State of Mind

Pregnant Patients With Panic Attacks Deserve Treatment. Yes, Sometimes Even With Medication!

My experience trying to get a much-needed benzo prescription showed me just how far behind the science some doctors are.

Pills falling into a cupped hand
Photo illustration by Slate. Photo by Getty Images Plus.

I wanted another child. A prior miscarriage left me empty, craving nothing more than to squeeze chubby baby thighs.

And yet, once pregnant again, my excitement felt distant and muffled. Like a pea beneath a pile of mattresses. I did not want to compare the baby growing in me to the size of a blueberry or kumquat, the way I did with my first.

I told the midwife at my first prenatal visit. Hormones, pregnancy, she said, with a wave of her hand. She placed me on a call list for the hospital’s mental health care group. Nobody ever called.

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I tried different doctors. “You don’t understand. This is bigger, worse,” I told the second obstetrics practice, and then a third.

The darkness gave way to  panic attacks. I could no longer drive. My writing came to a halt. I spent days on the couch with my 3-year-old watching The Octonauts. She occasionally patted my head.

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Just before the December holidays, the third obstetrician scribbled a prescription: a low dose of the generic equivalent of Zoloft. I had had depression and panic attacks before. I knew that for my brain, in this state, Zoloft was the equivalent of using a plant mister on a raging fire.

“This isn’t going to work,” I told the doctor. I had struggled with anxiety for decades and tried nearly every class of medication to stifle my symptoms. I also have a Ph.D. in pharmacology and molecular signaling. I know both personally and scientifically that, sometimes, a low dose of Klonopin is the salve to my agitated neurons.

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But when I relayed the need for Klonopin to the obstetrician, she looked appalled and told me to just try the Zoloft.

Some OB-GYNs are hesitant to prescribe psychiatric medication for pregnant people at all; the ones who do will turn to SSRIs like Zoloft, despite their variable efficacy and the time it takes for them to kick in. For many people, a small dose of Klonopin will provide relief much more immediately—it is a benzodiazepine, and it works to calm anxiety through the inhibitory neurotransmitter GABA. This is similar to how alcohol works, so unsurprisingly there is the potential for misuse. While a hesitancy to prescribe them to pregnant people is natural—and for some patients, warranted—what I experienced time and again during my pregnancy is that many providers have an outright fear of how benzos will affect the pregnancy, which often clouds their ability to properly treat the pregnant person. But even though research into benzos’ safety to the fetus is limited (as it is for most classes of medications), it does not support such fears or warrant the withholding of care.

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Anyone carrying a baby should have access to mental health care that works. And medications—including benzodiazepines—should, for many patients, be among the options that are available.

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Maternal mental health—or MMH—conditions are the most common complication of pregnancy. About 1 in 5 people will experience them during the perinatal period (anytime from the start of pregnancy through the first postpartum year) according to Elizabeth Cox, a perinatal psychiatrist at the University of North Carolina–Chapel Hill’s Center for Women’s Mood Disorders and an assistant professor. If someone is prone to panic attacks, pregnancy may trigger even worse ones. This is because physiological changes that happen during pregnancy, such as increased blood volume, heart rate, and breathing rate, can mimic symptoms experienced during a panic attack.

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Many, many people afflicted by a MMH condition during pregnancy will be left to struggle without proper help. Cox is first author on a review in the Journal of Clinical Psychiatry, which determined that only half of pregnant women with depression, and less than a third of postpartum women with depression, were properly diagnosed by doctors. Only about 15 percent of each group received treatment.

And note that receiving treatment is not the same as finding relief from symptoms. Those numbers are far smaller; less than 5 percent of people with perinatal depression experienced remission. Nonwhite birthing people and those living in poverty fare even worse. It’s estimated that Black women experience double the rate of MMH conditions that white women do and are half as likely to be treated. What’s more, all of these numbers were from before the pandemic and the reversal of Roe v. Wade—both factors that make anxiety and stress worse.

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Medication is not the only tool that can bring relief, nor is it right for every pregnant person experiencing a mood disorder. Since MMH conditions exist on a spectrum of severity, there are treatment options beyond medication for milder cases, including mindfulness, light exposure therapy, and talk therapy. However, from the data on treatment numbers, it is clear that pharmacotherapy is underused.

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It’s been ingrained in us that ingesting the wrong thing during pregnancy can harm the fetus. As a result, “many health care providers and women overestimate the risks associated with medication use in pregnancy, which in most cases are really, really small,” says Hedvig Nordeng, professor and head of the pharmacoepidemiology and drug safety research group at the University of Oslo.

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While there’s not a lot of research into the safety of benzos during pregnancy, the research that does exist suggests their effects on a growing fetus and pregnancy outcome are typically minimal. In a 2020 observational study in JAMA Network Open, Nordeng’s research group examined data from more than 82,000 pregnancies to determine what effects, if any, use of benzodiazepines or z-hypnotics (drugs for insomnia, like Ambien) had during pregnancy. Of 634 pregnancies, they found a slight decrease in birth weight of a couple ounces, likely related to the babies being born two days earlier on average. But that was it. They found no significant difference in the condition of newborns, respiration rates, suckling, head circumference, or incidence of C-sections. (In Nordeng’s research, most participants took benzodiazepines for two to three weeks. She notes that in any discussion of the safety of benzodiazepines it is important to distinguish this short-term use from a heavier reliance on the drugs, which comes with more risks.)

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Another study from the same group looked at prenatal exposure of benzodiazepines and z-hypnotics on behavior in 5-year-olds. Although there were some differences from the control group, like increased anxiety and depression, the researchers concluded this was likely due to underlying maternal mental health conditions, not medication that was being used to treat those conditions during pregnancy. “To provide evidence-based guidelines, we need to understand both the risks of the underlying maternal illness and the risks of different medications,” says Nordeng. In the childhood behavior study, the authors wrote that “although benzodiazepines have been on the market since the 1960s, only three studies world-wide have assessed their long-term developmental safety, in less than 1,000 [prenatally exposed] children.”

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Camille Hoffman, a high-risk obstetrician and associate professor at the University of Colorado School of Medicine, said in an email to Slate that she believes there can be a place for benzodiazepines in some pregnancies, especially when ramping up SSRI doses, which can take several weeks. Both she and Cox use this class of drug with patients when warranted.

Still, all providers stressed using the lowest effective dose for the shortest duration of time. Taking benzos for long stretches can worsen anxiety. And special caution is required in individuals with a history of substance abuse.

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Cox says that although a benzodiazepine is not her first choice (SSRIs are the “gold standard”), it is critical that the anxiety is treated, and this may require a combination of medications—at least in the beginning—to address symptoms, such as an SSRI alongside short-term use of a benzodiazepine. When I asked specifically about my own experience with panic disorder, she confirmed that that is a scenario in which she would likely use them.

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My own providers’ lack of care, unwillingness to appropriately treat my condition, and consistent downplaying of my symptoms led me to question myself and my reality. Midway through my pregnancy, I became alarmed by my own thoughts. I could not look out a window without thinking of jumping. I needed the suffocation to end. And there were only two ways to do that: take a low dose of Klonopin or stop existing. I filled an old prescription and breathed without effort for the first time in months.

Then I called my obstetrician’s office to tell them. They told me to go to the ER immediately. “We have to make sure the baby is OK!” the nurses screamed at me after I explained that I took a low dose of Klonopin. I spent a long night in a stark hospital room strapped into a fetal monitor, each readout perfect.

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Five years later, I still contend that the extreme reaction was misplaced. However, I cannot fault the doctors for the pervasive stigma attached to this controlled class of meds. A handful of prenatal rodent studies from nearly 40 years ago showed that these drugs can cause fetal structural anomalies and affect the offspring’s behavior or motor skills—so in some ways such reactions are understandable. But Nordeng says animal studies are very difficult to interpret, and she warns against extrapolating results of this research to humans. In fact, the newer studies on medication and pregnant people are reassuring, she says.

The day after the ER visit, a perinatal psychiatrist spoke to me over the phone. I told her my story—the feelings of suffocation, the need to do something—and how I had taken the old medication.

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“That’s fine,” she said, and hung up. Later that week I went to a perinatal psychiatry clinic at a major university that signed off on my low-dose benzodiazepine.

That same week I received a registered letter from my doctor’s office letting me know they were dropping me as a patient for “withholding information” despite calling to tell them exactly what I had done.

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While there are risks to taking benzos during pregnancy, there also are risks to forgoing them entirely. “There’s this perception that somehow you could white-knuckle it and work through it and just be OK,” says Cox. But untreated MMH conditions are their own form of exposure and can lead to a variety of complications for both the pregnant person and the baby. Those risks include preeclampsia, substance use disorder, and levels of stress that are toxic to the newborn. According to Cox, if extreme stress persists for a long period, the stress hormone cortisol can interfere with fetus’s brain development.

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Even mild MMH conditions can escalate quickly. Suicide accounts for 20 percent of postpartum deaths. Perinatal suicidal ideation and self-harm nearly tripled in the U.S. between 2006–17, with the greatest increase in Black women.

In 2017, Hoffman co-authored a commentary in Obstetrics & Gynecology. She says she and her colleagues “[tried to] address concerns and myths about prescribing. We sought to bring to light the risks associated with untreated depression and anxiety.”

Hesitancy to prescribe benzos is not simple to dismantle because it is likely a constellation of outdated beliefs (derived from animal-based studies or human studies with very small sample sizes and a lack of controls) and practitioners feeling unsure of how to screen and treat MMH conditions. According to Cox, there are only three perinatal psych inpatient units in the country, which means many OBs don’t encounter MMH conditions during training. The lack of mental health providers is apparent to her. At one point during the pandemic, she was getting nearly 16 referrals a day.

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Just as we would properly treat pregnant people who have diabetes or epilepsy, the approach to MMH conditions should be the same. And just like insulin or anti-seizure medication, antidepressants need to be at the appropriate dose, which, because of the physiological changes, is higher than that given to a nonpregnant person, says Hoffman.

“So with a woman with severe epilepsy, you wouldn’t say to her, ‘Let’s see if we can control that epilepsy with yoga alone,’ ” explains Nordeng. Patients should be screened at least once during the perinatal period, according to the American College of Obstetricians and Gynecologists. But Hoffman says she recommends screening at the first prenatal visit, again in the third trimester, and at postpartum visits.

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Cox says MMH conditions are highly treatable, so much so that when she sees a patient struggling, she tells them they will get better and she is confident of this. But she hurts for those across the country silently suffering: “It’s so worrisome and I know that we could do better.”

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Looking back at my experience, I’m resentful of those who dismissed me and of the obstetrics practice that dropped me after my ER visit, forcing me to seek yet a fourth practice of supportive midwives.

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I’m grateful for my stubbornness and education because they helped me to survive and to once again become a mom and squeeze chunky baby thighs. A few months after I filled my new Klonopin prescription, I had a healthy baby. And I didn’t have a panic attack once during my 26 hours of labor.

If you need to talk, text the Crisis Text Line at 741-741 or call or text 988 to reach the Suicide & Crisis Lifeline. Find more resources on MMH at Postpartum Support International, Maternal Mental Health Leadership Alliance, and at 998’s Maternal Mental Health page.

State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

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