I first wanted to introduce Dr. Tesler. She is an instructor at Harvard Medical School. She is a consultation liaison and perinatal psychiatrist at Brigham and Women's Hospital, and she's currently the co-director of the Women's Mental Health Fellowship at Brigham and Women's Hospital. She is a graduate of Tufts University School of Medicine, the University of Maryland Shepard Pratt Psychiatry Residency Training Program, and she's completed a fellowship in consultation liaison psychiatry at Brigham and Women's Hospital, where she primarily focused on women's mental health. Just to set the stage here before she starts her presentation, we're going to be taking a broad view, both in terms of doing a bit of review of reproductive psychiatry for the viewers in the audience, but we're taking a specific lens on reproductive psychiatry through the lens of health equity, which as we know, even if you take a briefest of glances at the maternal mortality statistics in the United States, health equity is a major issue within reproductive mental health. I'm delighted that the APA is taking up the mantle in really putting this front and center, and I'm delighted to introduce Dr. Tesler to give us our first presentation. Thank you so much. I'm really honored to be able to speak with all of you, and I will start by speaking in very broad generalities and just kind of covering how we think about medication use in pregnancy and postpartum, just the perinatal period in general. I don't have any conflicts, and as I said, we're basically going to be in this part of the webinar just focused on the generalities about how we think about safety of medication in pregnancy and lactation. So why is this such a big topic? Well, because perinatal mood and anxiety disorders are so extensive and so prevalent, and when you combine, especially with substance use disorders, affects about one in five pregnant patients. We know that untreated mental illness is a significant risk factor to the patient themselves, but also to the health of their pregnancy, the development of their fetus, as well as the development of the eventual child, with everything ranging from, you know, lower access and adherence to prenatal care. Patients with mental health concerns are more likely to be using substances of abuse when they're pregnant, which, of course, can lead to very significant adverse outcomes in pregnancies like preeclampsia, premature delivery. Their babies are more likely to require NICU hospitalization. And then there's also challenges in the postpartum period with lactation, with bonding, the relationships with the partner. Maternal suicide is something that we always are worried about and is a leading cause of death in the perinatal period in the United States. And of course, there's the effects on the child themselves with cognitive delays, difficulties with school, being described as having a difficult temperament and also having their own issues with depression and anxiety. This is just a quick view of the top causes of pregnancy-related mortality. And as you can see, mental health conditions is at the very, you know, not the leading cause, but it's certainly in the top of the things that adversely affect patients in the United States. In recent years, this issue has garnered a lot of attention from ACOG, from the Academy of Pediatrics, from the APA, also from the U.S. Preventive Service Task Force and the Council on Patient Safety and Women's Health. New guidelines actually were just published both by ACOG and the Academy of Pediatrics this month in terms of very strong recommendations for both screening and management of mental health concerns in the perinatal period. In terms of how to screen, the official recommended guidelines do recommend using a validated screener like the Edinburgh screener, like ePDS. Sometimes if clinicians are more comfortable with the PHQ-9, that's also been validated in this patient population. So that's a really good place to start. Of course, if a patient screens positive, you want to dig deeper to find out what's actually going on in terms of how long the symptoms have been present, how often it's happening, whether the patient is experiencing feelings of helplessness, if they're having any thoughts about self-harm or suicide, whether they've been in treatment before, what kind of treatment they're currently receiving, what the family history is. And then, of course, the question of whether or not to take medication. So Dr. Oho will cover a little bit more the nuances and cultural factors with this decision, but generally speaking, when advising patients, we think about how severe the symptoms are. If somebody is exhibiting and experiencing only mild symptoms of depression or anxiety, meaning that they're still functioning okay in their day-to-day life, they're able to care for themselves, caring for the children at home, they're able to still sort of enjoy things to at least to some extent, they're not having thoughts to self-harm, it may be reasonable to consider psychotherapies as first-line treatment. If they're starting to experience more moderate to severe symptoms, you know, they're really having trouble functioning, they might even be having some suicidal thoughts, then we would very strongly advise the use of medication and in extreme cases, perhaps even consideration of an inpatient hospitalization. When discussing the use of medication in pregnancy with patients, one thing that's really important for us to understand conceptually and to educate the patient on is that we do not have risk-free options. The reason why I say it that way is because as we had already talked about, not treating illness does not mean you're not taking a risk. Often patients are reluctant to expose their pregnancy to some sort of external chemical, they're worried if it's safe to take a medication, what we have to start with is the understanding that untreated illness is also not necessarily safe. So we're weighing the risks of medication use versus the risk of what's going to happen if the illness is untreated. What we do know about the use of meds in pregnancy is that interestingly, SSRIs are the most extensively studied class of medication in pregnancy, more so than any other routine medication that you can think of that OBs would use every day. Part of that comes from the inherent stigma of, do you really need this med? Can't you just sort of tough it out? Which we don't necessarily experience when people need insulin or antibiotics maybe the same way. But needless to say, even though we don't have randomized controlled trials, which of course would be the gold standard, we do have a lot of data. Fluoxetine came on the market in 1988, so that's 30 plus years of experience and safety data with this class of medications. What we know from the data is that we do not see any consistent link with birth defects or structural abnormalities in the developing fetus. There is a slightly increased risk of neonatal adaptation syndrome. This one is also important to understand that neonatal adaptation syndrome exists in nature. It is not withdrawal. I think it's best understood as adaptation to life outside the womb and some newborns have a harder time with that experience than others. It can absolutely happen without exposure to medication, but some studies suggest that with SSRI use in pregnancy, the rates of neonatal adaptation syndrome increase. Neonatal adaptation syndrome is self-limited. It does not require any sort of medical intervention or medication to manage. The only management that's really done is just extra soothing to the infant because they're often a little more irritable, harder to soothe, maybe not sleeping as well, not eating as well. It is self-limited, typically goes away in one to three days. The reason why it's really important to stress that it's not a withdrawal syndrome is that the data is pretty clear that discontinuing the medication prior to delivery or reducing the dose prior to delivery does not affect the rates of neonatal adaptation syndrome, so it would be ill-advised for a patient to try to wean themselves off their medication trying to prevent this from happening. Another risk that we do counsel patients on is the increased risk of persistent pulmonary hypertension of the newborn. Again, this also happens in nature outside exposure to medication. It's a very rare event. The data suggests that in nature, one to two per 1,000 births and with exposure to SSRIs, it maybe goes as high as three to four, so absolute increase looks like it doubles, but it's still very small numbers over the grand scheme of things. Some studies suggest that with SSRI use, there may be a slightly earlier birth and a slightly smaller gestational size, but even though this was found to be of statistical significance because the study was so large, it does not have clinical significance in the sense that it was not prematurity. It was about two to three days earlier delivery, and the size difference was in just grams, so one of those things where the stats say you've reached your p-value, but the pediatrician doesn't care, also keeping in mind that depression and anxiety are themselves risk factors for prematurity and small size of newborn. Then in terms of neurobehavioral effects, this is the one that I think most patients are worried about. When I was training, there were some studies that came out that reported a link between SSRI use and autism, and of course, everyone was scared. Those were not well designed. They didn't control for whether the patient actually took the SSRI that the Medicaid database said that they were prescribed. They didn't control for substance use. They didn't control for family history. They didn't control for the paternal history, but it made people very concerned and did lead to further research, mostly in Europe and Canada, where they have better access to everyone's health care records, and they're able to control for these things. At this point, we're fairly confident in saying that SSRIs do not seem to be causally related to autism. The more we learn about autism, the more it seems to be genetically probably related, and there does seem to be a link between both maternal and paternal depression as a possible risk factor. When you're thinking about which medication to use, let's say you've decided you're going to use a medication, what do you use? Here, what's really important is to get a good history of what has worked. What we'd want to do is minimize switching, and we want to minimize the number of exposures. If a patient has already been in treatment in the past, you really want to hear what has worked for them. This would not be the time to say, well, you've tried SIRT or LEAN, it didn't work for you, but I've heard it's the safest in pregnancy, so let's try it again. We want to really stick to what works, and we want to give the lowest but effective dose. There's an instinct to lower doses in pregnancy, but again, you don't want to be in the situation of now you're exposing to both symptoms and medication, so you want to make sure that even though you're using the lowest dose, it's the effective dose. I counsel my patients to expect that as their pregnancy progresses, we're going to be increasing their dose, because as they get bigger, their kidney and liver is working faster, they have twice the blood volume by the time they're delivering, they're going to notice that the dose they were taking before may no longer be effective. Some medications, for example, like Lamotrigine or Lithium, in particular, see a huge drop in level as pregnancy progresses, so those are also even more likely to need to increase, but you want to set the tone of like we're probably going to go up, not down. We would always prefer monotherapy, even if that means using high doses, and we definitely discourage any sort of dose reduction or stoppage prior to delivery. Sometimes patients want to do that because they're worried about NAS, but we know that the postpartum period is the most vulnerable time for a mood episode. Some studies say as high as 13 times more likely in the first couple of weeks postpartum, so this is not the time to stop them. One of the things that I was asked to comment on is the FDA risk categories, so this is kind of an interesting thing. The FDA created the category ABCDX system in 1979, and the purpose of this was to look at what do we know about the safety of these medications in pregnancy, and actually, fairly quickly after this system came out, people started to notice a significant flaw, and the flaw is that it was static. Once the medication got a category, it was basically based on whatever data was submitted for FDA approval at that time, so usually sort of like still industry-funded, and then as experience grew, it wasn't really revisited, so because of that, often what happens is newer drugs wind up being categorized as category B because if you look closely at what category B actually says, it doesn't say this drug is safe. What it says is we don't really have adequate data, and that's often true in the beginning, so for example, lorazadone is a category B, and I often hear people saying that's the one you should use because it's category B, but lorazadone is a pretty new drug as opposed to haloperidol, which has been around since the late 60s, so I do think it gives a false sense of confidence. People started asking the FDA to revisit this system, and they did, so in 2015, they came out with a new system which is more narrative-based. Instead of just giving a letter category, they actually go through like what is the data, summarize it, give the specific citation. The problem with this is that they are doing it forward-facing, so new drugs as they're coming to market are being labeled like this, but they're very slowly going through older drugs and bringing some of them up to date, but I believe they said, I may be mistaken here, but I believe they said 2012 is the cutoff, so older drugs than that, which in psychiatry is a lot of the drugs they use are never going to be revisited and relabeled, so a quick comment on breastfeeding. If a patient is taking SSRIs, it should not be a reason for her not to breastfeed if that's what the goals are. The American Academy of Pediatrics, ACOG, and WHO all have strong position papers on the benefits of breastfeeding and recommend that when possible, infants are exclusively breastfed for the first six months of life than other food being introduced up until two years of age. The only absolute contraindications to breastfeeding are active HIV infection, because it can transmit in the milk, and some but not all types of chemotherapy. I really like to stress this to patients to give them at least a little bit more confidence when they're thinking about whether they want to breastfeed on their sertraline that even some types of chemo would be okay. When a medication is evaluated for its safety in breastfeeding, this is actually done through a calculation, so basically what they do is they take a measurement of the dose that the adult is receiving, and they measure how much has transmitted in the milk, and then they adjust that for the difference in weight between the adult and the infant, and then that gets divided. And as long as that relative infant dose is less than 10% of the adult dose, it is considered safe in lactation. So here's a quick chart of just like antidepressants, the more common SSRIs and SNRIs, and one TCA, and as you can see that nearly all antidepressants that we commonly use are well below that 10% cutoff. The only one that can be questionable is fluoxetine because it has such a long half-life and active metabolites, it can actually build up. But other than that, all the other antidepressants we would use without hesitation. It's not on this chart because it's mostly focusing on depression and anxiety, but one thing to consider is if a patient is taking lithium, lithium does cross over in the milk in very substantial amounts, and it's not a contraindication to breastfeeding, but if a patient is breastfeeding while taking lithium, the pediatrician should be aware and involved because the baby does need to have lithium level checks and also monitoring for thyroid and kidney function just like an adult would if they're being exposed to lithium. In terms of safety resources, if you wanted to look up a medication, these are some of the best resources for looking up lactation safety data. I highlighted LactMed because it comes out from the NIH and it's free. Everything else here you would have to either have a subscription or fee for, but LactMed is totally free, NIH-funded. In my experience, the app is much better than the website, but the app is also free. So I do think that lactation is a very personal choice. It may not always be the best choice for the patient or their baby, but they shouldn't not lactate because they're worried about their psychiatric medication. Dr. Hudner, if you're there. Yes, I am here. I am unable to start my own video. I think the host needs to restart it, but I am here. Oh, here we go. Hello. So thank you so much, Dr. Tesler. That was a fantastic overview. And what I'm going to talk about for just a few minutes before we go to Dr. Ojo's presentation, which is focused on cultural considerations in the perinatal period and perinatal mental health, I'm going to talk a little bit about what to do with the patient who is sitting right in front of you, sort of the clinical, a real focus on the clinical considerations of particularly decision-making in this period, because as Dr. Tesler's excellent presentation pointed out, there's quite a lot of complicated information to go through. There's quite a bit of nuanced decision-making. And throughout the years of practice that I've had, both in terms of clinical practice, as well as the academic work I've had, we've sort of developed a certain type of clinical approach. I would say the first thing is, I mean, I don't know what you guys would say, but I think easily 90% of the patients who come to me for a consultation have already done some preliminary Google-based homework on what medications are like in pregnancy. They may have some very reliable information. They may have less reliable information. And one of the things I really try to emphasize from the start is what Dr. Tesler said in her presentation, which is there is actually a great deal of evidence in reproductive mental health. I think some of the confusion arises because we still do not do, of course, gold standard randomized controlled trials with pregnant patients. And so we do not have level one evidence for the most part when it comes to psychopharmacology in the pregnancy and breastfeeding setting. However, we still do have large cohort prospective studies, especially ones done in Northern Europe and other countries, some of which have over a million patients per study. And when we get to have a population in one study that's that large, we're able to control for a lot of potential confounding variables. And because of that, the evidence is actually really quite strong. So whenever I say to a patient exactly what Dr. Tesler said, which is, hey, actually SSRIs are the most extensively studied medications in all of pregnancy, I cannot tell you how many surprise looks I get because I think a little bit of the public sort of has an idea that this is not studied really at all. Plus the fact that there can be more or less reliable information found on the internet. So I do try to really emphasize an evidence-based approach and really emphasize the value of our evidence. On the other hand, I think, and I'd be so curious during the discussion section to hear about what my colleagues think of this. On the other hand, we all know that making a decision like this in pregnancy is not an entirely evidence-based decision. This is a person who is sitting in front of us who may feel guilt, who may feel self-blame, who may feel very, very, very worried. I have a lot of very anxious patients where no matter how much we try to reassure them about the relative safety of these medications, I know that the presence of the medication itself is going to fuel some additional anxiety. And so we want to take into account that there's a real-life human being here and that there's a second issue, which is that there are some relational ethics happening here. There's a balance because what we want to do is promote the mental health of the pregnant person, but that person is also thinking through the well-being of their developing fetus, as are we. So there's a balance here, and we want to really make sure that we give enough room, enough space, enough empathic communication, enough room for questions, enough room for doubt, enough room for guilt, so that we can have a humane conversation with this person who's trying to make the best decision that they can for them. I think the other balancing point about the evidence is that we can say, oh, the risk of a particular thing is, say, one in 1,000 or one in 2,000, which to us sounds like low risk. At the same time, what that person cares about most is their N of one. They care about their pregnancy. They care about their child. There's a bit of a telescoping phenomenon, which is we might say, oh, it's one in 1,000, but they're thinking, oh, but that one could be mine. I really try to emphasize and try to make it a collaborative effort as much as possible. I think a couple of other things. I really love what Dr. Tesler pointed out, which is just because there's evidence of certain things does not mean that that's clinically a relevant piece of data. For example, data about prematurity at times. Some of the data talks about babies being born, let's say, one or two days earlier than other babies. In general, that is not thought to be a particularly clinically relevant piece of data, even though it will show up in the evidence. I do try to point out that difference as well, or half score differences in APBAR scores, things like that. You can see it when we do large studies, but that doesn't mean that that's going to have an effect on their outcome. I think the other thing is knowing the person that you're speaking to. Some patients come armed with studies that I haven't even seen lately, or they come with a binder full of 10 of the most recent articles, a little bit of an obsessive coping style, really want to know all the information and really want to discuss things in a very rigorous and scientific manner. Other patients really have a slightly more felt experience where they are trusting a little bit more of their own intuition. They do think to themselves, okay, what feels most right to me, and they're not necessarily overly focused on the evidence. I try to tailor the conversation on getting a sense of who it is I'm speaking with. If I take a patient who is very rigorous in the science and I'm basically just saying, oh, it's up to you, you can just do whatever you feel, that's not going to be as satisfying as if I really review the evidence with that patient. I think the other thing, though, too, is that I do try to give a fairly firm set of recommendations. This is something that I would love to hear about with my colleagues. Over time, I started to think that the approach of, well, here's the data and the decision is ultimately up to you, while that's true and we always want to respect autonomy and we always want to do this in a very culturally competent and sensitive manner, at the same time, people are coming to us because of our expertise, because of our specialized knowledge, and because we've seen many, many, many, many cases. I will give them my direct opinion and then say, hey, I think it would be, all things being equal, if I were in your shoes or if I had to give a firm recommendation, this is what I would recommend, but I'd also love to hear your thoughts about that. I'd love to set up a collaboration with you understanding that this is where I would lean, just so that they get a sense, they're not trying to feel like the entire decision is up to them, especially because, again, this is a nuanced, highly personal, not entirely only rational decision. There's a lot of emotion that gets stirred up in this decision as well. I think the last thing I would say is a couple of things, which is really getting a highly personalized plan. What I mean by that is, all of us on this panel, we have seen patients who are quite low risk and probably didn't need to be on the Zoloft 25 that they've been on for 10 years anyway, that these are low risk patients. They could probably get away with doing a course of cognitive behavioral therapy, getting some extra support. Then we have patients who are bipolar one, have had pretty major high risk instances happen in their lives, and these are patients where we're going to take a completely different approach. I really try to make sure that I have a full understanding of what the diagnosis actually is, and I go through a diagnostic assessment with every single one of my patients, just to make sure that I am fully convinced that what appears to be anxiety in my mind actually is anxiety and is not something else, but also thinking through in my mind a risk stratification. What would this person look like if they went unmedicated throughout the pregnancy? Because, of course, this is not a neutral decision. This is not simply, oh, let's talk about the risks of the medication versus nothing. We're talking about the risks of exposure versus, as Dr. Tessler pointed out, versus the risk of untreated mental illness in that patient. To that end, two other tidbits. First trimester, second trimester, third trimester, and postpartum are different chapters in a book, and I do try to personalize the plan as much as humanly possible and emphasize that these things are, these times in pregnancy are different from each other, and there are times where we might hold off on the first trimester but definitely introduce the medication later, or I might say, hey, I think it's a really good idea for you to be on a medication all throughout, or with a low risk patient, we might say, hey, let's hold off, but let's really look and see how things are going late in the third trimester and early in postpartum. I try to make a very personalized, time-based plan based on the fact that the postpartum period is not always but usually the highest risk time from a mental health standpoint. The first trimester tends to be the second highest time of mental health risk. The last thing I'll say is that I do try to be as collaborative as possible with patients if they have partners and loved ones. If they would like to have that person in the room, then I think it is a very useful conversation so that we can have clarity of communication among all the interested parties, because sometimes there can be a little bit of a game of telephone where we say one thing to a patient, but then the partner might hear something slightly different. As much as possible, if the patient has that preference, and if they do have a partner that they would like to bring into the room, I really invite that level of collaboration. At this point, I'm going to turn the microphone over to Dr. Ojo. Dr. Ojo is a board-certified psychiatrist. She specializes in the treatment of women across the entire reproductive life cycle, including psychiatric disorders related to the menstrual cycle, pregnancy, perimenopause, and menopause. She has a specialized interest in working with women during pregnancy and postpartum. Where so often during pregnancy, women are expected to put both their mental health needs aside for the health of the baby. She strives to reassure women that we can find ways to ensure the health and safety of both mother and baby during this particularly vulnerable time. She is also trained in transmagnetic stimulation, which is a non-medication intervention for treatment-resistant depression, depression with anxious distress or comorbid anxiety, and obsessive-compulsive disorder. Dr. Ojo brings her expertise in public health and community health education to address racial disparities in health. She currently practices in an outpatient clinic serving patients in the D.C. area. So thank you so much, Dr. Ojo, and she is going to talk today on birthing people of color who may be reluctant to start psychopharmacologic treatment and how to navigate this challenge. All right, thank you for that introduction, Dr. Hutner, and I'm honored to share this stage with both you and with Dr. Tesler. So the objectives of my talk today are to explore culturally appropriate strategies to help providers educate patients on the available treatment options, as well as discuss ways and how we can navigate some of those challenges that birthing individuals of color face when it comes to that decision around psychopharmacological treatment. So before exploring that, so birthing people of color, a huge umbrella. Some of you may be familiar with the acronym BIPOC, which is inclusive of Black, Indigenous, and people of color. So we want to acknowledge that there's this full spectrum, which includes Latino and Asian, and this point is relevant because as much as I would want to be inclusive realistically, I cannot speak to the specific nuances of each culture, right? What you will find, however, is that overall concepts on how to approach patients of other races or cultures remains the same. And why does race even matter? Well, because racial health disparities are a reality of the American healthcare system. 38% of women of color experience postpartum depression compared to between 13 to 19% of all women, yet new mothers of color are less likely to receive help for their mental illness. And although not specific to postpartum depression, the National Latino and Asian American Study reported that while 18% of the general U.S. population sought out mental health services, only 8.6% of Asian Americans did so. And so here we see that there's a segment of the population that is at high risk for perinatal depression and anxiety and are either being missed or are underutilizing treatment. So before exploring this question of culturally appropriate strategies, I think it helps to review what some of those obstacles are that birthing people of color may face. Structural racism, as defined by Glazer and Howell, is the discrimination and differential access to opportunity that manifests in neighborhoods and institutions from past and present power structures and forms of oppression. So this may look like racial inequities in neighborhoods with redlining, schools and health centers, high poverty levels, high incarceration rates, environmental pollutants. The impact of these inequalities having downstream effects on many health indicators, including infant and maternal health outcomes. So then juxtapose that with interpersonal racism, whether that's overt discrimination or daily microaggressions. This could be cases where people of color are treated differently compared to their white counterparts when they walk into their OB clinic or perhaps enduring the provider's incorrect assumption about them that leaves them feeling judged and misunderstood. And, you know, social economic status does not protect from adverse health outcomes. So the knowledge that you as a person of color are at high risk for maternal complications or death or that your infant is at risk of infant mortality is a major stressor in and of itself. We have mistrust of the medical system, which may be a result of one's own lived experience or heavily ingrained through the narratives of historical medical abuses. We have intergenerational trauma and that is passed down, or that could be passed down from one trauma survivor to their descendants. And that can affect the lens through which a patient hears and receives information from you, the provider. Feeling unheard is such a big one. Countless stories of people, of birthing people of color who report that their that their pain was dismissed or ignored only to result in catastrophic health outcomes or birth outcomes. If they feel like you're not listening to them, it's going to be extremely hard for them to listen to you. Shame and stigma is particularly prevalent in communities of color and a major reason why patients may avoid seeking mental health treatment in the first place. In many cultures, which I don't think is news to any of us, mental illness is seen as a taboo, bringing shame to an entire community in some cases, and no one wants to bring shame to the family, right? So, you know, all of these factors are what a woman could be walking into the room with, or a reason for a patient to be hesitant to seek treatment in the first place. Now, many people of color say that they prefer a provider of the same race. There is a certain comfort level in working with a provider who has a shared cultural understanding, shared language, or lived experience. When you look at the statistics, this is clearly not possible. With only 10.4% of practicing psychiatrists either Black, Latino, or Native American, and only 2% of the estimated 41,000 psychiatrists in the U.S. are Black. But one should also be careful when viewing healthcare through a racial lens, because there's no one-size-fits-all or one-size-fits-most approach. As I'd mentioned in the introduction, BIPOC acknowledges the full spectrum from Black, Indigenous, Latino, to Asian. But what is Latino, right? Latino can vary in race, ethnicity, language, subculture, and more. Black can be African American, Caribbean, first generation African, African immigrant, mixed race, or some combination of the above. You know, take me as an example, right? A Black woman born in Germany, raised in Malawi, immigrated to the United States at the age of 16. My life is a very different lived experience from even that of my own two children who were born and raised in the U.S., so we cannot make assumptions. But we can certainly be curious and open to learning and understanding about that individual's background. In many cultures, women are viewed as the rock of the family, so there is no room for a foundational crack. This means you may need to take that one step further than the usual, how are you doing, to determine if there is something to be concerned about. The external appearance could be that of a mother who has it all together, and they may not be as open to volunteering that they are suffering. They've been raised in a setting where, you know, you don't air your dirty laundry, right? Or consider how perhaps an Asian mother who may feel that pressure to maintain the facade of the quote-unquote model minority, which is going to be clearly in conflict to the emotional distress that they may be facing. So we have a strong reliance on screening tools, such as the GAD-7 for anxiety, PHQ-9 for depression, the Edinburgh Postnatal Depression Scale. These are all validated screening tools. Some studies show that these tools may not necessarily accurately capture diverse populations, however, you know, I think the consensus is that if they are completed accurately, they can be quite helpful. Screening tools are exactly that, a screen, and they're absolutely not a substitute for a thorough clinical evaluation. Patients may have concerns about circling three on the EPDS, you know, three being high acuity or whatever question it is they're answering, but once trust is established, they may be more willing to open up. Again, in many cultures, depression or anxiety might not be a word that they even relate to. Recently, just a few weeks ago, one of my patients, she took offense almost when I suggested that she might be depressed. We explored further, and it was really just a matter of understanding what her idea of depression was and taking the time to educate. I think it's less important to get hung up on the definition if we can come to an understanding that there is suffering and that there are options available to alleviate that suffering. So you may hear things like, I just don't feel like myself, or I'm stressed, or the presentation may be more, you know, somatic. Is that my primary care doctor? I've been having these stomach aches. They say nothing's wrong, and I have to come and see you, right? A diverse workforce speaks volumes to the patient, but also reflects your commitment to creating an environment that values health equity. This may not be always something that you are able to control, but there are things that you can do on a personal level to demonstrate this commitment. This could mean obtaining educational pamphlets in different languages, having an established relationship with interpreter services, an inclusive and up-to-date resource list of local community services, midwives, doulas, OBs, and so on, and therapists. We also don't want to make any assumptions whatsoever about who we're seeing on the surface, right? I used me as the example of someone who I'm on the face of a Black woman, but different from a Black woman who was born and raised and has a very different historical context and background than mine. You're not expected to have all the answers, but you are expected to commit to learning and to be curious. There are a myriad of national, local organizations that you can tap in for trainings and other such resources. There are many reasons why individuals of color may be resistant to psychopharmacologic treatments. As Dr. Tesla explains, medication is not the first line of treatment necessarily, but in cases where medication is indicated, I always find it helpful to convey that therapy alone is helpful, medication alone is helpful, but it's usually the combination of the two that work the best. The benefit of an antidepressant in this scenario is that it, you know, it quiets the mind, it provides mental clarity, it gives the patient the mental space to dedicate to learning the coping strategies of therapy. It's helpful to explain that when there's that question of, I take a pill, but it's not going to change everything else that's happening around me, right? That's not the idea. It's to help you cope better with the factors around you that are contributing to the depression, if that's relevant. So stigma, right? It's stigma, again, a big one across the board. Medications are for quote, unquote, crazy people. And there's a fear and judgment from, you know, the community, the spouse, mother-in-law, I don't know, grocery clerk that, you know, that prevents them from taking that step towards wellness. The big, commonly cited obstacle is the myth of the strong black woman syndrome. The black woman has neither the time nor the space to falter and she therefore soldiers on. She brushes aside the emotional distress, and perhaps may have even come to accept that depression and anxiety is just part of the deal. The strong woman does not get depressed, does not cry, and certainly does not need an antidepressant and should be able to will herself out of the depression. Also common in many communities of color is a reliance on religion, faith, and spirituality as a substitute for treatment. And we can't ignore some of the real fears that some patients may have, that if they are deemed to be an unfit mother, welfare services could come and take their baby away. And so taking a leap from I am depressed, I need to take medicine, therefore I'm an unfit mother, and they will come and take my babies away can happen very quickly. So what can we do to make this decision more palatable for our patients? Well, we want to, I think, acknowledge a lot of what Dr. Hutner said, I think that was a very important sort of context, or setting the stage for this. We want to normalize conversations around mental illness. You know, how easy it is for us to forget that the brain is an organ. And that the same conversations we have around treatment of preeclampsia or gestational diabetes applies. So regardless of specialty, regardless of practice, a check on the mental well being of your patients should be routine at every visit. We want to undo some of these myths that we have around medication and mental illness. And this can take time. The patient has to feel safe in your presence. You can incorporate the patient's belief in the power of prayer into the conversation by accepting that the two can coexist, they're not mutually exclusive. And finally, I think, you know, acknowledging the challenges faced by people of color by being open, inquisitive, receptive to their needs as an image as an individual, as opposed to this sort of race blind approach is important. Because, you know, I think while those who say they don't see race may mean well, they might be the very ones who partake in implicitly biased behaviors that ultimately harm people of color. So you know, it's okay to see race, obviously not as a means for discrimination. But as a way to take pause, ask yourself what you need to do differently, or not differently in this encounter, to ensure the best health outcome for both the mother and the baby. There are a lot of as I mentioned, there are many resources out there on a national state local level that you can tap into. The ones that I'm showing here are just a few. And just a brief word about transmagnetic stimulation. So transmagnetic stimulation, or TMS, is a non pharmacological approach for the treatment of depression. It was approved by the FDA in 2008. If you look at the image on the left, this is brain imaging that demonstrates significant reductions and brain activity in the brain and that of a depressed person. By placing a magnet on the specific area of the brain, the left dorsolateral prefrontal cortex, and using high frequency pulse stimulation, TMS is a way to sort of wake up the neurons in that particular area of the brain. So the ideal patient for TMS is someone who has either had prior medication failures, treatment resistant depression, or could simply have a preference for a non medication option. TMS is effective up to 58% response, 37% of patients receiving complete remission of symptoms after four to six weeks of treatment and these symptoms of remission are long lasting. TMS is also safe and well tolerated. It's an outpatient intervention, you can drive yourself to the session and back, you remain awake and alert for the duration of the session, which lasts about anywhere from 20 to 40 minutes. There's a total of 36 sessions, usually scheduled four to five sessions a week. And so this is, you know, just one other tool under your belt that can be offered to your patients. I think it can be helpful to understand how TMS is different from ECT. ECT is a much sort of bigger, still very effective intervention. But with TMS, you do have to go under for anesthesia, and it's more of a sort of mild controlled seizure to the whole brain. And you're not able to drive yourself to these, to your, to your appointments. So, yeah, that's all I have. Thank you for your attention. So thank you so much to Dr. Ojo. And thank you again to Dr. Tesler for their presentations. And, boy, there was so much to say here that unfortunately, we're not going to be able to have time, I know, we're not gonna be able to have time to take questions here. Actually, there's one question here, which is that, Dr. Ojo, could you show your resource slide again, the the question that's in the Q&A is, thank you all for such an informative presentation. This is so timely given peri and postpartum mortality disparities in women of color. Yes. Dr. Ojo, can you show your resource slide again? Would that be possible? That is terrific. And so we could maybe leave that up there if anybody wants to take a screenshot. The other thing is Madonna Delfish, who was introducing this panel today, has very kindly offered her email. If anybody has follow up questions that we weren't able to get to, she is able to distribute those questions to us. Her email is mdelfish at psych.org. And I think I'm going to be able to put that in the chat to everybody. Oh, no, I think I can just post them panelists. But it's mdelfish at psych.org, which is spelled M as in Michael, D as in David, EL, F as in Frank, ISH at psych.org. So I'm so sorry, we're going to have to draw this to a close. But it's been wonderful to be on a panel with you both. This is something that I know that all three of us are very passionate about. And there is a world that is just opening up in terms of reproductive mental health, particularly through the lens of equity. So more to come. And I will leave it there. Take care, everybody. All right. Good night. 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health equity

reproductive mental health

untreated mental illness

perinatal period

medication use

SSRIs

risks

birthing people of color

psychopharmacologic treatment

culturally appropriate strategies