Another lesson in how Hashem runs the world and not psychiatrists

Ruchy was a European-born chassidish young mother with OCD who had come to me for an evaluation after the birth of her second child. She’d been working with a life coach named Suri, who knew she was out of her league with Ruchy’s symptoms, and grateful her client finally found her way to treatment. Part II

As it turned out, Suri, Ruchy’s life coach and confidante, wasn’t at all the roadblock I’d imagined her to be, and was in fact extremely supportive of Ruchy, my new patient, getting formal treatment. And for my part, I had to ask forgiveness for judging her as someone who didn’t know the limits of her own skill set — because it was Suri who in fact encouraged Ruchy to be an active participant in the standardized treatment plan that we’d drawn up. With a few months of cognitive behavioral therapy and an antidepressant medication working in tandem to control her symptoms, Ruchy was back on track and her obsessive thoughts of hurting the baby, her compulsive need to check halachos, and other symptoms were under control.

We’d followed up a few times over the year to ensure that things remained stable and Heshy always came in beaming, happy to have his wife back.

As we were about to complete our first year together, Ruchy asked me about coming off of her medication. It was a very reasonable and predictable thing to ask, given her long-term stability and the fact that most people don’t like taking psychiatric medications long-term unless they’re sure there’s an acute need for it.

We discussed the benefits and risks of stopping her antidepressant and came up with a plan to decrease the dose slowly over a few months. She’d been stable for nearly a year so it certainly was reasonable to try decreasing her medication in a controlled environment with the proper support and monitoring. In order to prevent a relapse of her OCD symptoms, we also discussed the need to have ongoing communication with her psychotherapist and to maintain a healthy lifestyle with regular cardiovascular exercise and good sleep hygiene.

And then I received that call that they needed an urgent appointment.

Ruchy was trying to remain calm as she and Heshy sat across from me — and this time Heshy looked as though he needed his wife’s support as much as she needed his.

“I’m so nervous again, Dr. Freedman!” she practically wailed. “I’m keeping Heshy up all night about sh’eilos and I’m worrying about the kids and—” Ruchy was getting unwound and beginning to cry so I cut her off to provide a bit of reassurance.

“Rebbetzin, everything is going to be okay. We’ll just restart the medication and you’ll be back to your old self in no time,” I said as confidently as I could.

“But Dr. Freedman, I’m expecting again! What am I going to do?!”

Well, that was another lesson in how Hashem runs the world and not psychiatrists, but the truth was, this wasn’t the disaster they expected it might be.

“Beshaah Tovah!” I said enthusiastically. “The emes is, I’m not concerned. If you need to restart the medication, we will restart it — and don’t worry, you’ll be fine and so will the baby.”

That was a surprise for them, certainly not the response they’d expected. Was it really possible to continue SSRI meds for OCD during pregnancy?

“Listen,” I told them, “while this might not seem ideal, the specific medication you were taking is actually thought to be quite safe in standard doses during pregnancy. The chemical itself doesn’t pass from the mother to the fetus in any kind of significant amounts. And studies show that it’s better to take it during pregnancy than to suffer through the alternative horrendous stress and anguish, which for sure isn’t healthy for your baby.”

Ruchy didn’t seem too happy about that. “I don’t care about studies and research — I care about my baby! Is this safe or not? Have you seen it work where the babies are healthy or does it cause problems!?” She started to tremble. “Dr. Freedman, you can’t imagine what it’s like — ever since I discovered I’m pregnant, my brain’s been working in overdrive! I know it’s crazy, but I feel like there’s danger at every turn, lurking in every corner — I stopped drinking water because I know it’s contaminated, I don’t trust my babysitter to take my kids outside, and I even dumped out my vitamins because I was sure they’d lied about the expiration date!”

Given her story and current presentation, it was clear that Ruchy was too stressed out to manage her symptoms without a medication protocol. In general, rates of anxiety disorders are higher for women, and according to studies, pregnant women are especially vulnerable for OCD or anxiety relapse. Many women with existing OCD experience an exacerbation of symptoms during this time — either due to added stress and overwhelming feelings of responsibility, or because of hormonal fluctuations that can affect the brain chemicals related to OCD. Either way, suffering was definitely the worse option.

“Rebbetzin,” I told her, “think about what your suffering and anxiety is doing to your baby. It’s true that meds feel scary, but a crazy mom isn’t any healthier, and can be even more dangerous. I’ve seen dozens of women take this medicine during pregnancy and haven’t seen a single baby born with three arms.”

Heshy, for his part, felt comfortable enough that this was the right choice, but knew there was only one way his wife would agree. “Ruchy, I’ll ask the Rebbe himself, to make sure we’re making the right decision.”

Ruchy agreed, and we planned to be in touch.

Heshy phoned me two days later to let me know the Rebbe had told them that untreated psychiatric illness during pregnancy is dangerous for the mother and dangerous for the baby. “And while it might be a bedieved for some people, it’s l’chatchilah for us.”

I had a prescription waiting for them that afternoon and was glad to see that Ruchy was stressed but smiling.

I reassured her that we’d follow up in a month, and even got a giggle when I offered to be the sandek in eight months.

“We’d let you,” she smiled, “but Heshy already promised it to the Rebbe.”

“That’s the only answer that doesn’t hurt my feelings,” I smiled back.

(Originally featured in Mishpacha, Issue 822)