who take benzodiazepines during their pregnancy also take selective serotonin reuptake inhibitors, or SSRIs, to treat their anxiety or depression. This is generally thought to be safe—studies have shown that women who take SSRIs during pregnancy have a similar risk of miscarriage to those who stopped their SSRI use three months to a year prior to pregnancy. “I think in general for a large class of SSRIs, it does not seem like there are significant risks that we can see in the data,” says Emily Oster, a professor of economics at Brown and author of Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong—and What You Actually Need to Know. When it comes to benzodiazepine use during pregnancy, though, there’s not enough data to offer certainty. How would Oster advise an expecting parent to go about making this decision? “The first thing I would do is try to figure out how big these effects are,” she says. Benzodiazepines are a Class D drug, according to the Food and Drug Administration’s rating for drug use during pregnancy. But that doesn’t necessarily tell us much. “A drug can be Class D because we’re very sure there’s a very small effect or we’re very sure that there’s a reasonably sized effect, so that’s kind of a big range,” Oster says. The relatively low instance of any sort of side effect (remember, the incidence of cleft palate was 1 in 10,000) was a good sign, Oster tells me. And in addition to advising people to think through all possible effects of the medication they take during pregnancy, Oster also encourages pregnant people to seriously consider their own mental health: “People don’t just take Ativan for kicks and giggles; it’s not like you’re doing it for fun,” she says. (I wasn’t, although some people do.)

The upshot of all of this is that there isn’t a clear indication of whether taking Ativan during pregnancy poses any additional risk to your child. Still, you’re unlike to find a doctor who will happily prescribe it to a pregnant woman. My psychiatrist warned me to be prepared for pharmacists refusing to fill my prescription once they saw my condition, so I took to going to CVS in flowy shirts and jackets that covered my growing belly. Some doctors refuse to prescribe even SSRIs to their pregnant patients. Others urge caution or refer patients to psychiatrists who specialize in treating pregnant people. This lack of consistency in the medical establishment means that women in need might receive entirely different care for no standard reason. This is confusing to patients in need, who, like any other confused patient, often end up on the internet looking for answers.

This is sure to activate anxiety even in people who don’t suffer from the clinical type. Online forums are full of misinformation and opinions with little factual basis, but we’re drawn to them because it is helpful to get instant input when you’re wondering if that twinge you felt was normal. I visited one particular BabyCenter forum at least a dozen times during my pregnancy, where I found another woman who took Ativan and was worried about the health of her fetus. “My baby is almost 9 months old and he is absolutely perfect,” one responder wrote. “I was soooo anxious during my pregnancy about having to take Ativan and Zoloft and was convinced I hurt my baby. I was even suicidal that’s how bad it was. My son is the light of my life and I live for him.” But for every comment like that, there are sure to be several that misunderstand the complicated relationship some of us must have with our medications.

Some of these judgments even come from inside the medical system, where I was sure people would know better. Contrary to narratives that focus solely on postpartum mental health issues, pregnancy can actually exacerbate some mental health issues. But when I went to my doctor’s office early in my pregnancy, a nurse clucked her tongue at me when I told her I had gone back on my SSRI due to worsening anxiety. “I know a lot of people, and I mean a lot, whose anxiety got better during pregnancy,” she told me. I stared at her, dumbfounded. “It can happen!” she exclaimed. “Maybe you will get better, too.” Meekly, I told her that I hoped I would get better, but in the meantime things were pretty bad. She left to tend to another patient, and I left feeling incredibly dejected, like there was something deeply wrong with me—and only me—that caused me to become more anxious during a time when most women would be thrilled, relieved, and glowing with joy. The decision to take medication during my pregnancy was one I made with all the urgency of a panic attack, and with all the care of a woman who desperately wanted to be pregnant with a healthy baby.

I eventually found a psychiatrist who specialized in treating pregnant patients. “I’ve seen patients take anywhere from 1 to 3 milligrams of Ativan daily throughout their pregnancies,” she told me, “and none of them had cleft palates, and none of them ended up being damaged by it.” Of course, that last claim can be hard to verify—the long-term effects of benzodiazepine use during pregnancy have not been studied, and if a baby were to have something wrong with him several years down the road, it would be entirely impossible to tell whether we could trace that to his mother having taken Ativan during her pregnancy. Eventually, I realized that what I wanted the whole way through my pregnancy was some kind of guarantee that the outcome would be good. Coming to terms with having an imperfect pregnancy—which, in some ways, they almost all are—was one of the hardest processes of my whole life. Not because I expected a perfect pregnancy, but because I was forced to confront the fact that this thing I wanted so much, and wanted to do so well, had taken me beyond what I was capable of on my own. I needed help. For me, that help came in the form of a pill that made me nervous.

“We’re used to having a lot of control,” Oster says. “And [pregnancy] is fundamentally uncontrollable, and it remains uncontrollable once the baby has arrived. This is an exercise in loss of control, and it’s some ways an exercise in fear that something bad will happen or you’re not doing it right. And I think some of it is trying to step back and be rational.” Relying on facts rather than fear, we can start to make informed decisions. We can also ask the medical establishment to become a bit more comfortable with uncertainty, informing women of concrete risks and benefits rather than shutting down conversation. We can train OB-GYNs in maternal mental health. We can implement better postpartum care for mothers. We can examine and discuss perinatal mental health at each OB-GYN appointment during a pregnancy.

When I look at my beautiful, chubby son now, I know part of me will blame myself if we are ever to find out that something is wrong with him. I also know I have a lot of compassion looking back on my pregnant self. In a time of acute panic and fear, I did the best I could in order to survive and contribute to the health and growth of my son—the same thing I’m aiming for each day now.