Psychiatry & Psychotherapy Podcast - Pregnancy Planning for Patients Taking Psychiatric Medications or with a Mental Health History

Episode Date: June 23, 2023

In this episode, Dr. David Puder, Dr. Kristin Lasseter, and medical student Cara Jacobson discuss treatment of psychiatric illness in the peripartum period.   Dr. Kristin Yeung Lasseter is a renowned reproductive psychiatrist who has dedicated her career to the intersection of mental health and reproductive medicine.    As the founder of Reproductive Psychiatry and Counseling, Dr. Lasseter has been instrumental in expanding access to reproductive psychiatry services in Texas but also worldwide through her teaching and online presence. Through her steadfast devotion to comprehending the singular hurdles faced by individuals as they navigate the reproductive journey, she has garnered immense respect within the field.   Dr. Kristin Yeung Lasseter's profound contributions to advancing women's mental health in Central Texas have been recognized through the prestigious Association of Women Psychiatrists Symonds Fellowship in 2018. Through her expertise, compassion, and advocacy, she is transforming lives and dismantling the stigma associated with perinatal mental health.   Of note, this episode, and the article below is for information purposes only and we recommend talking with a specialist doctor when considering what is the risk and benefits of particular medications in an individual's specific situation.  By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.  

Welcome to the Psychiatry and Psychotherapy Podcast. I'm your host, David Puter. This is your gateway to the intriguing world of mental health. As one listener put it, this is the podcast that your psychiatrist listens to. And we're incredibly proud of that endorsement. Whether you're a loyal, active listener who's been kind enough to reach out, maybe send an email at DM or put in a review, or you're new to this community. We have an exceptional opportunity for you, not only to learn, but to also, earn continued medical education credits with each episode. Our credits are meticulously designed to empower you in your field, demystify complex mental health topics, and transform your learning journey into a truly rewarding experience. To access this and more, just visit Psychiatrypodcast.com. We're grateful to our valued subscribers who are already reaping the benefits of these credits. Your support is instrumental in allowing us to devote time each week to curate. this podcast, sharing cutting-edge insights, featuring top professionals, and exploring the latest

research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today with Dr. Kristen Lassiter. She is hailing us from Austin, Texas. She is a reproductive. psychiatrist, a psychiatrist specializing in women with peripartum and postpartum depression and women's mental health. And I'm also joined with Kara Jacobson, who has, let's see, probably a couple more months before she's applying to psychiatry residency, and she is a fourth year. Welcome to podcasts. Thank you. Happy to be here. Same. Yeah. So I kind of had this idea,

and Kara Jacobson was like really excited to help out with it. And so really, really glad to bring on an expert to kind of field our questions and field the audience's questions on peripartum, you know, preparing for pregnancy. And one of the things I wanted to kind of start out and ask you are like, how do you have this conversation with patients about the risks if you are depressed and anxious during pregnancy. Yes, very carefully because a lot of times women will kind of blame themselves for the issues that are going on and feel even more guilty about having the illness.

But I try to gently explain, you know, this is not something that we can control. It is a mental illness or an illness just like any other illness that we can experience in our body. And I go on to explain how in our body it's changing. the environment that the baby's developing in. And so there are risk just like if you were to have, you know, another medical illness. So a baby can be, you know, small for gestational age or be born preterm or have a lot of different developmental issues that go on from kind of the effects on brain development and just overall development

in general. Okay. And so this is, if the person is just untreated, not on medications, and really suffering, there can be consequences to the child. Yeah. Yeah. It's hard. I get what you're saying that.

It's hard to talk about this because it's like, it's like we don't want to increase anxiety around. Yeah. What do you see there? Yeah. Yeah. So a lot of times, a lot of times the feedback then I get sometimes is, well, they made me feel really bad that, you know, I was, I was having anxiety and depression or a lot of times they just, you know, put that shame on themselves of it's, it's been, you know, hard. I'm being such a terrible mom or I'm already can't be a good mom. So things like that. So they're already, of course, with the critical, if they have mental illness, they're already critical of themselves. That's common.

And it's just amplified so much during this time period. Yeah, there's so much societal pressure to be a good mom and have everything perfect. And we see all this stuff on social media and Instagram on how everybody's doing it just right. And they can do everything. So a lot of moms take that in. Yeah, tell me more about that, like the weight of that perfection. And is that a necessary weight? or how do you talk to women about that?

You know, a lot of times I just bring in my own personal experiences because I feel like people can relate best to that if I'm like, you know, it's normal not to feel super excited about the pregnancy or to have, you know, these extra worries. Or when baby comes, it's normal not to feel immediately bonded to your baby. Just yesterday I had a patient who was, you know, super depressed and feeling like she was a terrible mom because she didn't feel like, you know, her baby was someone she knew and didn't feel kind of this immediate attachment.

But that's totally normal and it's ridiculous that we have, you know, social media kind of looking at pregnancy and postpartum as if it's rainbows and butterflies when most people don't have that experience at all. Yeah. I was not posting pictures of when my kids had colic, you know. It's like, so no one really talks about more of the difficult moments. Yeah. So you find that a lot of people have this sort of false image of what it's supposed to be like,

especially coming from like social media nowadays. Is that right? Yes, definitely. Okay. And Kara, I want to bring you into the conversation. What did you find as you were kind of looking at this, this question of the consequences of not receiving treatment? Yeah. There was a lot of interesting findings.

There was actually quite a bit of research on all of this. It kind of seems like in previous years, many studies have kind of shown, oh, treatment with antidepressants, for example, is associated with all of these negative effects. but a lot of those studies were really not well controlled. They were looking at the risk of those negative outcomes compared to, like, healthy, normal controls, rather than comparing the actual effect of the medication in somebody who already has depression. And so, like, more recent studies that have actually controlled kind of more apples to apples, like people, for example, with major depression on meds versus not, they really have not borne out a lot of those risks that people have kind of been worried about

over the years and I think still are really worried about. So I'm glad that we're doing this episode to get Dr. Lassiter's kind of expertise out there because I know a lot of people are very, very worried, of course, about negative effects to the baby. But I think it's not as common to really be thinking about the effects of just the mental illness to begin with. Yeah. Any thoughts on that, Dr. Lasseter? Yes, I think that's an excellent point. there are so many studies looking focusing on the risk of the medication and they failed to kind of look at well could these risks also be associated with the mental illness and so there really

aren't great studies yet you know I think now that we're privy to knowing that mental illness can cause a lot of issues now people are kind of looking at that in comparison to medication but there's not a ton of studies yet showing like here's somebody with mental illness who's untreated versus here's somebody with mental illness who's treated. And what are the risks that we see specifically from the medication versus, you know, what are the risk we just see across the board with people who are experiencing mental illness and, you know, what that poses to the pregnancy and to baby. Yeah, I wanted to ask you to, I know the medication proxatine or paxil is a little controversial. Like some people are very against prescribing it or will have people

completely get off of it in pregnancy no matter what. But I know some people are also more comfortable prescribing it. Can you tell us about kind of your approach and your thoughts on that? Yeah. So I think that was one of the ones that's been, you know, it's an older medication. So it again, we have these older studies on looking at what are the risks of this medication in particular. And so a lot of there was a bigger older study that showed that it could increase the risk of cardiac defects. But then now that we've had, had, you know, newer studies and different ways of looking at kind of statistical analysis, we see that there actually might not be any kind of increased risk for cardiac defects.

The same thing goes with Prozac or fluoxetine. So, you know, for me, I feel comfortable just kind of talking that through with my patients. And if they've been on that medication before and it's been really effective for them, I don't see a reason to tell them you need to stop this or you need to switch to a different medication that's safer because really when you're looking at that medication with other SSRIs, you know, it's pretty close to being the same safety profile. Good question, Kara. Yeah.

Yeah, maybe we could talk about in general the SSRI as a class, SROIS as a class, you know, serotonin re-uptic inhibitors as a general class. And, you know, like, what are there risks? What are the risks during pregnancy? How do you explain it to patients when you talk to them? So the biggest risk is neonatal adaptation syndrome, which I think occurs in about 30% of babies who are exposed to SSRIs in pregnancy. And I think the most important thing to get across to patients is then it's time limited. and it's not something that causes long-term effects or issues in the baby. So most cases resolve within five to seven days. I think the longest documented case study was like 30 days,

but that was really abnormal. And in most cases, there's not any kind of intervention that needs to be done or extra monitoring. It's just kind of, you know, baby comes out being a little bit more fussy or having more trouble with feeding or breathing or keeping up their blood glucose. And it's not it's not something that we get super concerned about. And in very extreme rare cases where it's more severe, babies can have seizures or need more help with breathing.

But again, even those babies that resolves and they go on to develop normally just like other babies who weren't exposed to the medication. Another risk that can happen is persistent pulmonary hypertension of the newborn, but that can happen in any baby. And we see that with SSRIs, they increase the risk so minimally, then it's not even clinically worth mentioning half the time. Like it's not, it's such a tiny increased risk. that it's not significant clinically.

Okay. So because it's similar to the control or because it's... Yes. Yeah, I can't remember the, like, the adjusted odds ratio or whatever. I think one of the studies I was looking at had shown maybe like a six-fold increased risk, But even that, it was like 1% of babies exposed to SSRIs in late pregnancy. But then other studies have found like an even lower risk and have not found that increase in risk. So if it's there, it's not like a huge overall risk and might actually not be much of an increase anyway.

Yeah, I think this goes back to the difficulty of studying these because what's your control? and if your control is people who aren't depressed or anxious, it's probably not the best control because like we said before, if you're depressed and anxious, you're high cortisol and your baby's impacted to some degree. And also women are maybe higher risk to other things that might harm them, like maybe more apt to use substances

or other ways of coping with the anxiety. Yeah, not to, I don't know. Sometimes I feel like, I don't know, does it seem heavy to talk about this? You know, like it's like a difficult thing to talk about for people probably who are in the Mississippi. What are you thinking? Yeah, no, I mean, half the time I don't even want to mention the risks of the medication because I'm like, they're so, you know, tiny compared to the risks of the mental illness. Like if it's not, you know, it's not a comparison half the time. But I do think it's important that,

you know, people are educated on all of the. risk, but I think that's why it's so important to bring up the risks of the mental illness, which oftentimes isn't even part of the discussion. Okay. Yeah. One thing I found, too, when I was researching this, is I was kind of surprised, but I think that mental health, including kind of like substance use issues and suicide is actually one of the leading causes of maternal mortality. So it's not even just, oh, you know, there's bad

outcomes for the baby, but mom and baby can both die, like, just as a result of mental illness. And of course, that risk will be higher if you're untreated or suboptimally treated. So I think it's really important that we don't just kind of, like you said, get fixated on, oh, this medication may have like a small increased risk, but like if the risk is the mom might commit suicide or even infanticide or, you know, have a substance use problem, like an overdose, then we really need to weigh both sides of the equation appropriately. Yeah, that's an excellent point. The, you know, the biggest risk, I think, are one of the most proven risks for having depression or anxiety in pregnancy is preterm birth and preterm labor, which is the number one risk of neonatal infant death. So yeah, I mean, these are,

it's serious it's not something that you know we should be leaving out of the conversation um okay what about s nr i so serotonin noropin norapenoprene reuptake inhibitors what are the are there any risks with that with that group in particular so we see the same risks in terms of neonatal adaptation syndrome that may or may not be a little bit higher in those medications um and And I don't think there's the risk of persistent pulmonary hypertension in the SNRI group, but there is more of an increased risk of having gestational hypertension. And so, you know, really monitoring blood pressure in pregnancy is important too. Do you have like a favorite SSRI if you're going to use one?

No, I feel I get so triggered. Is that the right word when people say, oh, Zoloft's the safest one to use? So that's really not true. I would say Zoloft, Lexapro, Selexa. I would even add in Prozac are kind of all on the same playing field in terms of safety and pregnancy. If I have to pick one, maybe sometimes I'll pick Zoloft because it's secreted the least amount in breast milk. but, you know, that's if the patient even breast feeds and, you know, that's way down the line. So it's not a huge part of it.

It's more kind of what have you responded best to in the past. If they've had a good, successful treatment with a medication in the past, it's usually you always want to go with that one unless it's like depa coat. That's good. It's good. So it's like if they come in on something and it's working, you're not apt to change them to Zoloft or Certraline. That's what you're saying. Absolutely not.

And I see that all the time. People get switched all the time and then they'll feel worse or, you know, symptoms will come back and then you have to put them back on the medication they were originally on. And then babies exposed to, you know, two different medications plus the mental illness. And you should have just left them on the original medication. Okay. What about buproprion? anything with buproprione?

Buproprion, maybe Kara can speak more about this medication. There is, like, again, this controversial risk of are there cardiac defects or not? Most of the newer studies have shown that's not the case. But yeah, that's what I found. There's not as much research on any of the other antidepressants compared to like SSRIs. But yeah, it sounds like there was some older reports showing increased rates of heart and great vessel malformations. But then even like more recent studies, like there was a retrospective cohort study with 1,200 infants exposed to buproprion that didn't show an increased risk. And also the actual like bupropion pregnancy registry, which is like the official medication like registry shows congenital malformation rates that are really in line with kind of the general population.

So it doesn't seem to be a significantly increased risk of those kinds of malformations. Okay. Yeah, and Kara Jacobson did this, like, amazing handout, or I thought it was amazing. And she's, I don't know, probably spent at least 80 to 100 hours, I would say. Would you say, am I? Yeah, at least. I don't, I've lost track, but it's a lot. We'll put it on psychiatrypodcast.com. Yeah, we'll put it on psychiatrypodcast.com. and Kristen Lassiter will look at it with me and make sure it looks pristine by the time it gets up there, but it doesn't look like we'll have to change much. So, yeah, anything on tricyclics, Dr. Lasseter?

Tri-cyclics, they're not as well studied, I would say, then definitely the SSRIs. We see, I think in some of them, there's an increased risk, again, for gestational. hypertension. There doesn't seem to be any kind of increased risk for congenital malformations. They're, you know, again, kind of the neonatal adaptation syndrome might be part of the picture. But unfortunately, we don't have a ton of research, especially looking at like the individual tricyclics, but they have been around for so long that, you know, by now if there were major issues with it, we probably would have caught on to that. Anything else, Kara, you want to add?

Yeah, like you said, not as much research on this, but one thought that, like I had seen somewhere was that just kind of more based on the side effect profiles of them, it might help guiding, picking one. Like, for example, dyspheromene and nortryptylene might be a little bit safer just in terms of, like, less antichlorinurigity and maybe. a lower risk of orthostatic hypotension. Is that something that you've heard as well? Or do you have other thoughts on kind of like picking those?

Yeah, I usually try to go with nortyptylene anyways just because for mom, it usually tends to do better. And I've seen people have a lot of weight gain issues with the other ones, especially in pregnancy. So, yeah, again, kind of picking it based on just your regular side effect profile. Okay. How about MAOIs? Oh my gosh, I don't know anything about MAOIs. I usually avoid them, period. I feel like if someone needs an MAOI,

they probably need to go see like a treatment-resistant depression specialist who has a lot of experience with MOIs. Kara, it looks like you found that they're usually avoided. Yeah, yeah, that was what I found as well. There was kind of an interesting effect like with tocolytic medications. So like I believe that's just medications to stop contractions, for example, if somebody's in preterm labor, so this wouldn't be a very common medication used in pregnancy for everybody. But if you take the MAIs with turbutylene, for example, to stop contractions, that can increase the risk of hypertensive crisis, which is obviously a side effect of MAIs. So I agree, probably best to avoid unless no possible other options.

Okay. Any other comments on like trazidone or metazepine? Trasidone, we really don't have a lot of research on. Another one that I see used pretty frequently is B. Sparone that we also don't have hardly any research on. I think there's research study currently going on Buesprone. So hopefully that will kind of give us better information. But yeah, I try to avoid using those medications unless there's something that the patient's

been on for a long time and it's worked really well for them. I try to go with other more well-studied medications. Okay. Kerr, do you want to talk about this next one? Sure. Yeah. So this is kind of a newer medication, maybe a little less traditional. but bruxanelone it's basically like an intravenous progesterone metabolite so it's it's it was approved in

2019 and it's specifically intended for postpartum depression so this is something that again is newer of course and it's only really recommended for people with really severe postpartum depression who either like can't take or have declined or have not responded to antidepressants and or electroconvulsive therapy as well. So some studies have found like a statistically significant improvement in postpartum depression with this medication. But when we kind of looked into it, it sounds like maybe the actual improvement in symptoms was not like a huge difference.

So like the Hamilton Depression scale, like an average of 2.6 points different. which we have a copy of the, we were looking at a copy of what's actually on that scale. And that's really not a lot of points to be reducing for such an expensive and hard to get medication. It's like thousands and thousands of dollars. Dr. Lasseter, have you used this or seen this used or have other like kind of thoughts on it? Yeah, I've used it in a couple of patients or have referred them to get to get it. It's, you know, when it first came out and especially here,

in Texas, it's really hard to have access to. And it would take insurance companies, you know, a couple of weeks to approve it. So by the time that we found a place where the patient could get it, insurance approved it, a lot of times they've already been, you know, getting better with traditional antidepressants. But yeah, and I've had some patients who have, who have gotten it and, you know, really didn't have any response. And I've had some patients who had dramatic responses. I think what was interesting in those studies, too, is that even moms who got placebo got better. And I think part of that is just like having this time, this break to just rest and get some good sleep in and have somebody else kind of be there to take care of them, which, you know, is huge. Like we see that women who have really good support actually have significantly decreased risk of perinatal mental illness.

And so I don't, you know, I don't think that's unimportant. Absolutely. I think that's like an excellent point. And something that people might not know. I didn't know this certainly is it's not just like a quick infusion over 15 minutes. This is over like 60 hours. So over a day that you would have to be, you know, monitored. And like you said, probably getting a little more sleep than you would at home with. anymore. Yeah, you get to lay in a bed, somebody bring you some water, food. Okay, so if you're a guy listening to this, this is like, you know, knock knock or, you know, a partner of the person who's pregnant, it's like knock, knock, like, yeah, showing up, being present, giving your partner some

breaks, so, so valuable, right? And can't be, can't be understated. We had, we had, two tough kids both colic and i would take them for walks in the morning to give my wife a time to sleep before i went off to work so i'd take them like six to eight or whatever go for a super long walk and then i would um bounce them at night because that was the only way to get them to stop crying we tried everything you know tried every every machine that's out there we tried and it was like the red ball and me bouncing that was the only thing so for about three to four hours every night. That's what I did.

Sounds like some good exercise. Yeah, yeah. You could call it that, I guess. Okay, so, yeah, how about let's jump to bipolar, unless there's something else, Kara, that you wanted to add in here. No, I think that sounds great. Okay. So why avoid phalopoproate, you know, foproac acid at all cost?

I wouldn't say at all costs. I would, you know, in some rare cases where it's the only thing that they can take or, you know, have responded to, obviously, that's your only option. But it has significantly increased risks of congenital malphys. formations, particularly spinal defects. It also has increased risks of neurodevelopmental issues and decreased IQ. And so it's one of these medications where the risks of it actually do outweigh the risks of the mental illness in some cases. And so we want to avoid it if we can. Interestingly, it's compatible of breastfeeding though. So once you get them through the pregnancy period, you could use it in when they're breastfeeding. Kerah, anything you wanted to add from this one study we were

looking at? Yeah, I mean, I think Dr. Lasseter kind of covered the major points definitely. We found kind of an interesting study that actually was not looking at bipolar disorder or like psychiatric illness, but it was looking at anti-epileptic drugs like in epilepsy. And so it was a really big study, like a registry of like over two million people, I believe. And they were looking at those kind of developmental and intellectual outcomes from some of these medications. So the kind of two highlights from that were valproic acid and also topurimate, which is used somewhat in psychiatry as well. Those had like pretty significantly increased risks of these, of autism spectrum disorders as well as intellectual. disability. It sounded like Lomotra gene, for example, was one of the ones that really didn't

increase that risk. And I believe maybe you could speak to, I think Lomotrogen is one that can be used with pregnancy in terms of contendal malformations and stuff like that as well. Yeah, it's one that we're getting a lot more research on, especially recently. And the more research that comes out, the better the medication looks in pregnancy. So it used to be, you know, again, in these older studies, there were some concerns of congenital malformations. And now we see in a lot more newer, more robust studies, and that's actually not there. And there's really, you know, very minimal risks to baby and to mom in taking that medication and pregnancy. So it's a great option if somebody has responded well to

it and they're or they're doing well on it. Absolutely leave them on it. I think The important part with Lomotrogen and pregnancy, which we don't really do in psychiatry, is hopefully having a level on them before they ever get pregnant so that you kind of know, okay, this is the level that they were doing well at. And as the pregnancy progresses, like with a lot of our psychiatric medications, the metabolism of the medication changes and the level the medication drops significantly. And so being able to kind of know, okay, this was the level they responded at. let me try to get back to that level if they start having symptoms.

That's probably like the biggest thing with Lomotrogen in pregnancy. Okay. Excellent. Yeah. Any other medications, Kara, from this study that jump out to mention, I see a lot that haven't been studied very much. Yeah. Those were kind of the biggest takeaways that I had.

Was there something else you wanted to add? Oh, I just think like pre-gabalin and gabapentin. And there's just not a lot of people that were exposed in the study. Yeah, I know for sure. Definitely. Like, there were not picked up, like, increased risks of these outcomes of, like, the autism and intellectual disability. But, yeah, I think there's not really robust enough data to say, like, yes, they're definitely safe. It's just, you know, not used as commonly as some of the other medications.

Let's jump to lithium. Yeah. Dr. Lasseter, you want to give your take on lithium? I personally love lithium. I think it's a great medication. If the patient can tolerate it, if they're on it and they've done well on it, I usually encourage them to stay on it in pregnancy. There are, you know, again, in these older studies, this, you know, it was really

concerning that there was this huge increased risk for a cardiac defect Epstein's anomaly. But now that we've kind of had newer studies and more refined studies, we see them that, yeah, that's a little bit of an increased risk. It's, you know, not, again, you know, a huge increased risk over the general population. And so it's really, it's really one that if they've done well on it, then I keep them on it because bipolar disorder in pregnancy is just so high risk for relapse that you really want to kind of do whatever you can to keep them well. There's also, you know, later on in the pregnancy, some increased risks to baby like polyhydramneos and lithium toxicity with birth, but those are even, you know, those are not very common at all.

I did have another question about lithium, though. So when I was looking into kind of, I know you mentioned the SSRIs in general, and especially certuline are excreted very minimally into breast milk and very low levels. It looked like lithium is one medication that kind of is excreted at higher levels. What is your general approach like to, if you have a patient who has been doing well in lithium and wants to breastfeed? My general approach is to just educate my patient and really try. try and work with their pediatrician and let the patient decide what they feel most comfortable with. I have had patients who have breastfed on lithium and, you know, their babies do great and

breastfeeding goes well. And we've even tested levels in the infant. And again, it's lower than levels that we're in mom. So I'm comfortable with it. I think it's just really important to have a pediatrician who's supportive and on board and can kind of help guide mom. be there to support baby and mom if she does decide to breastfeed on it. But, you know, it can be done safely. I think it just involves more monitoring. Okay. What about, let's move to antipsychotics. What are some of the general findings with antipsychotics, Dr. Lasseter? And do you have favorites and less favorites? And if they come in on an antipsychotic for whatever reason and they want to get pregnant, what's the conversation you have?

around it. Yeah, so antipsychotics aren't very well studied in pregnancy. Unfortunately, the ones that we do have a little bit more research on are zyprexa or olanzapine, quatyapine, risperidone, and apiprosol. Those are probably the ones that we, that we have, you know, more research on. And out of all of those, I think alansapine probably looks the best, but of course we don't like using that as much because of all the side effects that we get with mom. So if a patient comes in on one of these medications before they're getting pregnant, I'll usually have the conversation of, you know, what has worked in the past? Like, have you tried lithium or limekdoll?

And is that something that we maybe want to test out before you decide to get pregnant? But if they come to me and they're already pregnant on these medications, then I usually have the conversation of we just don't have. a lot of information and this is what has kept you well. I think we should we should stay on it. There's not, you know, the research that we do have doesn't show that there's an increased risk of congenital malformations for the antipsychotics that we do have with the research available. There's, you know, questionable increased risk of gestational diabetes. And, and I think maybe in one of a newer research study that was kind of small, there's maybe some.

I'm concerned for some neurodevelopmental stuff with Arapypresol, but it was like one small study. So again, we don't have a lot. Okay. Yeah. It's helpful to know that we don't know sometimes. But I like your take that if they're really stable on it, then, you know, it's like risk and reward of changing them. If they come in before they're pregnant, maybe look at Lamotrigine or. Lithium. That's your summary. Yeah. Okay. Yeah. And, you know, there was a great study done

from Mass General Hospital on looking at if patients decided to stop their medication. And these were patients who stopped their medication before they got pregnant and they were stable and then got pregnant. Their risk of relapse with bipolar disorder was 87%. And of those people who had a relapse in pregnancy who had stopped their medication, they spent like over 40% of the pregnancy in an illness episode. So I think, you know, it's really important to highlight for patients with bipolar disorder, and this is a very risky time for their illness to come back up. And so we really don't want to be, you know, gambling with that. Okay. Let's talk a little bit about if someone comes in with a substance use disorder and they want to get pregnant. Well,

I imagine usually they don't come in with that sort of history. But yeah, any thoughts on how you manage substance use disorders during pregnancy, Dr. Lasseter? Again, it's a lot of preventative use of medications like buprenorphine and methadone. those, you know, are safer for the baby to be exposed to than obviously drug abuse. And so I try to encourage people to look at doing that. But, you know, a lot of times moms kind of want to try and do it without taking any medications. And if they have a really good support system and they have a lot of things in place, I think that's perfectly reasonable to try.

Kara, any findings that you found on the risks of drug use during pregnancy that you want to highlight? I mean, I think there's, it obviously is going to vary quite a bit based on what like the different drug of use is. Of course, like cocaine has some risks of like spontaneous abortion and sober, with premature labor and stuff like that. And then like, of course, fetal alcohol syndrome is something that we're all kind of aware of I wanted to also kind of talk about stimulants. So you can have obviously stimulants, for example, like methamphetamine use or, you know, illegal stimulant use, but also a lot of moms take ADHD medications. And I just wanted to kind of hear about your approach to that. Yeah, so it really

depends on the patient and kind of the severity of their ADHD symptoms. Also in terms of safety. So, you know, if I've had a patient who, you know, might be getting into more car accidents without their medication or, like, leaves on, you know, the stove or the burner, like, then, you know, I think that there's a good reason to continue those medications. Or if it's really needed, like, that's really something they cannot go without in terms of functioning and work in their everyday life. That's important. And that can, you know, we've seen in, and I think there was a small study that came out showing that in women who stopped their ADHD treatment, they, even if they've never had a depression episode before or symptoms of depression, they stopped their ADHD medication and pregnancy. They were, they scored higher on depression scales than women who continued their medications because it's affecting kind of their function and their view of themselves. And so I think it really depends on the patient. And it's unfortunately, we don't have a lot of research on these medications and pregnancy.

We have more research on if somebody's abusing these types of medications. But the research that we do have, you know, looks fairly, fairly good. So I try to, you know, do it on a case-by-case basis and also just educating my patient and letting them decide what they feel comfortable doing. Yeah, no, I really like that approach, and I think it does have to be super individualized. One other thing, too, that has, I feel like kind of gotten more common or, like, more commonly discussed is like marijuana, THC and pregnancy.

I think a lot of people have the perception like, oh, it's like not bad for you. It's not like unsafe in pregnancy. But based on the like research that I have, was kind of doing, it sounds like that's not the case. Do you see that a lot where patients are coming in either pregnant or wanting to get pregnant and using marijuana? I don't see that a lot, but I have had had a couple of patients who are, you know, regularly use marijuana or THC, and that's, you know, a conversation that we do talk about is the increased risks of using that in

pregnancy. There is a lot of patients who use like CBD in pregnancy. And so, you know, kind of having the discussion of, you know, the only research we have on CBD in pregnancy is looking at marijuana and pregnancy. And we don't know, you know, is the exposure to marijuana and pregnancy from the CBD or from the THC? And so really kind of being safe in terms of just avoiding that at all costs. Okay, so no marijuana during pregnancy is what you're saying for the ideal outcome. I don't have numbers, but there's increased risk of infertility in long-term cannabis users, and then decrease sperm count and motility in men. And then in terms of babies, there's increased risk of withdrawal, ADHD, autism, and heavy users.

behavioral disorders, and then mental illness later in life. Okay. So pretty clear necessity to get off THC if you're pregnant. Let's say someone was watching this and then they're pregnant and they're also on that. What would you say to that person? Like are they doomed? Like there might be like an ominous. No, I mean, again, we're talking about risks, right?

So that doesn't mean it's for sure going to happen. And it's just there's this increased risk. So they're not, they're not doing it. Yeah. I think there's something about anxiety. I mean, even I felt it when I had kids, you want to do everything right, you know. And it can feel very ominous to feel like you're doing something wrong. Yeah, you don't want to mess up your baby.

Okay. What about exercise? Kara, do you want to mention kind of a summary of the studies you found on exercise? Sure. Sure. So exercise is obviously well studied in lots of other things, including like depression treatment in general. And it sounds like there is some effect for like positive effects of exercise in pregnancy on like mental health as well as outcomes for the baby. There's not been a lot of like kind of specific like randomized controlled trials where we really know what the best like the best type of exercise or the exact right amount of. exercise. But I think kind of in general, just it's good for you and like it makes you feel better. And so really, I think if people are doing something that moves their body and like makes them feel good, I think that that's probably a pretty good place to start with like trying to optimize

your health and mental health in pregnancy. Yeah. I think there was this one meta-analysis of 12 for randomized control trials that said the effect size for the relationship between physical activity interventions during pregnancy and the postpartum period in postpartum depressive symptoms was 0.41, which is pretty reasonable. Any thoughts, Dr. Lassiter? Do you recommend exercise often? Yeah, if it's something that especially they did before they were pregnant, I encourage them to keep up with that and keep doing it. A lot of times there's kind of this thought, like, well, exercise might increase my risk of miscarriage or, you know, bad outcomes for the baby, but I, you know, again, try and educate them.

No, it's, it can be really safe in pregnancy, especially if it's something that your body's already used to. It's important to keep it up. And then another thing that I really encourage for my patients is good sleep. Like that, I think does a lot to protect against mental illness coming back or if they're even having symptoms, I think it's a big thing to help their symptoms get better, especially in that postpartum period. Okay. Yeah.

I think there's some thought that kind of postpartum depression is really largely linked with sleep deprivation. And like even in somebody maybe who doesn't have like a predisposition towards like mental illness specifically, like just not sleeping can can, with all the stress and hormones and everything can very easily kind of trigger depressive symptoms. Yeah. So I think that's very important. Yeah, and I try to encourage my patients to get four to five hours of uninterrupted sleep each day. So a lot of times we'll kind of strategize on bringing in a partner or, you know, hiring someone or another family member who can kind of split up the night.

So then, you know, this first half or second half of the night, you are not even in the room with the baby. you're not being woken up at all, and you get kind of this really good, deep restorative sleep. And then overall trying to get, you know, of course, your eight hours total in the day. But when you're postpartum, that might look like, you know, an hour nap here and there, in addition to that four to five hour of uninterrupted sleep. Yeah. I think that's really good, really good advice. What about psychotherapy?

Like, how do you talk to patients about getting psychotherapy? when it would be helpful? Yeah, it's a huge thing in terms of preventing mental illness but also treating mental illness. So I try to encourage it for all of my patients who come with a history of depression or anxiety or bipolar disorder. It's, you know, especially if they're wanting to decrease the amount of medications or, you know, prevent, decrease their risk of mental illness from coming back. It's great. And so I definitely encourage it. I think the types of therapies that have the most research in pregnancy and postpartum are cognitive behavioral therapy and interpersonal psychotherapy. But really, you know,

kind of like we see with any therapy, just having a good relationship with your therapist, I think is important. If it's somebody who hasn't been involved, in therapy, I'll usually try to encourage them to go to a therapist who has like perinatal mental health training because that can be really helpful for a lot of the nuanced things that we experience as parents. But yeah, therapy is awesome. Fantastic. Yeah, Kara, anything, I know we have a section here on couples, dads, and the important of supportive time. Anything you want to put out there on this? Yeah. I mean, there was a. a couple of different things that I thought were interesting, but for one, like, just having,

like, the dad involved with, like, parenting and support and all of that is actually increased with better, like, infant neurodevelopmental outcomes. And it's thought that maybe, like, the impact of having another partner, and it doesn't have to be male necessarily, but, like, to have a partner and have support helps decrease stress in the mom, and that can possibly explain some of that explanation as well. Another thing, too, that I think it doesn't get talked about a whole lot that Dr. Peter kind of encouraged me to look into more is postpartum depression in dads, actually. So that's actually not an uncommon finding, I guess, that new dads or dads to be will have, like, depressive symptoms. And I couldn't find like a really good kind of specific

estimate, like I saw, you know, like 1% to 25%. So it's kind of unclear, but it's definitely something that affects not unsignificant amount of dads. And I think that, you know, obviously we talk a lot about maternal mental health and that is very, very vital as well. But I think to kind of have a bigger picture of all of the factors that impact like the family and the mom and the baby, we really have to look at the whole family, including the dad and their mental health, too. Yeah, I think the estimate is like one in 10 dads can get postpartum depression. And that's, we haven't even looked at like postpartum anxiety in dads, which is also, you know, something that can occur. And if one partner has mental illness, that increases the risk, I think, by 50%

of the other partner getting it. And so it's really important that if you are managing a patient who is experiencing symptoms to make sure that they're getting good support and that their partner's getting good support too, because baby then being exposed to two parents with mental illness is obviously going to increase risk pretty significantly. And with dad's postpartum, we actually see that they're having hormonal changes. similar to mom, obviously not to the same degree that a female might experience, but they are also having hormonal changes and there's brain changes going on. So it's, you know, there is kind of this

biological component that might be at play too. Great summary. Yeah, I've seen this in clinical practice a couple times. And I think when you have two partners really working together, it lightens the load so much. and I think the main takeaway here is if you know to not just put all of the onus on treating the female who had the baby but to also incorporate you know extra help coming from the partner and making sure the partner's healthy as well to be able to give that extra help I don't know anything else on that I think it's important to talk about this yeah I mean I think there's just so much stigma You know, there's already stigma for mental health. And then women experience, you know, this stigma of like, you know, postpartum is supposed to be glorious and wonderful. But for men, I think it's even worse. It's kind of this, you know, you're supposed to be the, you know,

the one who has it all together and kind of like providing for the family and being strong. And all of these things that kind of are opposite of what you would imagine somebody going through depression or anxiety. And so I think it's really hard for men to even recognize when they're experiencing those symptoms. And oftentimes because it looks a little different than it does and a woman who's experiencing postpartum symptoms. But yes, it's, you know, hard to recognize and it's hard to get treatment for. But it's just as important and can have significant effects on babies development.

Yeah, I think some of the most important lines of research for me as a man when I was in the midst of this with my kids was looking at the stillface experiment and also Beatrice BBs like which is like on mirroring. But basically the still face experiment is showing the importance of attunement to your child who's pre-verbal, right? And I've heard from a couple guy friends like, oh, I can't wait until they start talking so we can communicate. It's like, no, no, you can communicate the moment they exit the womb, you know, there's communication happening all the time. And just learning how to like attune to your child is so powerful and not being on your phone. I would add that. I think that's like probably the greatest modern temptation is to be on your phone.

And that is just not that. the best for the child and they're that mirroring any thoughts on that dr lasseter excessive phone use that's great yeah that's a good study to kind of bring up i i forget about that one but it's it's such a cool study okay we got a couple more lifestyle things let's do more rapid fire uh kara omega-3s yeah um omega-3s might help a little bit with depression um and like in pregnancy specifically. And some, like there's a subcommittee on the American Psychiatric Association that does recommend that pregnant women with mood disorder should consume like one gram of fish oil per day.

There's a couple of different recommendations. But it's potentially helpful and likely doesn't have a lot of risks to it. Okay. Dr. Lasseter, do you recommend? fish oil? Yes. And my patients who have a history of depression, I usually recommend it. And I think there specifically has to be like this ratio of EPA to DHA and the fish oil then is shown to be helpful for depression. So I usually try to steer them more towards using those particular fish oils supplements. Cool. Yeah, a little bit more EPA than DHA, right? Is that? Yeah, at least two to one.

Okay. And then diet, Kara, what did you find? Yeah, the research on this, I think any like kind of diet studies in general are, you know, hard to find, hard to like really control for things. And I think especially when we're looking at this really more specific question of like, you know, perinatal reproductive mental illness and mental health. But it sounds like in general, just eating like more fruits and vegetables, like phytochemicals and stuff like that, having more omega-3s, which we kind of talked about, but not having a lot of like kind of processed high-fat type food has been associated with like improved mental health outcomes. Dr. Lassert, is this something you talk to your patients

about, like diet or? Yeah, all of my patients get this handout and it talks about diet, exercise, sleep, and more like natural ways to kind of help prevent symptoms like yoga, meditation, all that kind of stuff. So it's something that definitely comes into play. But unfortunately, there's not a ton of great research studies specifically on foods that can help in pregnancy and postpartum for prevention. I don't know if there's any at all. But, you know, I think it's very similar to what we're talking about outside of pregnancy. these are the foods that tend to be healthier for our brain. And so obviously those would be good for our brain in pregnancy, too.

Okay. Kara, anything on vitamins? Yeah. One of the significant things is like folate, which obviously we recommend to all women of childbearing potential because of the risk of or the decreased risk of neurotube defects when you have increased folate. But something that I thought was kind of cool is sometimes,

times people have used folate as like an adjunctive treatment for depression and there may be like a small antidepressant effect of adding folate on to like for example another antidepressant which i thought was kind of interesting yeah i think then that's specifically been shown for women who have um higher levels of homocysteine um and so maybe they're not you know breaking down folate as well as um somebody who you know, maybe has has better metabolism of that particular supplement. So substituting with, you know, methylated folate in those patients can sometimes be helpful. But there is, you know, some studies coming out showing that maybe if you're taking too much folate, then that can be harmful or have some risks to the baby.

So, you know, I think it's one of those things that needs to be done in moderation. Okay. Vitamin D? Yeah, vitamin D. I couldn't find a lot about like vitamin D and perinatal depression, but it does sound like having like a vitamin D deficiency can increase the risk of the offspring having like ADHD and autism spectrum disorder. And this might even be in kind of like a dose dependent manner where like if you have worse

vitamin D deficiency, that would increase. the risk. It's also, this is not like a clear thing or anything, but it's been kind of hypothesized that prenatal exposure to, to like, low vitamin D levels can increase the risk of schizophrenia in the offspring. And that's kind of based on observations that people born in like the winter or spring when there's less sunlight, less vitamin D levels. And also offspring of like darker skin migrants living in like cold climates tend to have a little bit higher rates of schizophrenia and those groups also like have on average more vitamin D deficiency. So obviously it's not something where we know that like vitamin D supplementation decreases

the risk of schizophrenia, but it's something that is I think just maybe a new area of research that it'll be interesting to see if that kind of bears out or not. I know speaking towards sunlight vitamin D on that, on that same, you know, topic. There's a lot of more research coming out about using lightbox therapy and pregnancy and postpartum and how that can be a really good treatment too. Yeah. Yeah, I saw some data on like bright light therapy. I think is what this one article I saw called it as well.

And I think it does have like somewhat of an effect on depression, which is cool. Yeah, so you have like basically 10,000 lux, like one foot from your face for like 10 minutes every morning while you drink coffee or something. How about caffeine? Any risk for caffeine? Yeah, I mean, with caffeine, I think there's a newer study came out showing that any amount of caffeine in pregnancy can can affect baby's growth, but I think still the general recommendation is keeping it below 200. Milligrams, yeah.

Yeah. I think a Starbucks is like, on average, like 300 to 400. They just, it's a lot higher in Starbucks, so be careful. I didn't know. Or like a pourover is a lot higher than like other types. Okay. Yeah, any like,

pet peeve alternative medicine things, Dr. Lasseter, that you're like, that doesn't work for sure. So in Austin, it seems that placental encapsulation is pretty big here and taking progesterone postpartum. I don't think that that's as popular in the rest of the country, but we definitely see it here in Austin, and it's that has both of those have shown, they've actually been studied and both have shown not to have any significant improvement or treatment for, you know, postpartum depression. With placental encapsulation, it actually has some, you know, risks that can be involved in terms of infection that can happen with both mom and baby.

And, you know, when we're talking about the placenta, it's something that carries a lot of cortisol. And so when you're taking extra cortisol, you can get more anxious, more jittery. that can spur on, you know, even some hypomania and mania and some people. So I generally recommend not to do that. Kara, any other things that did not work that you found? Well, this, maybe it does work, but it's not necessarily safe, like St. John's wort. I think might have, like, antidepressant effects, but it just because, one, it's not, like, well-studied,

and to it affect so many different kind of different pathways. It's not really recommended to use in pregnancy or breastfeeding. And then some other things that I kind of looked into were like massage. And there were some evidence that maybe massage like during pregnancy might reduce rates of prematurity and low birth weight. And they, one study combined like massage plus group psychotherapy and found that they had lower cortisol levels in that group compared to the people that just got group psychotherapy. So maybe some like stress reduction. And then I looked a little bit into

acupuncture too, but it didn't sound like there was a whole lot of data clearly showing a benefit over sham treatment compared to just like not doing anything. Yeah. And I think with this like some of the studies on massage therapy, it was like an hour massage once a week. week, which, sure. Realistic, realistic. Especially for pregnant if you have other kids. Probably stay away from like the deep tissue massage. I had a patient recently who had like a super deep tissue massage had bruises and had like flu-like

symptoms and fatigue for like three days afterwards. Oh, no. So, yes, go away from that. Okay. So kind of like bringing it all together, kind of closing up our time here. big big takeaways or things that you haven't said that you always say to patients dr lasseter um so mental illness can be very high risk in pregnancy we really want to try and avoid that if there's a medication that you've tried before that you have been had success with before

that's usually the medication that we want to continue or or use in pregnancy something that we didn't really talk about then i i often talk about that i often talk about to my patients about is that, you know, I think the impulse is to decrease the medication, the dose of the medication in pregnancy, but we actually, you know, with the majority of medications, we see that their levels decline in pregnancy because of liver metabolism and, you know, blood volume expansion. And so it's not uncommon that we actually need to increase doses in pregnancy. And then for some people, we even go above the FDA approved max dose because that's actually, you know, getting to a level, that's more how it was before pregnancy.

But, yeah, you know, really kind of looking at the risk of mental illness versus the risk of medication and not focusing all of our attention on the risk of the medication is important, too. Great. Wonderful. Thank you so much. Yeah. Kara, any other final thoughts? I think we've covered a lot. I just, I'm so glad we were able to have this conversation. I think it's been really cool to hear from somebody who does this every day and kind of look at the research and thank you for being here. Yeah, thanks for having me. Just for those who might be listening to our patients, do you just have a Texas state license or do you have other state license as well? Yeah, just Texas for now.

Okay. Do you ever have people like fly out for one-time consults or stuff like that? I have. Okay. Yeah. And then, and you're also on Instagram, pretty active there. What's your Instagram handle? It's the dot reproductive dot psychiatrist. Yeah. So is that the best way, what's the best way of getting a hold of you? Is it your website? And what is your website? Yeah, it's probably through my website. It's Kristen Lasseter, MD.com. If it's specifically regarding like patient care, then they can visit my clinic website, which is. RPCClinic.com.

Great. Okay. And we will have the full article on the website, Psychiatrypodcast.com, for those who want to dig deeper and have something maybe at their fingertips when they forget which medications are higher risk and which ones are lower risk.

And it's always good to come back to this. And thank you so much, Kara Jacobson, for coming and diving into this. I really appreciate you doing that. And Dr. Lassiter, thank you so much. much for your time. I know. It's, um, it is great to have someone who's in the, in the trenches who can kind of distill their wisdom for us. Yeah, thank you. It's been really fun. Thank you so much.