Hello and welcome to this four-part webinar series on perinatal mental and substance use disorders. This webinar series is a result of the work conducted by a group of clinicians, researchers, and clinical researchers from across various disciplines in mental and behavioral health. Before starting the webinar, we would like to acknowledge that this product would not be possible without the partial funding from the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services, grant number NU38OT000288. In addition, we would like to stress that the contents provided herein are solely the of the authors and do not necessarily represent the official views of, nor an endorsement by, HHS, CDC, or the CDC Foundation. Similarly, the contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the American Psychiatric Association, the APA. We would like to draw your attention to terminologies used in the webinar series. Where possible, we have used inclusive language such as person or persons instead of woman or women. For example, we refer to pregnant persons instead of pregnant women. This has been done consistently throughout the webinar, except in instances where the research we cited specifically stated that they are inclusion of women only in their study population. Similarly, we use the inclusive term parental instead of maternal. In contrast, you will notice that we used the word breastfeeding throughout the webinar. This was done because the studies we reviewed talked about breastfeeding. However, we would like to acknowledge that breastfeeding. However, we would like to acknowledge that chest feeding is a more inclusive term. Other terms of interest include antenatal or antepartum, which refers to before birth. Postnatal refers to after birth. Perinatal covers the pregnancy and postpartum period. Peripartum covers the period shortly before, during, and immediately after given birth. Postpartum refers to the postnatal period up to one year following given birth. We also use the acronym PANPBH, and this is used to refer to psychiatrists and non-physician behavioral health when referring to the practitioners who participated in the focus groups and surveys associated with this initiative. So, why is this topic and webinar series important? Well, studies have shown that mental and substance use disorders are associated with poor obstetrical outcomes, as well as poor outcomes for a fetus or child. Despite these findings, the rate of psychiatric treatment in the perinatal population remain low. Furthermore, there is limited research on best practices for the treatment of perinatal mental and substance use disorders. Compounding the issue of low rate of treatment and limited research on best practices are the findings that there is inadequate training of psychiatrists and non-physician behavioral health practitioners in the United States. Understanding the factors that contribute to the inadequate training of psychiatrists and non-physician behavioral health practitioners is important for the field of perinatal mental health care. Osborne and colleagues and their 2015 survey of psychiatry residency training directors found that only 36 percent of directors believe that their residents required competencies in competencies in this area. These directors cited lack of time to teach a topic as the primary barrier. These observations, plus the anecdotal reports by persons with mental and substance use disorders of having their clinical care dropped by their behavioral health practitioners once they become pregnant, was the impetus behind the project that resulted in this webinar series. The project aimed to investigate if the anecdotal report was supported and to try to identify potential causes and consequences as well as strategies to address this issue. A number of methods were utilized to address the issue with the goal of developing a perinatal psychiatric toolkit, which includes this webinar series as well as to formulate educational and training recommendations. Methods used included separate focus groups and surveys of pregnant persons and psychiatrists and non-physician behavioral health practitioners and their trainees. Similar to the 2015 survey of psychiatry residency training director conducted by Osborne and colleagues, we surveyed program chairs and training directors of mental and behavioral health training programs. But in addition to psychiatrists, our sample included clinical psychology, clinical social work, clinical mental health counseling, and advanced nurse practitioner programs. In addition, we conducted literature review on various topics in the broad areas of epidemiology, etiology, and adverse outcomes, clinical management of perinatal mental and substance use disorders, perinatal mental and substance use disorders in vulnerable and underserved populations, and training gaps in perinatal mental health care. The results of the literature review formed the basis for this webinar series with supplemental information from the focus groups and in some instances the surveys conducted. The work was informed by an advisory panel of experts from across various disciplines in behavioral and mental health. This four-part webinar series aims to enhance your awareness and understanding of treatment and training gaps in perinatal mental and substance use disorders and their impact. The series highlights ways to address these gaps. The webinar series include webinar one, epidemiology, etiology, and adverse outcomes of perinatal mental and substance use disorders. Webinar two, which covers clinical management of perinatal mental and substance use disorders. Webinar three, which focuses on vulnerable and underserved populations with perinatal mental and substance use disorders. And the fourth webinar that covers behavioral health education and training in perinatal mental and substance use disorders with a focus on gaps and recommendations. We hope you find each session and the full webinar series informative. Today I would like to welcome you to our second part of our four-part webinar series on peripartum mental health and substance use disorders with a focus on clinical management. My name is Nina Kraguliak. I'm a professor at Ohio State University. I'm joined today by three experts in peripartum mental health. First, I would like to introduce Margaret Howard. She is a professor at Brown University. Jeffrey Newport comes to us from the University of Texas at Austin Bell Medical School. And finally, we're welcoming Jacqueline Hobbs, who is a professor at Washington University. Before we get started, here are the disclosures of each speaker that you can review at your leisure. So let's dive right into the main issue that we're facing here. Mental health and substance use disorders can severely complicate pregnancy courses and can have very harmful effects on mothers and their infants if they're undetected or untreated. Unfortunately, mental health and substance use disorders are one of the leading causes of pregnancy-related deaths, of which 84% are preventable. The reason why there's such a large number of preventable deaths is that there's not enough psychiatric providers available to meet the growing needs for this population. This especially affects individuals from marginalized backgrounds who are much less likely to receive care in the first place and much more likely to have poor health outcomes. The lack of training during clinical training on this specific patient population often is what leads to hesitance to provide clinical care once people are practicing. And to the extent the training is available, it often only focuses on the harmful potential side effects of treatments and often does not discuss the benefits of pharmacological treatment or has a balanced discussion on the systemic barriers that prevents care delivery to the patients who need it the most. As to our learning objectives for today, we first will take a deep dive into the landscape of perinatal mental health and substance use disorders as they are right now. We will then discuss the importance of preventing perinatal psychiatric disorders and review some screening tools that can be available to identify patients who are in need of psychiatric care. We will then discuss follow this by explaining the risks of untreated perinatal mental health disorders and substance use disorders. And finally, provide a outline of pharmacological and non-pharmacological management and alternative care approaches. So I will now give it to the next speaker. Hello, my name is Dr. Margaret Howard and I'm a clinical psychologist and affiliated with the Alpert Medical School of Brown University Department of Psychiatry and Human Behavior as well as Women and Infants Hospital of Rhode Island. And today I'm going to be speaking with you about prevention and screening. So, excuse me, I forwarded a little too fast. Prevention of mental health and substance abuse disorders may reduce maternal morbidity and mortality as well as healthcare costs. Now there are several initiatives that were started by the federal government including the White House Agenda for Maternal Mental Health which aims to eliminate coverage gaps by encouraging states to expand the Medicaid coverage from 60 days postpartum to 12 months postpartum. Additionally, around the clock, 24 hour a day, seven day a week national support hotline for pregnant individuals and new mothers that have mental health challenges as well as improving provider education was also started. In addition, public insurance coverage was expanded to include midwifery as well as doula care. Under the Affordable Care Act, the Maternal Infant and Early Childhood Home Visiting Program provides federal funding and oversight to states, territories, as well as tribal communities highlighting maternal mental health as a measured outcome. So, these have been some really important initiatives in expanding both coverage as well as awareness and advocacy. So, in terms of interventions for prevention, the U.S. Preventative Task Force categorized existing interventions for preventing peripartum depression into the following categories. What they found was psychotherapy was the most effective option and again I want to highlight that this is for prevention. Other effective interventions included health system interventions, physical activity, education, social support, infant sleep, debriefing of the birth experience, particularly if it was a traumatic delivery, antidepressants and supplements, and other behavior-based approaches. So, some of the CBT, which stands for Cognitive Behavior Therapy-based Programs for Prevention, include the Mothers and Babies Program, which is an evidence-based intervention for pregnant individuals and new parents to help manage the stress of, you know, a new baby and it's designed to prevent postpartum depression. Now, this intervention is delivered in a one-on-one setting and focuses on psychoeducation. The program also includes resources for both practitioners as well as clients. It creates a healthy physical, social, and psychological environment for participants and their infants. Now, interpersonal psychotherapy is probably the most evidence-based intervention currently for postpartum depression. It's structured, it's time-limited, and it focuses on relieving symptoms by improving interpersonal functioning. This can be delivered both in individual therapy as well as group therapy formats. The ROSE program, which stands for Reach Out, Stay Strong, Essentials for Mothers of Newborns, is a prevention program that has been widely disseminated and has been shown to be quite effective in preventing postpartum depression. The focus is on stress management and it also focuses on the facilitation of developing a strong social support system. It helps with transitions and associated change and assists with interpersonal conflicts that are common around childbirth. This program has been studied in high-risk populations of mothers prior to delivery and has been shown to be really quite effective. The other intervention that is getting more wide dissemination is the PREP program, which stands for Practical Resources for Effective Postpartum Parenting. It is a dyadic model in terms of prevention. It targets both maternal well-being as well as infant behavior and maternal-infant bonding. It's effective in at-risk populations, including those with sub-threshold symptoms of depression or anxiety and those from disadvantaged backgrounds, which, as we know, incur higher risk. Other programs and interventions for prevention include doula service, which is really effective for patients with risk factors for poor birth outcomes and subsequent psychiatric illness. It seeks to offer security to those who lack social support and are generally isolated. It ensures patients' understanding of clinical terms and procedures, which leads to a more positive birthing experience because they just have more awareness and understanding of the process. It also assists in strengthening the connection between birthing parents and their babies during the peripartum period. The other program seeks to prevent insomnia, which seems a little oxymoronic for when we're talking about the postpartum period. However, what we know is that protected sleep time is imperative for preventing relapse as well as treating current episodes of maternal depression and other psychiatric disorders. In terms of antidepressant use, there's not a lot of gold standard empirical data on the benefits and harms of antidepressants in at-risk mothers for preventing perinatal depression. I want to really emphasize this is about prevention. However, as you've heard in other parts of this webinar or will hear, it is we know that antidepressant use is very useful in the treatment of perinatal depression. And it's also widely noted that there is encouragement to not discontinue antidepressant treatment during pregnancy or the postpartum period, even if a mother is euthymic. Other programs for the prevention include the home visiting program, which includes trained social workers, nurses, and early childhood education specialists who meet routinely in the homes of pregnant individuals with young children. All 50 states have some form of this federally funded visitation program. It's funded by federal primarily as well as state and county maternal and child health programs, boards of education, community-based organizations, as well as philanthropy. Healthy Families of America is a program dedicated to child abuse and neglect prevention, and it promotes healthy parent-child relationship development. In this program, there's an initial evaluation that is conducted for at-risk parents for at-risk parents, usually parents who are likely to be single parents, who have a history of psychiatric illness, who may have socioeconomic stress. And what it seeks to do is to strengthen the family functioning in light of these risk factors. It includes weekly in-person and virtual home visits during pregnancy through the first five years of the child's life across all 38 of 50 states, as well as the District of Columbia and five of the U.S. territories. Other programs for prevention include parents as teachers. Now this program is delivered by way of in-home visits in person or virtual. Of course during the pandemic everything switched to virtual and these in-home visits are conducted by parent educators who are employed by whatever the affiliated organization is. It supports first-time parents of newborns through education and training and just general support. It educates parents and families on early childhood development and it supports healthy well-resourced home environments from pregnancy up until kindergarten education. Now I'm going to shift to screening. Why screening? Screening by perinatal health care professionals serving pregnant and postpartum individuals and their families helps to facilitate referral to treatment and typically treatment is conducted in an evidence-based model. So currently given the maternal mortality crisis in the United States several professional organizations recommend screening for mental health and substance abuse disorders and these recommendations come from American College of OBGYN, American Academy of Pediatrics and now the USPS, U.S. Preventative Services Task Force has also started, has also delivered their recommendations that all pregnant women as well as postpartum women be screened. And it's known that an interdisciplinary approach to screening during routine obstetric visits through pregnancy postpartum as well as screening in well baby visits with pediatric clinicians is really necessary. We have to remember that the pediatric providers you know are really the captive audience because they are seeing moms on a regular basis through that first year of postpartum. So also to increase treatment rates it's really imperative to first identify those who may need treatment and for that reason there are a number of recommended screening tools. For anxiety which is oftentimes overlooked and yet contributes to quite a bit of morbidity in the postpartum period and that the GAD-7 is a seven item general anxiety disorder scale and it is a self-administered scale that really just takes seconds to minutes to minutes to complete and seconds to score. Additionally there's the 21 item depression anxiety and stress scale, the perinatal anxiety screening scale and the the Edinburgh postnatal depression scale which many of you may have heard of is EPDS because it's widely used for depression screening also has a three item anxiety subscale that can be used. For depression the two most commonly utilized self-report measures are the PHQ-9 and as I mentioned a minute ago the EPDS. The PHQ-9 is a nine item self-report scale and the Edinburgh postnatal depression screen is a 10 item self-report scale available in multiple languages. For bipolar disorder, bipolar disorder screens include the composite international diagnostic interview as well as the mood disorders questionnaire. Now the mood disorders questionnaire is a self-report questionnaire and of note there's a very high rate of false positives. So for non-mental health professionals it's important if you get a positive screen on this scale to approach it with some follow-up questions. I mean this is true for mental health as well as non-mental health providers but you really want to follow up with some direct questioning based on the answers that your patient may give on the MDQ. So for substance use disorders the recommended screening tools are the four P's which stands for Parents Partners Past and Pregnancy and this screen shows strong sensitivity to detecting substance abuse disorders and also just test giving you know urine screens, blood specimen screens as a primary method is not always recommended because for a multitude of reasons including the risk of false positives. But the four P's is a really very very quick screen and it's reliable, it's valid, it's sensitive and it's specific. For obsessive compulsive disorders the kind of the gold standard is Yale Brown obsessive compulsive scale which we refer to as the Y box and also what has been developed is the perinatal obsessive compulsive scale which has been and which is was was designed to be administered after childbirth. A third screen is the parental thoughts and behavior screen and again I want to emphasize that these are all screening tools they are not definitive diagnostic tools. For psychotic spectrum disorders there really are no current guideline recommendations for screening for psychotic disorders during the perinatal period but there is the clinician rated dimension of psychosis symptom severity scale that can be used as a screen. Now for insomnia just a general physical examination and testing may be warranted for sleep disorders especially if you know obstetric sleep apnea is suspected but there is the promise which in the short form is assesses for sleep disturbance in adults. But there's you know there's nothing that beats you know kind of good old-fashioned questioning of the mother as to how much sleep she thinks she's getting and obviously having this corroborated by other family members or someone close to the mother is is extremely helpful. So I will stop there and let my colleague take over in discussing risks of untreated perinatal mental health and substance use disorders. Hello I'm Jeff Newport. I'm coming to you from the University of Texas at Austin Dell Medical School. In this section we're going to talk about the risks of untreated mental health and substance use disorders during pregnancy and the postpartum period and it's really these issues that drive home the importance of the screening measures that were previously discussed. If if the objective of an expectant parent is to maintain her own well-being but also maximizing her baby's well-being then having a clear understanding of what risks these disorders pose to both parent and child during the course of pregnancy in the postpartum period is critically important. So with that in mind it's it's also a key that we recognize that there are barriers that come into play in terms of accessing mental health care and substance use treatment during pregnancy in the postpartum period just as there are at other points in life and these barriers can be individual, cultural, structural level barriers as well as organizational barriers and it's very clear and a consistent message has been that populations that are deemed marginalized are at risk of not receiving appropriate care or or appropriate diagnostic assessment for that point. The other issue that comes into play here is very often providers are focused upon concern about the effects of the psychotropic medicines not just antidepressants but psychotropic medicines on the mother the unborn child and developing baby and while that's important and there's no medicine that we should assume has so much comprehensive reproductive safety data that we give it a blanket assessment of it is safe to use that had that concern about the safety of the medicine has to be counterbalanced with concerns about the risk of the illness if it's left untreated or poorly treated and that poorly treated concern comes into play with regard to dose management. It is not unusual for patients to be encouraged by family members, friends or even their clinical providers to discontinue psychotropic medicine upon learning that they're pregnant or if not to discontinue the medicine to reduce the dose of the medicine and the thing that to keep in mind is when using pharmacologic agents be it for mental health disorders or any medical condition the the key concern is that that medicine should be dosed at a minimal effective dose but I would argue that the adjective effective is just as important as the adjective minimal and so if a patient conceives while taking a medicine at a at the higher end of the dose range but her prior experience with that medicine indicates that at lower doses it just was not fully effective then the knee-jerk response of of recommending that she reduced the dose when she's pregnant is just going to leave her vulnerable to relapse and then you have both mother and child exposed to whatever potential harms might come from the medicine but also now exposed to heightened risk from the illness left untreated. So speaking of the risk of the illness and we'll break this down by by different different syndromes first in terms of depression depression and mood disorders we conceptualize as episodic and so it's it's possible that for people to discontinue their treatment and remain euphymic for a period of time and sometimes even an extended period of time however what the data has shown is that when antidepressants are discontinued in women who are taking them due to a history of depression and they discontinue that medicine at knowledge of conception or just before conception rates of relapse were quite high and particularly among those with histories of severe and recurrent depression which really is not not surprising. If they do experience that relapse into depression then there are a variety of harmful consequences that can affect both expectant mother and child and those consequences can be increased likelihood of psychiatric severe psychiatric illness warranting hospitalization but also it can adversely affect obstetrical outcomes and infant outcomes leading to poor maternal weight gain increased likelihood of preterm birth low birth weight operative delivery and a variety of other things. In addition when people are suffering with depression or other things they look for relief and if that relief is not coming in the form of treatment be it psychotherapy or pharmacotherapy it's not unusual for them to turn to substances like tobacco alcohol other illicit or habit-forming substances for relief and the data has shown that pregnancy does not prevent that from happening. Depressed pregnant women are much more likely to use these substances. In terms of anxiety and trauma the the pattern of the data while it's not as extensive in terms of the volume of the data the pattern is very very similar. One of the things we know is that certain populations are at greater risk for experiencing trauma and thus at greater risk for developing trauma-related disorders which can carry over into into the perinatal period. Anxiety disorders including trauma have have an array of adverse effects on pregnant women their unborn child and their families at large including increased risk poor adherence to obstetrical and other medical care use of substances as as we mentioned in in the context of the discussion of depression has other psychosocial consequences with regard to socioeconomic status interpersonal relationships and even suicide and infanticide has been reported in associate in association with these. In addition there's some evidence linking anxiety to poor obstetrical outcomes like low birth weight and pre-term birth. Now we're talking about bipolar disorder leaving bipolar disorder untreated during pregnancy has an extremely high rate of relapse and with 85 or more of women who are have bipolar disorder who are euthymic at conception but discontinue their mood stabilizer will experience a relapse and you see that hazard ratio there of 5.0. Now it may be that gradually tapering the mood stabilizer as opposed to abruptly discontinuing it may afford some delay in the time to relapse and so may open the door to minimizing exposure during particularly sensitive windows of pharmacological effect on embryonic development but but but all the more reason to really be committed to monitoring things going going forward. In addition left untreated bipolar disorder carries a variety of of risks of relapse suicide infanticide use of drugs and alcohol and other high risk other high risk behaviors. In terms of psychotic disorders it goes without saying that being psychotic when pregnant and having impaired reality testing really is not conducive to a healthy pregnancy or postpartum period and therefore it represents a significant threat to mother and child by impacting her self-care or parenting and even again the risk for infanticide during the postpartum period and you see here the the 10-month relapse rate is reported to be you know half of patients with schizophrenia who discontinue medicines compared to 16 percent who remain actively treated and this is true in pregnancy as well as outside of pregnancy. In terms of substance use disorders prenatal opioid abuse increases the risk for a variety of negative outcomes diminished fetal growth preterm birth risk for intrauterine fetal seizures fetal or neonatal withdrawal and fetal death. Marijuana exposure is also associated with preterm birth low birth weight and NICU admission and some recent evidence has raised concern regarding longer-term neurodevelopmental effects that had not been previously appreciated. Tobacco use during pregnancy has been well known for a number of years to be associated with poor pregnancy outcomes linking with miscarriage stillbirth preterm delivery low birth weight and then health outcomes for the children including asthma visual problems and so forth and even secondhand exposure to tobacco during pregnancy or during infancy is a risk to children during pregnancy doubling the risk of stillbirth. In terms of obsessive compulsive disorder it's also associated with a greater risk of preterm birth and low birth weight and can lead pregnant women to engage in more frequent fetal monitoring due to anxious uncertainty excessively seeking reassurance from obstetrical providers and then avoiding normal activities they erroneously believe will lead to fetal demise. During the postpartum period obsessive compulsive disorder can be particularly noxious especially if the new mother is experiencing violent obsessions which is the second most common type of obsession experienced by people with OCD or scrupulosity obsessions which are sexual in nature and the result of those types of obsessions is they create such distress that the new parent will then back away and delegate child care to to others who will who will stand in that gap but then that has consequences for that bonding experience for parent and child and then finally sleep disorders and and we can include in this non-syndromal sleep disorders insomnia which is a you know can be symptomatic of other syndromes like depression and anxiety disorders untreated sleep disturbance can can lead to a variety of poor outcomes like intrauterine growth restriction preeclampsia preterm birth and obstetrical deliveries operative deliveries gestational diabetes and you see these other things reported here so now what what can we do about that what once we've you know identified through screening that that a pregnant patient may be exhibiting symptoms of one of these disorders and and then we're we know now the risks that those disorders left untreated can provide or can convey, what treatments can we bring to bear that may overall improve the safety profile? Well, there are a variety of different strategies, psychotherapies, which will be discussed later by my colleagues, neuromodulation treatments, but also pharmacological treatments. And we're gonna discuss the psychotropic medications first. So all psychotropic drugs, your presumption should be that they will cross the placenta. And the reason you can assume that is for those to work at all, they have to cross the blood-brain barrier. And any molecule that will cross the blood-brain barrier, you should assume will also cross the placenta. But they don't all cross the placenta at the same rate. And so the extent of placental drug transfer depends upon a variety of factors. First, the physical chemical properties of the drug. So drugs that are smaller molecules, more lipophilic, will more readily cross the placenta than bigger molecules, which may underlie why, for example, fetal levels of venlafaxine, which is a small molecule relative to the SSRIs, are higher than SSRIs. But that's not the only issue. There's an active transporter at the placenta called placental glycoprotein, often abbreviated PGP, which transports molecules from the fetal circulation back out to the maternal circulation, in effect, removing potentially harmful substances from the baby's system. Well, that PGP transporter is of fetal origin. Fetal origin. And so it's the fetals, it's the baby's genetic profile that determines whether that baby's PGP transporter is a highly active one, or maybe has a polymorphism for being less active. And so that can factor in to how readily different medicines cross the placenta and then stay there once they've arrived. And then finally, interaction with other drugs that may alter PGP transporter activity can come into play. For example, if you're managing the care of a pregnant person who has opioid use disorder and you're wanting to use medication-assisted treatment and your options are methadone or buprenorphine, there are a variety of factors that may go into choosing between the two of those. But one thing to consider is that methadone inhibits PGP activity, whereas buprenorphine does not. And that in turn can lead to higher fetal concentrations of other medicines that may be taken along with the medicine being used to manage the opioid use disorder. So before starting any psychotropic, it's important to consider the following. One is patient preferences. It's critical in this area, as well as others, that we take a patient-centered approach. What is it that they want to do in terms of treatment? What are they going to be most invested in and most comfortable with? Second is the individual's disease and treatment response characteristics. We've already talked about depression, for example, having a high rate of relapse if treatment is discontinued. But not everyone who discontinues treatment will be likely to have experienced relapse in the near term. And so doing a careful review of the patient's prior course of illness can be very important, as well as their treatment response characteristics. And this goes back to the comment I made earlier, that if using a medicine and choosing a medicine and choosing its dose, you want it to have minimal exposure, but also be effective. And in a medicine that a patient has previously taken, which was not effective for them, no matter how much reproductive safety data it may have, you're ill-advised to switch the patient to that medicine because she's pregnant, simply because of that, because her own past history tells you that medicine's unlikely to be beneficial. Next, you also need to think about the gestational timing. When you're encountering the patient and making a decision about the medicine, at what point in the unfolding timeline are you? Is this a preconception decision, early pregnancy, late pregnancy, as it relates to particular exposure risks? So for example, if a medicine is known to convey a risk of heart malformations and a patient comes in and she's taking that medicine and she's preconception, then your discussion may revolve around, let's see if we can eliminate that medicine either by stopping it or replacing it with something that does not have that heart defect risk before you become pregnant. However, if the patient's already pregnant and taking that medicine, by the time she sees you, she's likely gonna be seven, eight, nine weeks into gestation. Well, heart formation begins at week five and is largely complete by week nine. So discontinuing a medicine at that later stage along the timeline, it's too late to protect the baby from that heart defect and risks that may be there with that medicine. So you need to think about those things. And then finally, think about the medical comorbidities that a patient has. So if you know from prior experience, she's prone to hypertensive disorders of pregnancy or gestational diabetes, choosing agents that are unlikely to exacerbate those comorbid conditions can be very, very important. The bottom line is the primary clinical objective is minimizing potentially harmful exposure, but that exposure is that you're concerned about and you're trying to minimize is minimize the harmful exposure to medicine, but also minimizing the potentially harmful exposure to the mental disorder or substance use disorder that is in play. And in effect then, it often becomes a feeling of choosing between the lesser of two evils when trying to choose an appropriate course of treatment. So looking at specific classes of drugs, most extensively studied are the SSRIs, Selective Serotonin Reuptake Inhibitors, which as you know, were developed for treatment of depression and they all have an indication for that, but many of them have secondary indications for a variety of anxiety disorders and the like. Their safety data for the SSRIs by and large has been very reassuring. Overall, no increased risk of birth defects. However, some concerns with specific SSRIs, particularly paroxetine, which has a black box warning on it with regard to cardiovascular defects. There are some isolated studies that have suggested that even fluoxetine and sertraline may be increasing the risk of cardiovascular malformations, although most studies have not found that. And it's also been suggested that in any of those studies, when you're looking at cardiovascular malformations that are surveillance bias may underline those research findings and so it may not be real. So jury is still out on that question, but by and large, with regard to teratogenic potential, with the possible exception of paroxetine, the SSRIs have been looked upon in a very favorable way. In terms of neurodevelopment, things have looked very good there. No differences in cognitive language and motor development, whereas some studies from nearly 20 years ago found that maternal depression during pregnancy and early childhood did have some adverse effects on neurodevelopment. The only outlier was one study reporting some minor differences in fine motor skills, but that was transient. And on reassessment, those differences were not sustained. There were concerns raised beginning about 10 years ago that antidepressant exposure may be connected to risk for developing childhood autism. Subsequent studies incorporating a novel approach called discordant sibling analyses demonstrated that apparent connection between antidepressant exposure and autism really was due to an ascertainment bias, and therefore, there does not appear to be any link between antidepressant exposure and autism, which is very reassuring. In terms of fetal growth and timing of delivery, the data there is very mixed as to whether antidepressants negatively impact those things. And part of the problem there is that depression and anxiety have also been linked to those outcomes. So it's difficult to get a definitive answer from the research studies when both the medicine in play and the underlying condition, which it's being used to treat, have both been linked to those negative outcomes, but continuing work is being done. And then finally, there's data with regard to the neonatal impact of SSRI exposure and a variety of studies have linked SSRI use approximate to delivery to poor neonatal adaptation. It's not definitive that there's a link there, but some concern has been raised. When that does occur, it appears to be time-limited and requires supportive care, but not a detoxification or anything of that nature. In terms of persistent pulmonary hypertension of the neonate, which is a severe neonatal syndrome, there's been a couple of pendulum swings with regard to that. When the report first came out about this potential linkage, the FDA issued a warning in 2006 about SSRI use and PPHN or persistent pulmonary hypertension of the newborn. In 2011, the FDA retracted that warning. More recent meta-analyses of the now about 10 studies that have looked at this question do indicate there may be a very small increase in the risk for PPHN associated with SSRI use in pregnancy. And so how do you use that information clinically? Well, essentially what you do then is, if there is that small increase in that risk, that would be a negative for continuing the SSRI exposure, but then you have to weigh that against, if you discontinue the SSRI and the depression or anxiety exacerbates or recurs, what are the negative outcomes linked to that, and then choose the path, which overall maximizes safety as well as possible. Serotonin norepinephrine reuptake inhibitors, very similar medicines. The risk for individual antidepressants, you know, within each of these classes varies, and the thing to keep in mind is, although their mechanism of action is very similar, their pharmacological properties otherwise can be very different. And really only venlafaxine has had any significant study in this regard, and the data with regard to malformation rates with venlafaxine have been very inconsistent. So there's no clear definitive information with regard to that. In terms of birth defect rates associated with desvenlafaxine or levomimazeprine or duloxetine, there have been no reports regarding birth defect rates, but so we should not, therefore, assume that they're safe until we learn bad news. Our assumption should be there could be problems. We just don't have the data yet to determine that. Now, despite these inconsistent data, what do you do with that information? Should you, therefore, discontinue an SNRI? Well, again, you have to weigh that against the risk of recurrence of the illness and what risk that poses. And I would remind you that if a patient is taken an SNRI, you have less data, but she has a track record of doing well with that. She's now already pregnant. The baby's already exposed, and the alternatives that you might switch her to, like the SSRI, she's tried and failed in the past. It may be the wise thing to just continue the SNRI that she's currently taking. SNRIs have been linked to hypertension during pregnancy, particularly at higher doses, which we should not find surprising because we know that's the case outside of pregnancy, that high-dose SNRIs can contribute to the development of hypertension. And then, finally, the PPHN question that has been most extensively studied with the SSRIs has also been looked at with regard to the SNRIs, and they have also been linked to a small increase in risk for PPHN. The other groups of antidepressants, the tricyclics, there were decades of use of those in pregnancy prior to the advent of these newer agents, and so there are large-scale studies and meta-analyses that have looked at these. They've demonstrated no evidence of increased risk for malformations. The limited look at neurodevelopmental effects with prenatal tricyclic exposure have been reassuring. There are a variety of fetal and neonatal complications reported in the older literature, but smaller sample sizes, and they kind of follow the same pattern of what we've seen with the SSRIs and other antidepressants. And then, finally, they, too, have also been linked to the small increase in the risk for PPHN in newborn infants. And then, finally, you've got this conglomeration of what are collectively called atypical antidepressants, which are all very different in terms of their structure, their mechanism of action, and the like. The data on those is very limited. And one thing to keep in mind, newer agents are going to have much less data when it comes to their safety of use during pregnancy and lactation. So compared to SSRIs and tricyclics and even SNRIs, we have less information with regard to those. What we do have, though, although the numbers are small, are malformation rates among these agents appear to be consistent with population norms, but there's no data yet. On the newest of these agents, 40-oxetine and velazodone, unfortunately, in neurodevelopmental and neonatal outcome data, following use of these medicines is very, very limited, and there's not enough there to really offer any clear guidance as to what their effects might be. Now, moving on to other classes of medicines, antipsychotics. The antipsychotics have been used in pregnancy for a number of years and actually for a number of indications. And so first-generation antipsychotics, historically, it's not unusual to use low doses of them for hyperemesis gravidarum and still can be used for those purposes. It does not appear that they constitute a major risk for malformations. Unfortunately, their neurodevelopmental outcome data is very limited and difficult to draw any conclusions. As for the so-called second-generation antipsychotic medicines, and as you know, they have several different subgroupings and mechanisms of action. They do cross the placenta during pregnancy, but as we mentioned earlier, not at the same rate as other agents. So olanzapine has a fairly high placental passage ratio followed by these other agents. Quetiapine actually has the lowest placental passage ratio in infants compared to moms of 23% among all psychotropics that have been studied to date. But just because less of a medicine makes it to the baby does not necessarily mean that it's safer because sometimes the negative outcomes might be independent of the level of exposure, quantitative level of exposure, I should say. Now, looking at major congenital malformations, eripiprazole, olanzapine, quetiapine, the data has been reassuring, but again, I want to remind you, it's very limited in scope and number when we compare it to the antidepressants, for example. There has been some hint with risperidone and its related compound paliperidone that there may be some small increased risk of major malformations. And again, unfortunately, I have to tell you that neurodevelopmental outcomes following fetal exposure to the second generation antipsychotics is very scant and there's too limited to provide any meaningful guidance. With regard to lithium, it's well known that lithium is associated with cardiac malformations. The key thing that's talked about is a condition called Epstein's anomaly, where the baseline rate of Epstein's anomaly is about one in every 20,000 children. It's a 20-fold increase with lithium exposure, but again, that puts the absolute rate of Epstein's anomaly, even in the face of lithium exposure, at only one in 1,000, which is small compared to the rate of risk we'll be talking about with some other mood-stabilizing agents. There's also the potential for lithium toxicity in newborns and infants, but that lithium toxicity has been clearly linked to the level of lithium in the newborn at delivery. Despite these safety concerns, given the dangers posed by untreated bipolar disorder, there may be situations, many situations, where continuing lithium during pregnancy, despite those safety concerns, is the preferred thing to use, the preferred path to choose. And so it's important to weigh those risks and benefits of using lithium in individual patients based upon their history of treatment response, severity of illness, and so forth. Also among the mood stabilizing agents is lamotrigine. This is among the most extensively studied psychotropic medicines for pregnancy safety, with the vast majority of that research actually being conducted in women taking lamotrigine for seizure disorders. And in those studies, which are very voluminous in terms of numbers of pregnancies that have been studied, no increase of malformation rates, despite an early report raising concern about oral facial clefts that's now been dispelled, no evidence of increased risk for neonatal complications, or adverse neurodevelopmental outcomes. For example, the so-called NEAD study looking at IQs in children whose mothers had taken a variety of anti-epileptic drugs, the IQ in children whose mothers took lamotrigine during pregnancy was right at 100, the average I should say, which is where you would expect it. So one of the complicating factors with regard to lamotrigine is it has a very unique path of metabolism through a glucuronide enzyme that happens to be induced by estrogen. And so there's drug interactions between lamotrigine and oral contraceptives, for example, where oral contraceptives can lower lamotrigine concentrations. Well, the same thing can happen with the increasing levels of endogenous estrogen during the course of pregnancy, where as estrogen levels climb, that can induce lamotrigine metabolism and lamotrigine levels can fall. Now all medicines can, you can see some decline in circulating concentrations during the course of pregnancy due to increased volume and distribution, increased hepatic metabolism, increased renal clearance, but typically that does not come into play until the latter stages of pregnancy. Due to this estrogen-induced metabolism of lamotrigine, careful monitoring of the dose may be important throughout pregnancy as those lamotrigine levels can fall. Finally, it's important to keep in mind the scope of what lamotrigine does for bipolar disorder. Its FDA indication is as a maintenance treatment. It clearly offers prophylaxis against bipolar depression, but more limited against recurrence of bipolar mania, but it offers no therapeutic benefit at all for bipolar mania once the person is actually in a manic episode. So that has to be kept in mind in terms of the utility of lamotrigine. Other agents for bipolar disorder, valproic acid, extremely high rates of serious complications. So neural tube defect rates with valproic acid are on the order of three to four percent when you compare that to, like I said, the one in a thousand rate of Epstein's anomaly with lithium. Other organ major malformations, including facial and limb anomalies, reduced IQ. So the NEAD study that I mentioned with regard to lamotrigine earlier, the average IQ score in that study of children whose mothers had taken Depakote or valproic acid was in the 80s. So very concerned about that. It should be considered a medicine that is contraindicated in pregnancy, and because half of the pregnancies in the U.S. are unplanned, it should be used only as a medicine of last resort for any indication, be it bipolar disorder, seizure disorder, whatever, among persons of childbearing age to avoid those situations where someone comes in taking valproic acid and they're already pregnant and, you know, four, six, eight weeks into pregnancy by the time they see you, the neural tube closes at week four of gestation. And so by the time they would come in to see you, if the baby's going to have spina bifida, that will have already happened. Carbamazepine and oxcarbazepine. Carbamazepine does also increase the risk of neural tube defects, although not to the magnitude of valproic acid. It's more like 0.5 to 1%, but also been linked to other organ malformations. The data on oxcarbazepine is a bit mixed. The thing to keep in mind with these two agents is they are enzyme inducers, and because they induce enzymes, one of the things they can do is render hormonal contraceptives less reliable. And so it's important if someone is taking these agents and not planning to get pregnant, that she use a so-called barrier method of contraception, be it a condom, a copper IUD, to help minimize the potential for an unintended conception while taking one of these agents. And then finally, tropiramate, although, you know, it certainly does not have, you know, well-defined utility for bipolar disorder, we include it here, it has been associated or linked to a variety of different facial malformations with exposure. Now, when we talk about managing substance use disorders, one of the things that has emerged, at least with opioids, alcohol, and tobacco use, is medication-assisted treatment. And most strongly in the opioid use disorders, this has been shown to demonstrate a tremendous advantage when it comes to sustained sobriety and abstinence from recurrence of substance abuse. And so, again, the protective benefit of these medicines used to manage these substance use disorders during pregnancy, and protecting mother and baby from exposure to the illicit substances, must be weighed against the risk of the medication-assisted treatment. And what we see in the medicines being used for opioid use disorders, patients are better engaged in their obstetrical care with reduced infection risk, with reduced infection risk, baby fetal growth, it looks better, fetal and neonatal mortality is improved, although there are some risks. You know, with methadone, you can get evidence of vascular malformation risk in the CNS, obstetrical complications, and neonatal withdrawal, although the degree of neonatal withdrawal from methadone is going to be less severe than for someone actively abusing opioids. And then buprenorphine, while there can also be a neonatal withdrawal syndrome, it's even more limited in scope compared to methadone and other agents. For alcohol use disorder, the limited, the approved medicines are naltrexone, acamprosate, disulfiram, very limited reproductive safety data on these agents, and so it's premature to really provide any meaningful guidance. I will say disulfiram, the consensus is that it's contraindicated in pregnancy due to the potential dangers of the disulfiram reaction during pregnancy were it to happen. And the other agents, naltrexone, acamprosate, again, we're at a point where they're just not routinely recommended during pregnancy, although that has to be weighed against the risk of relapse into alcohol abuse. And then finally, when we're talking about medicines to aid in smoking cessation, those agents in the U.S. include buprenorphine, forenicline, nicotine replacement therapy, and the American College of Obstetricians and Gynecologists recommends that offering medication-assisted treatment as an aid to smoking cessation is appropriate during pregnancy, and we would concur. Next are the benzodiazepines and benzodiazepine-like drugs. You know, despite these medicines being available for a number of decades now, there's just not the volume of safety data that we would have anticipated or would like. With regard to their teratogenic potential, there's been some conflicting data. Early reports link the benzodiazepines, particularly diazepam, to increased risk for oral facial clefts. Subsequent reports did not bear that out, and so hopefully that's not an issue, but I don't think we have the definitive answer on that. Definitely, these medicines can affect neonatal well-being, and so if a baby is born shortly after mother has taken a benzodiazepine, particularly at a higher dose, you can see evidence of neonatal effects, be it poor muscle tone, known as floppy baby syndrome, poor respiratory effort, and so forth. If the benzodiazepine has been taken on a regular basis heading into delivery, then the baby, as well as the pregnant woman, will have developed some tolerance to the benzodiazepine and therefore potentially will experience withdrawal upon delivery, and so that has to be monitored and managed. There's no clinical data to address the neurodevelopmental effects of exposure. However, there is cause for concern because there are animal studies where benzodiazepines in stress models were administered to pregnant laboratory animals, and then the offspring were tested and showed some evidence for some cognitive impairment related to the benzodiazepine exposure. Despite all of that, this is similar to what I said with regard to lithium, there may be situations where continuing a benzodiazepine during pregnancy, either for sporadic as needed use or even for regular use for certain conditions, may be appropriate, may be the best thing to do. If you find yourself in that situation where benzodiazepine needs to be continued and used during pregnancy, generally speaking, low to medium potency agents that have no active metabolites and therefore are going to be less prone to accumulation and fetal circulation are preferred. Examples of those will be lorazepam and oxazepam. In terms of the hypnotic benzodiazepine receptor agonists, the so-called Z-drugs like zolpidem and ezzopiclone, there have been very few studies with regard to their effect in pregnancy and postpartum or breastfeeding, no solid link between them and major congenital malformations, but there have been some concerning signals with regard to obstetrical outcome being associated with higher rates preterm birth, low birth weight, small for gestational age, but again, these studies were limited in scope. Other agents taken as hypnotics, antihistamines, be it doxylamine, diphenhydramine, have been widely used to help with insomnia during pregnancy, but also with nausea, vomiting, and itching, and occasionally for anxiety as well. Most of the evidence shows no association between these agents and significant malformations or other poor pregnancy outcomes, although there have been a few studies that have suggested there may be a link, but by and large, the data there has been reassuring. With regard to trazodone, which in terms of its class is an antidepressant, but because it is so sedating in this day and time when trazodone is prescribed, it's most often as a hypnotic. It's not being dosed at levels where it would be effective to treat depression or anxiety. With regard to the trazodone data, what data is there has been promising, but it is limited due to the small number of pregnancies exposed, and you see that 200 number here, and safety profile comparing it to SSRIs was reassuring in one study. So again, the data with trazodone is limited, but has been on the whole reassuring. Now, perhaps one surprising finding is concern raised with regard to melatonin, and I say it's surprising in that melatonin is an endogenous substance that we as humans produce, but so you would think that it might not do any harm, but what has been reported in the animal literature, the laboratory animal literature, is administering exogenous melatonin to laboratory animals contributed to the development of genital malformations, particularly in female offspring, and there's no clinical data that has explored that same question, but given the underlying mechanisms, there's certainly reason to be concerned that that same thing might hold true in human pregnancy, although we don't know the threshold at what dose that would occur. Given the paucity of clinical data and the concerns raised by these animal studies, melatonin use during pregnancy is not encouraged. Now, what about breastfeeding? What do we apply there? So, you know, choosing whether or not to breastfeed is a difficult decision for any individuals, but particularly those with mental and substance use disorders, in part because of the concerns about infant psychotropic exposure, but also by, you know, what's the impact on breastfeeding on the course of illness? So, for example, a disorder like bipolar disorder, where a regular sleep-wake cycle can be critical for some women in terms of mood stability, you know, breastfeeding can represent a challenge. So, how do you make that decision? Well, you review with the patient the severity and frequency of episodes of her illness, the level of family support she has in terms of support for, you know, care for the baby, but also emotional support for whatever decision she makes, the birthing parent's general cooperation with treatment, and the ability to closely monitor the baby. One of the things to keep in mind is that newborns have, you know, lower hepatic enzyme activity, lower renal filtration, and thus the levels in their system may be higher than one would anticipate based upon the level of exposure that is occurring via lactation. It's also important to think about whether or not the infant has already been exposed to the medicine during pregnancy, and whether or not the infant has any health concerns that may compromise his or her ability to tolerate the medicine exposure. With regard to, you know, whether the baby's already been exposed, here's the thing to keep in mind. Infant level of exposure to medicines via lactation as opposed to intrauterine exposure via transplacental passage, the level of exposure for medicines has consistently been shown to be higher in the fetal circulation or newborn circulation from pregnancy exposure than in breastfeeding babies. And therefore, if a patient has already taken a medicine throughout pregnancy, and she's continuing to take that medicine during the postpartum period and wondering whether or not to breastfeed, one point to make is baby's already been exposed. Continuing to take that medicine that you took during pregnancy is simply going to continue your baby's exposure to the same medicine at a much lower level at a time when arguably, the baby would be less susceptible to at least harmful neurodevelopmental effects of exposure. Looking at the various classes, SSRIs very commonly studied for breastfeeding safety, and you see the list of medicines there that have the best pharmacokinetic profiles indicating relative safety during breastfeeding. SNRIs, the data is more limited. Best studied are venlafaxine, desvenlafaxine, which have relevant relative infant doses of 6.8 to 8.1 percent, which is within the notional 10 percent presumed safety level. By comparison, sertraline, the relative infant dose in breastfeeding is between 0.5 and 2 percent. And tricyclic antidepressants, safety profile during breastfeeding, similar to that of SSRIs. The one exception is doxepin, which in light of the severe respiratory depression in a nursing infant, generally people are encouraged to avoid using that. In terms of the atypical antidepressants, again, as you might imagine, very limited data. The best studied among them is mirtazapine, which was not found to be associated with any adverse effects on infants during lactation. Among the antipsychotics, it is not recommended that women discontinue an antipsychotic in order to breastfeed because that leaves them susceptible to, by definition, what should be a very severe illness, either a psychotic disorder or a bipolar disorder. Routine lab monitoring is not indicated, but it raises an interesting question. During breastfeeding, if a nursing child develops some symptoms or adverse effects that may be due to the medicine, what do you do? And so the consensus within the field is, if you suspect that the medicine may be causing that adverse effect, don't wait to get some laboratory tests of what's the level of the medicine, the baby, because quite honestly, that's not gonna tell you anything. If you suspect the medicine is causing an adverse effect, then given the nature of that adversity, the recommendation is to discontinue breastfeeding or discontinue the medicine. Most common adverse events you see are somnolence, irritability, tremors, and then the opposite, insomnia. In terms of mood stabilizers, valproic acid, carbamazepine, oxcarbazepine, tamarimate, lamotrigine, all are considered to have a favorable safety profile for lactation, though it should be added that there are reports with valproic acid and carbamazepine linking them to liver test abnormalities and blood cell disgraces, such as anemia, thrombocytopenia, and so forth. Bottom line is, any of those medical complications that these agents can cause in adults, your working assumption should be they could produce those same sorts of complications in a breastfed baby. With regard to lithium, though it's controversial, and once lithium was considered an absolute contraindication during breastfeeding, that has now been relaxed, and there is evidence that lithium can be compatible with breastfeeding if particular care is taken and measures taken. Opioid use disorder medicines, new mothers stable on an opioid agonist therapy, and who's remaining abstinent from illicit opioid use, to actually encourage to continue breastfeeding. And matter of fact, one of the recommendations is this may actually help reduce any neonatal withdrawal symptoms that a baby may be experiencing. Alcohol use disorder medicines, no published reports regarding those, and so not enough information to develop recommendations. Smoking cessation medicines, you see the list there, no published reports on varenicline, but bupropion has some data, limited data on nicotine replacement. Bottom line is what data we have is reassuring. Thank you very much, and I'll now hand off to our next speaker. Hi, I'm Jackie Hobbs from the University of Washington, and we'll now turn our focus briefly to the management of postpartum mental and substance use disorders. Postpartum depression is one of the most common complications that can arise from pregnancy and childbirth. Much of the treatment is derived from strategies for treating major depressive disorder. And selective serotonin reuptake inhibitors, or SSRIs, as you heard from Dr. Newport, are widely prescribed for postpartum depression because of their safety profile. And data has shown that sertraline is a very effective treatment for postpartum depression. However, overall, the quality of studies conducted for postpartum depression is low to moderate. So that should be kept in mind. So one of the emerging pharmacological treatments for postpartum depression is Brexanolone. This is a neurosteroid, it's naturally occurring, and is really the first pharmacological treatment designed specifically for postpartum depression. It was approved by the FDA in 2019 and demonstrated efficacy in reducing depression in postpartum women using validated depression severity scales. It was really developed based on the hypothesis that hormonal fluctuations are really the primary postpartum depression trigger. Now, Brexanolone is an infusion, so intravenous infusion, that takes about 60 hours or two and a half days, but again, has very high efficacy for postpartum depression. Again, because of it being a long infusion, it requires a REMS protocol, and there has to really be a strong infrastructure and resources to allow for and establish this treatment protocol in a center. So it also has a very high cost, so preauthorization is necessary. Really, the key elements to the success of this treatment include cooperation from multiple departments of a hospital, and you have to have outreach to obstetrics colleagues. There's a tightly designed protocol, and there must be a lot of structured, frequent communication among members of the clinical and non-clinical teams. Postpartum psychosis is a medical emergency, and it's associated with suicide and infanticide, and can often lead to hospitalization of the patient. It has a very low prevalence. It's considered rare, but when it does happen, it can be devastating. And again, given its rare occurrence, we don't have a lot of empirical data to inform our treatment decisions. Long-term treatment includes pharmacotherapy and sometimes electroconvulsive therapy, or ECT. Lithium is also a supported form of treatment, and it's considered a rare occurrence. It's a supported form of treatment for postpartum psychosis, and as well, there's evidence for olanzapine and benzodiazepines contributing as other options. It's important to consider the effect of breastfeeding that it can have on a new mother and the stress that it can cause. One of the things that we do in order to help in postpartum psychosis to help stabilize the patient is to make sure that they have enough sleep. And so foregoing breastfeeding in the overnight period can help a lot with that. If postpartum psychosis is recognized and treated quickly and appropriately, it can be achieved by two months postpartum, so that is reassuring. While pharmacological management is often important to treat and prevent relapse in patients with postpartum psychiatric disorders, especially severe forms, it's also critical to ensure that individuals and their families have adequate support. Research is starting to focus on other promising treatment approaches, including psychotherapy, support groups, and alternative treatments. So we'll start with psychotherapy. For anxiety disorders, it's recommended, one of the first treatments to really consider is cognitive behavioral therapy, or CBT. It's well-established as evidence-based approach to peripartum populations. Also, interpersonal therapy can be effective. It focuses on four interpersonal problems, such as role transitions, which are quite common during this period, interpersonal disputes, grief, and interpersonal deficits. It can be done effectively in the individual or group format, and it can also be done in person or online. And it's so adaptable and flexible, it can be used in a lot of different treatment settings, including outpatient. Psychotherapy for insomnia is important as a first-line treatment. CBT-I for insomnia in particular is commonly recommended. Medications, again, as with any insomnia, we try to keep treatments as short-term and avoiding medications as much as possible. PTSD, there's individual trauma-focused psychotherapy, which is first-line. For obsessive-compulsive disorders, CBT combined with exposure response prevention is very effective and really should be considered first-line. For psychosis, there are no psychotherapy modalities specifically to target in the peripartum time, but CBT-P has been shown to be effective for psychosis in general and may be indicated for perinatal psychosis, but further research is needed. Turning to support groups, this can be very valuable and an alternative to individual psychotherapy that may not be available in all areas. Having in-person group formats was found to be superior to in-person individual format for short-term effects on perinatal anxiety. It really helps group members to feel accepted, understood, and to validate their experiences. The support groups can be much more affordable and sustainable than individual therapy. And they meet weekly or biweekly and are facilitated by a mental health professional trained in this form of therapy. And really the main thing is highlighting the importance of social connection and belonging during the postpartum period. We'll now turn our focus to neuromodulation. Neuromodulation treatments affect brain circuits through electromagnetic stimulation, and this helps to improve mood and other psychiatric symptoms. These treatments include, but are not limited to, deep brain stimulation or DBS, electroconvulsive therapy or ECT, transcranial magnetic stimulation or TMS, and transcranial direct current stimulation or TDCS. These treatments are not typically used first line. They're usually used for more treatment-resistant disorders. However, they can be highly effective and they are non-pharmacologic. So they are very advantageous for those very advantageous for those individuals who are pregnant or lactating and really want to avoid medications. In general, they're considered safe in pregnancy and postpartum, though a lot more research is needed in this area. So let's look at each type of neuromodulation therapy. For deep brain stimulation, this is usually done in major centers. Trials for this are often limited in terms of number of participants. So the data is also limited, and especially for pregnancy, because most studies will exclude those who are pregnant or planning to get pregnant. There was, however, a recent study of 29 pregnant persons that showed a low rate of perinatal complications, so that is reassuring. But again, the data is, the N is small, and there's really insufficient data on full benefits and side effects in both postpartum and during lactation. ECT is considered a clear choice for those who are pregnant and facing an acute life-threatening mental illness. And there are possible adverse events that can occur in pregnancy due to ECT. These can be vaginal bleeding, abdominal pain, and miscarriage. So special precautions should be used, such as fetal monitoring before, during, and after ECT. Ultrasound and fetal stress testing should be sought. And there should always be collaboration with obstetrics specialists. TMS is effective, both in terms of response and remission rates. The side effects generally are minimal and very well tolerated. And so this is really a very viable option for pregnant and postpartum persons who don't want to take medications or otherwise can't tolerate them. TDCS is also non-invasive. So again, is a favorable choice for those who are pregnant or postpartum. Risk can include preterm birth, low birth weight, and other neurodevelopmental type delays. But we really need more data on this. Again, looks reassuring. And we may find that the benefits could surpass the use of psychotropics in the future, but we'll need to see how the data go. We'll look now at a few alternative care approaches. Physical interventions like exercise or targeted nutrition, yoga, or any stress-reducing activities can be very helpful and particularly for reducing anxiety symptoms. There are also complementary treatments, but we really don't have a lot of data on these. The data is inconclusive. These can be treatments like supplements, vitamins, bright light therapy, acupuncture, herbs, and aromatherapy. But again, we don't have conclusive data. There's also a common intervention of placental phagia, which is ingestion of the placenta and afterbirth components. And this really, there's no significant clinical evidence to support this practice at this time. So in conclusion, overall conclusions for this presentation is that clinicians may not know the most recent evidence or the best strategies for preventing and managing perinatal mental and substance use disorders. And though there are risks involved in using psychotropic medications, the risks of not treating mental and substance use disorders can result in serious negative effects to both mother and child. Clinicians really need to stay informed on current studies and reviews on the topic. There's a lack of randomized trials, which is a major limitation. And despite the lack of empirical evidence, mental health professionals should not avoid treating pregnant persons with mental health and substance use disorders. These individuals need clinical support to make informed decisions for themselves and their children. It is our pleasure to acknowledge the many people who have contributed to this webinar and to the APA and CDC Foundation project it represents. This includes the APA research team and the principal investigator of this project, Dr. Diana Clark, as well as the CDC Foundation team, our science writer, and the panel members of the physician and non-physician behavioral health advisory panel, drawn from the disciplines of psychiatry, psychology, counseling, nursing, and social work. Those of you who would like to learn more about this initiative can go to this website, www.psychiatry.org, and visit the website. www.psychiatry.org, backslash maternal, hashtag section four. In addition, for those of you who wish to see the references cited in this webinar series, those are listed in the following slides.

perinatal mental disorders

substance use disorders

webinar series

CDC

obstetrical outcomes

mothers

infants

clinical management

medications

pregnancy

lactation

opioid use disorder

risk-benefit analysis