Thank you everybody for coming to our talk, Prescribing in Pregnancy, What Every Psychiatrist Should Know. And it feels like every psychiatrist is in the room right now, so I appreciate everybody for really listening to the call of the title. So introducing ourselves before we talk content. So I'm here with Dr. Nancy Byatt, who is the Executive Director of Lifeline for Family Center and Lifeline for Moms Program and Professor of Psychiatry at UMass Medical School. That's just to summarize. Honestly, she has more titles even than are on the slides, so you'll have to read and look up even more about her. And I'm Amanda. I'm a PGY-4 at Brigham and Women's Hospital and student starting as an attending in the Division of Women's Mental Health and Reproductive Psychiatry at Brigham and Women's Hospital. And I also have here Dr. Reed Mergler, Assistant Professor of Clinical Psychiatry at the University of Pennsylvania and Penn Center for Women's Behavioral Wellness. You can see here any disclosures that we have. And moving on through, because we have a lot of content to cover and we want to leave a lot of time for the cases and for Q&A. So to introduce what we hope to cover, we plan to address common myths and misconceptions regarding psychiatric medication use during pregnancy and breastfeeding. And in service of that, to summarize evidence-based data regarding teratogenic and long-term neurodevelopmental risks of psychiatric medication use during pregnancy. To talk about a framework for discussing risk versus risk with patients, and I'll talk more later about what I mean by that. And to provide resources for ongoing education on this topic, both for you and for your patients. And at the end of the day, the main overarching goal here is to increase your confidence and willingness to treat perinatal patients because, as I'll tell you in a moment, there's a lot of them and they need you. So we printed out some handouts with the cases. Maybe you have a neighbor with one or you have one, hopefully, but all that content is also going to be on the slides. So what we want to do here today is encourage you to keep that patient when they become pregnant or state that they're planning to become pregnant. Or accept that patient if someone is interested in coming to your clinic and that's a part of their clinical background. 85% of women become pregnant at some time in their life. 20% of women experience perinatal mental health conditions. So that's a very large patient population. I think sometimes reproductive psychiatry gets sort of described as a very subspecialty interest but that's a very large population. And mental health conditions are the underlying cause of 23% of maternal deaths in the United States. So it has long-reaching consequences. And even if you had hoped to never treat a pregnant patient, about half of pregnancies are unplanned. So too bad. So we're going to get prepared. So perinatal mental health conditions are very common. Postpartum and perinatal depression, substance use disorders, anxiety disorders, OCD, very common. So you can see here postpartum psychosis is relatively rare compared to other diagnoses. Although when it does happen, it has negative outcomes, it's very prominent in the media. That said, having a mental health condition in the peripartum feels like it's more likely than not. It's a very large number of patients. So these patients depend on you. There was an interesting study a couple of years back looking at patients who might try and find help and who are trying to self-refer from the community. And the academic medical centers for their fellowship programs often do not accept self-referrals, sending patients out into the community. And even when they do, the average wait time for an appointment was six weeks or more, which when you think about the length of a pregnancy is too long. When these patients then go out into the community and say, all right, I'm going to go on psychology today like the podcast told me or like Google told me, only 30% of psychiatrists advertise on psychology today that they are willing to treat in pregnancy and postpartum. And that's not even considering do they take insurance, do they have any space, you know, any of that. Some states actually have almost no psychiatrists or none at all in their state that advertises treating perinatal patients. And in the meantime, mental health is decompensating. The length of wait time is positively correlated to the increase in that depressive symptom score. And each month spent waiting for an appointment increases the odds of clinically significant worsening depressive symptoms by 77%. It increases the odds of developing new onset self-harm ideation by 44%. So waiting a month for that appointment, that's not a casual thing. People need help a lot sooner. So one common myth that has been spread is like, you know, pregnancy is joyous and everyone's glowing and it's like a really amazing, miraculous time in life. And that can be true and at the same time, not everyone is glowing. There's a lot of anxiety and depression during pregnancy in the first year of the infant's life. I think this breakdown is interesting, though, because it highlights that when we think of peripartum depression, actually a large portion of these individuals enter pregnancy already with anxiety and depression. Like about a third is pre-existing anxiety and depression. And about another third develop their symptoms during pregnancy. And then, well, now I'm saying a third, but you can say it's not exact, 40% develop the symptoms truly postpartum. So frequently what is being diagnosed as postpartum depression, perhaps when it comes to you in the clinic, may have started much earlier, either in pregnancy or even before. All right, hello, everyone. Thank you for joining us. So we will talk about that pregnancy affects medication efficacy. And so why does this happen? Going back to like biology class, there's drug absorption differences. So there's slower gastric emptying and slower bowel and colonic transit during pregnancy. For drug distribution, there's increased plasma volume and a change in protein binding. And even a lower ratio of lean muscle to adipose tissue in pregnancy can lead to changes in the drug distribution. There's also difference in hepatic metabolism. So we have to consider this when prescribing medication. And there is increased activity of the CYP enzymes. When thinking about drug elimination, with the increased renal blood flow that happens in GFR, there can be increased excretion of these drugs, and we have to take that into account when prescribing. So for specific medications affected by pregnancy, just to cover three, very commonly prescribed by many of you, I'm sure, SSRIs, so the effect on metabolism in pregnancy, is the hepatic CYP enzyme metabolism. When antidepressant levels may fall, especially in late pregnancy, you want to increase the dose if symptoms re-emerge, but of course you're not getting a level of Prozac in pregnancy. But definitely paying attention to if the patient is getting worse, is it due to the drug being metabolized faster, or is it due to something else going on? It's very hard to tell that, but you could at least validate the patient's concern. For lamotrigine, there is increased phase two glucuronidation, and levels may decrease by about 50% in the second trimester. So you do want to increase the dose. There are some people in the field who may draw levels, I don't, and many other people don't, but really paying attention to the fact that the data does support that if the levels go down by 50% in the second trimester, with somebody who is at higher risk, you may want to increase the dose from 150 to at least 200 or 250, let's say. And then for lithium, with the increase in the GFR, there are reduced levels. So at delivery, the vascular volume and the lithium clearance is actually reduced. And this can pose some challenges. So you want to be able to monitor these levels and really stay in that therapeutic range. Most people say it's 0.6 to 1.0, and so I would say that really making sure that you're not hitting ranges of toxicity, you know, after delivery when the vascular volume and the lithium clearance is reduced. You know, unfortunately, and, you know, speaking to why this talk is so important, is that mood recurrence is so common with or without medications during pregnancy. So mood recurrence, mood episode recurrence is common even if medicated. Here you see for major depressive disorder and bipolar disorder, the blue is when they continued the medication, and the red is when they discontinued the medication. So yes, as you may expect, mood episode recurrence is even higher if medications are discontinued. And it's a staggering number that the recurrence rates can go as high as 70% in major depressive disorder and then 60% in bipolar disorder. And this is something you really want to consider when counseling patients about just discontinuing the meds because it's not safe for the baby, which we will go over that as well. And so almost all psychiatric medications can be continued during pregnancy. So we want to empower you all to trust your clinical judgment. What would you do if this patient was not pregnant? The baseline risk of congenital malformations is 2% to 5%. So when we look at the data, we can't just look at it blindly saying, oh, this causes a malformation of this amount. We really have to think about it compared to the baseline risk. Few medications demonstrate clear evidence for increased risk of congenital malformations, and we will go over those. And then maternal euthymia is key. So as one of the leaders in the field says, Dr. Lee Cohen, he says maternal euthymia is key to prevent that postpartum decompensation. And you want to use the fewest medications possible at lowest doses needed to reach this goal. And so many of you may have learned in med school or earlier on that there are categories. And a drug is category C or X even for pregnancy. But there are actually no more A, B, C, D, X. And even though that might be a little confusing, it's actually beneficial. They were first in use in 1979. And then in 2015, when I started medical school, it was replaced with the pregnancy and lactation labeling final rule. For this, the PLLR, as abbreviated, there are narrative sections for drugs in 2001 and onwards that were created in 2001 and onwards, and they recommended that the other drug companies or the other drugs have this implemented as well. But this has narrative sections on pregnancy, lactation, and the research in females and males of reproductive potential. So goodbye to the A, B, C, D, and really hello to the PLLR. But it just shows you that it really changes over time. And that's one of the beauties of reproductive psychiatry. Using psychiatric medications in pregnancy is often safest for the fetus as well. So untreated mental illness has risks too. And as we've shown, the recurrence rate of mood episodes is so high. So what can happen? There can be maternal suicide, unfortunately. There are epigenetic changes of mental health issues during pregnancy that can affect the fetus. And the illness decompensation, whether it is leading to more substance use or other mood conditions, can lead to more or new exposures or poor prenatal care. You always want to consider making relevant comparisons. So when thinking about are we studying those who are medicated versus those who are unmedicated, a diagnosis that is medicated versus unmedicated, not the ones that are medicated versus not having a diagnosis at all. And then there is no such thing as a no risk option. So it can be scary, but discontinuing medications does not protect you from lawsuits. There's also no true no risk option for you as the psychiatrist. You want to fight against omission bias. Omission bias occurs when physicians are more concerned about the acts of commission in which treatment leads to a negative outcome than they are about acts of omission, which involve not treating the patient's illness. For mom, fetus, and psychiatrist, the best approach is an informed discussion of potential risks and benefits of treatment options. When engaging in a risk versus risk discussion, you want to highlight the following. So the baseline risks of complications in pregnancy, the relevant comparisons of potential risk, the relevant comparisons of potential benefit, the exposure to the fetus, the relevant timeline of organogenesis, and breastfeeding considerations. So I will hand it off to Dr. Khoury to talk through some cases. And we do apologize for not having enough case handouts, but this will go through it all. All right. So we're hoping that we have four cases as part of this talk, and we hope that they will highlight both the content that we've already discussed and also give a launching point for a more in-depth discussion of certain medications and common clinical scenarios. So I'll read out this case, and we want you to think about it before we sort of give our answers of how we think about it. So this first case is about lithium. This is a 33-year-old female. This is her first pregnancy, no prior pregnancies or births, with a history of Bipolar I disorder, who had been taking lithium for several years after she'd had several manic episodes that resulted in hospitalization. She became pregnant unexpectedly and self-discontinued her lithium as soon as she found out, around 12 weeks gestational age. She's referred to you by her PCP at 20 weeks gestational age so that you can discuss with her her questions about whether lithium is safe in pregnancy and whether she should resume. She at this point is not sure whether she plans to breastfeed or not, still deciding. So how would you conceptualize that risk versus risk formulation with her going into that discussion? So I'll give you a few minutes to talk amongst yourselves and think, and then we'll talk about it. a little more directive because a lot of people are just not talking to anybody, and then if they say it, people are like, oh, I guess I go to my right, you know what I mean? Good point. Yeah, yeah, yeah, yeah. Yeah, no, it doesn't have to be a long time. No, it's fine. yeah, yeah, yeah. and who are on lithium-become-pregnant, it's maybe one extra case. And it's somewhat dose-dependent, with the risks being higher at much higher doses of lithium. And these are exposures in the first trimester. And when it comes to that Epstein's anomaly in particular, that is a really, really uncommon outcome. So that's like 1 in 20,000 pregnancies, if I'm recalling correctly. So even if you're doubling the risk, that's 2 in 20,000. It's still quite low, compared to 86% chance of a mood episode recurrence of the mom's bipolar disorder. So the other thing to highlight is those risks that do exist are related to exposures in the first trimester. This patient in this clinical scenario is now at 20 weeks gestational age. That isn't the first trimester anymore. So you can think about maybe how you'd advise if she was coming to you at six weeks gestational age instead, and we could talk about that in Q&A. But right now, I would say that the benefits to her mental health likely outweigh risks to the fetus, as you talk about that with her, because that heart is developed at this point, at 20 weeks. The other things to think about in terms of lithium have to do with, all right, so let's say you're both on board with that. She's stable, she's on the lithium. Now we're getting to the postpartum. How does that intersect with a desire to continue breastfeeding or not? One thing I would say is don't assume that everyone wants to breastfeed and start making decisions and recommendations for people without actually eliciting their preference in that regard. But sleep is really important for mood postpartum and for prevention of mania and postpartum psychosis. So it is important to have a wraparound discussion of what is that gonna look like if you are going to be breastfeeding in terms of protecting a stretch of sleep while maintaining supply. In terms of lithium safety during breastfeeding, lithium is excreted in the breast milk at higher levels than some other medications like SSRIs. I think the amount that I typically see reported around 25% gets into the infant level. It's like the infant levels are about 25% of the mom's level. That doesn't mean that it's inherently incompatible with breastfeeding, but it's a larger discussion of what that looks like, in part because it can often help to have a pediatrician who's on board, aware, has done that before, is willing to help monitor the infant. There aren't a ton of, say, direct negative outcomes for infants who are breastfeeding while their mom takes lithium. But since they are getting some amount of a dose, they're also going to be sensitive as an infant to the same things that your adult patient would be, say, like dehydration. And it can be a lot harder to just tell looking at an infant when they're toxic compared to an adult. You're gonna want to ideally have, in an ideal situation, the mom's not on a lot of other medications that might be interacting with the lithium and affecting the infant. The infant's fairly stable themselves, and there's some collaboration to monitor TSH, kidney function, lithium level immediately postpartum, and at some other time points as well. Usually it goes well. So our next case is going to be talking about SSRI class antidepressants. In this case, Ms. B is a G2P1. So this is her second pregnancy. She has one prior child with a history of generalized anxiety disorder. She's requesting a consultation with you about the management of fluoxetine 20 milligrams during pregnancy. She is at six weeks gestational age, so earlier in pregnancy this time around. And she's concerned about the risks of the medication to the fetus, because she's read that SSRIs can cause heart defects and withdraw symptoms after birth. She asks, should she discontinue entirely? She asks, should she ask the PCP prescribing her medication about switching to sertraline, which she has heard is maybe better? Or should she be tapering during the third trimester? She has a lot of questions, and she's very anxious. So she also plans to breastfeed, this she is sure about. So we're going to be addressing those questions with her. Is her Prozac associated with malformations? Should she switch to sertraline? And should she discontinue in the third trimester? And this time, I'll have everyone look to their right to find someone to chat about with this case. And if there's no one to your right, look to your left. You're now a group of three. Yeah, they're waiting. No, I said I've seen isolates everywhere. I'm like, not over there. You know? That didn't take long. Yeah, I've seen them a lot. And it's fine. I feel like they're good. I'm like, they're good. They're good. That's interesting. They don't have to be. Well, we're early enough in our careers, too. So we don't really care. If someone says, hey, can I have your appointment, we'll be like, hey, maybe you should invite us to give a talk to your group. Yeah, well, yeah, that's true. I mean. You don't need that anymore. Yeah, I probably use it. No, no. I don't know. Yeah, no. Listen, you could also send us a PDF. But I don't know if it would be downloadable anymore. Like, I don't know if it would be easier to do a PDF because I don't send my responses anymore. Unless I, like, say it was downloadable. But send us a PDF. I don't know how to use it. But you can send us a PDF. You're going to have to send it to me. It's a happy situation. But you have to send it. It's just a PDF. I don't want to do it though, people are going to ask me for slides, and I think it's like, it's collaborative to do it. It's not about the slides, it's about you. So it's not about the slides, it's about you. And so, if you're, if you're, you know, if you develop your expertise, you're not going to look at whatever slides you need to ask me to talk. You know what I mean? I mean, it's a little different for other folks than you'll feel like, I think generally it's just collaborative to do it. And if you're living all around sharing with them, it's like, I think, for me, the benefits are way greater. Even if I was just. Yeah. No, I would really like to say never again. Like, I don't understand that at all. Yeah, yeah, yeah. But you know, you can also sign through EDF, and then you can be like, and if you have somebody who's just casually going to discuss it, you're terrible because they want to know why you're doing it. I don't know. I don't know that I've ever had one. I mean, I've had people talk to people. Like, I don't know that I've had a session. I know I haven't. It's been like this many people crowding in. You know what I mean? I think there's an intensity to it. All right, everybody, let's bring it back. All right, let's talk to this patient now. Okay, so we have some reassuring news for this patient. So the SSRIs are not consistently associated with an elevated risk of congenital malformations above the baseline. What I find, though, is that in practice it is sort of shocking and distressing to people to realize that the baseline risk is as high as it is, that 2% to 5% seems like an awful lot. And so that is part of the conversation that is really hard, especially when there's already anxiety in the mix, that there are no guarantees of the outcome that they're looking for, of an outcome without congenital malformations, no matter what they do. But that said, the SSRI is not likely at all to be playing a role if their child is born with a congenital malformation. So in terms of switching to a different SSRI, in this case, well, let's assume the Prozac is already effective. I feel now like the way I wrote that case, I'm like, is it? But if the Prozac is already effective, there is going to be risk in switching to another SSRI. That SSRI might not work as well as you're tapering one thing down. You know, you're adding on a lot of new variables, new exposures, as opposed to either saying, well, what you have is working, so let's keep it to the one exposure we already have in a medication that's working for you. Or if you felt like it was clinically appropriate, because we're not going to diagnose someone based on a vignette, you know, then you could also consider increasing the dose of the medication that they're already taking that has been effective for them and that the fetus is already exposed to at this point. But the reason this comes up a lot is that Sertraline has gotten a lot of attention around how little of it is transmitted in the breast milk, that it's basically undetectable in the breast milk. And so especially for women who are planning to breastfeed, that is of particular interest to them. Like, that's the good one, right? But it's great. There's also other ones that are great. The greatest medication is the one that works in this case. And the amount of the fluoxetine that would be transmitted to breast milk is also extremely low and is well within the range that's considered, like, extremely low and safe. So even if it's not undetectable, that wouldn't necessarily be something that you're recommending to make major shifts in the management based off of. The other question was, should the medication be tapered down or discontinued in the third trimester? For a long time there was this thought that babies, when they were born and the moms had been taking antidepressants during pregnancy, that they seemed a little, like, jittery. They weren't adjusting as well. And so the answer to that must be to stop the medication during pregnancy. So what's being described there is something called neonatal adaptation syndrome. This does happen, and this is actually one of the things that I do counsel about as a risk. It occurs in about 25% of newborns born to women who are taking SSRIs during pregnancy. And it's effectively very short-term, self-limited jitteriness and fussiness in the immediate postpartum, after birth. But this can also happen without SSRIs on board and is not dangerous. It doesn't represent withdrawal. And there's no benefit in tapering or discontinuing the SSRI prior to birth in terms of the fetus or the neonate, not in terms of outcomes. But it also doesn't even, like, change the rate of that happening as an outcome, aside from the fact that it's not a dangerous outcome when it does occur. However, discontinuing medication in the third trimester, in terms of the maternal mental health, right as they go into postpartum, which is not always a smooth transition and can be very challenging in itself, that does raise risks of depressive or anxiety recurrences in the mom. Another question that's often raised is, is SSRIs antidepressant associated with autism risk in the neonate? People are really, really scared about this. And it seems like every other week there's some sort of paper in the media of SSRIs cause autism, or now it's Tylenol, or now it's something else. It's everything. It's living. So the existing data does not establish or really even suggest a true association. So that's many, many suspect, because association isn't causation, but there isn't even data to really establish association. And that's because meaningful studies need to control for a number of factors. So when somebody is saying, I read this really terrifying news article. It says that the risk is almost double of children of mothers who use antidepressants in pregnancy having their child have autism. When you look at some of the research studies that really start to parse out, okay, let's like dig into this a little bit deeper. There's some interesting things where they've said, okay, well let's look at moms who were taking antidepressants, those who continued their SSRI during pregnancy versus those who discontinued it right before becoming pregnant. And there is not a difference in terms of the rates of autism in their offspring. And if it was related to the SSRI, you'd think that there would be. And then, again, so what about women who were on an SSRI? They had a child. The child developed autism. They wonder, could it be the SSRI? There's a research study that was done that said, all right, well often women have more than one child. Let's see what happens next time that same woman becomes pregnant. Oftentimes they're not going to want to take that SSRI the second time around. And so when they looked at that, the rates of that second child, now that that same mother was not taking an SSRI the second time around, not different rates. So those are just two different ways that you can sort of control this to get down to like what is it that's really the SSRI versus genetics versus something else versus the risk of depression itself or whatever the depression is sort of a marker for perhaps genetically. There is no more association. So can you find a p-value less than .05? Almost anywhere. But it should not be guiding your treatment recommendations in this regard. So our third case now is Depakote. And I will give a little bit of a hint in that we said nearly all medications are safe to continue during pregnancy. We did not say all psychiatric medications. So let's talk about Ms. D, who's a 39-year-old woman. This is her first pregnancy. Well, she's not pregnant. She's thinking about pregnancy. She's undergoing egg retrieval for IVF. And she's sent for psychiatric clearance due to her medication regimen. Her current regimen includes Depakote for bipolar I, which she's been well controlled on since her diagnosis at age 24. Now, in this case, how would you conceptualize a risk-risk formulation for a discussion? And how would you address clearance status with both the patient and REI who referred her? I'll give you guys a few minutes again. This time, look to your left. Thank you. I mean, when I was a resident, I mean, I didn't know any more. We're just guys right now. I mean, we start getting the code online, and it's amazing. We're going to bring it up today. It's like we just started getting the code, and I didn't know anything. It's one of the things, you know. What's that one thing about? I mean, this was, like, a long time ago. Still, you know. You know, one of the trainings for our group, I don't know how far, I forget the year. We're going to do a QI project in the fall. Will it be still happening in our long-term? Is that a key answer? Or is it more just a thing? Oh, yeah. No. I mean, I was a resident for 12 years. Okay. I'm going to bring everyone back a little sooner on this one in the interest of time and leaving time for Q&A. All right. So let's talk about Depakote. This is the most definitive I'm probably going to get in this talk. I would recommend discontinuing the Depakote. So Depakote increases the risk of neural tube defects 10 to 20 times. The rate of neural tube defects goes from a baseline risk of 1 in 1,000 to 2%. So that's a lot. And it also increases the risk of any type of malformation, inclusive but not limited to neural tube defects, to about 11% of the pregnancies. Absolute 11%. That's a lot. There are significant and dose-dependent long-term effects on the child's IQ. Obviously IQ isn't the only thing that matters, but that's one of the things that gets measured in research studies. And it's typically 6 to 10 points lower for children whose mothers took Depakote during pregnancy. So if you have a patient who is reproductive age, even if they're not planning pregnancy at this time, I would recommend not starting this medication at all. If they come to you and they're already on this regimen, well before they're planning to become pregnant would be the time to be ideally trying to switch to a different regimen. Talk contraception if they're not planning pregnancy. And then in terms of for this particular case and presentation, you'd want to focus on psychiatric optimization, not clearance. I think this gets talked about in a lot of contexts, but we can't necessarily clear anyone in terms of guaranteeing any particular outcome for the fetus or for the mom. But in this case optimization would include a transition to a safer medication regimen for pregnancy and then demonstration of sustained stability on that new regimen prior to pregnancy ideally. Both Depakote use and a manic episode or depressive episode would represent an increased risk to this clearly much desired future pregnancy. So you'd want to switch them to a different regimen and then make sure everyone was stable there for a while before starting that process. And I'll hand off to Dr. Mergler for our last case and then we'll finish up with some resources and go to general Q&A. All right, so our final case is Ms. D. So this is definitely a hot topic, and she is a 32-year-old female, G0, with a diagnosis of ADHD. She's planning her pregnancy and inquires about the safety of continuing Adderall 10 milligrams daily. She wonders whether there are safer options for management of ADHD. So we want you all to think about what additional questions would you ask to guide her risk-risk discussion? What are the risks of stimulants during pregnancy? And what are the risks of untreated ADHD during pregnancy? So I guess turn to your right or left this time. And we'll give you like one minute, one to two minutes. And I think that people who are like, like not exactly into like stimulants, like what the other people do is like, I mean, some people are like, I mean, some people are like, yeah, this would be more of a problem. I mean, some people are like, you for watching! All right. Okay, so let's all come back together. Okay. But I'm glad there is such active discussion on this topic because it clearly is very important. So we want to understand the severity and the impairment prior to treatment or when meds have been stopped. So for this patient, you want to find out when did she start this medication and in what context. And what was she actually suffering from, right? Was she not able to get through her day of work? Was she failing out of classes? And what was her work like when she did stop these medications or when she took smaller dosages? Most studies are reassuring for stimulants and there is no increased risk of adverse outcomes. There is a potential association between methylphenidate and cardiac malformations, but it is a very low risk and confounded by other variables. And we also want to consider the fact that some of these people, you know, do abuse these medications and not taking them at the prescribed dosages. So when they do take them at the prescribed lower dosages for their own jobs or relationships, that it's not as risky as it seems. There is long-term, for long-term developmental outcomes for amphetamines, extra amphetamine and methylphenidate, there is no association with autism, ADHD, or other neurodevelopmental disorders in the children. And discontinuing ADHD medications does put people at risk of depressive symptoms and more family conflict. And that's the last thing we need during a pregnancy. Now, there's really, when thinking about breastfeeding, and on these handouts that have been passed out, LACT-Med is an amazing resource for breastfeeding and educating our patients on the latest data about medications in breastfeeding. But there is no evidence that the traditional pump and dump is beneficial. There is evidence that this makes breastfeeding way harder, which often affects mental health. As Dr. Corey said before, you know, breastfeeding can put people at risk, right, of mental health illness, especially in bipolar disorder and when they are at risk of postpartum psychosis. So we do want to consider that and that fed is best, right? So never really making sure that the patient knows that they can either breastfeed or formula feed. But that exposure was usually higher in utero than through breastfeeding. And for most psychiatric medications, the infant serum levels are less than 10% of the mothers, and that is considered safe. When it's 10 to 25%, we should use caution. And when it's over that 25% level, like in lithium, where it's right at that 25% mark, we do need to use extra caution and collaborate with the pediatrician like we spoke about. So there are many additional training opportunities, which is wonderful. There is an APA toolkit and a textbook. Many residency programs offer women's mental health tracks and concentrations. But also, as we said, the prevalence is so high that if you are interested in getting more experience in your residency, just ask the questions. 16 fellowship programs exist nationally for women's mental health with about 20 spots annually. CL fellowship is another possible path. But during residency, there are plenty of things you can do to become well-trained in this field, such as the National Curriculum for Reproductive Psychiatry that has modules that are free and available for all trainees. Postpartum Support International provides a certificate. And then lastly, Dr. Khoury and I did create Reaper Psych trainees in 2021. And we're very excited that it has over 800 members and lectures every month with journal clubs and podcast clubs. So hello, I'm Nancy Byatt. Thank you, Amanda and Reed. You guys did a fantastic job. So there's also, in addition to the resources that were just mentioned, there's also expert consultation available. So the Perinatal Psychiatry Access Program model is a model that our team developed in Massachusetts where perinatal psychiatrists provide consultation to other psychiatrists and any other perinatal care providers, in fact, but also psychiatrists. For example, in our program in Massachusetts, almost 20% of our calls come from psychiatrists. And they also do training and toolkits, provide resources and referrals. And some of the programs see patients for a one-time consultation. And they also work with practices to help them integrate mental health care into their workflow with OB practices. So the way it works, for example, so if you as a psychiatrist was seeing a patient and you want to call one of these programs, and there may be one in your state, I'm going to show that in a minute, but there's also a national consult line as well. So this is a resource available to all of you in one way or another. So what would happen would be, you would make a phone consultation, you'd call the access line, and a perinatal psychiatrist would return your call and you can ask them questions. So for example, a call I got recently was from a psychiatrist. They had a patient on lithium. They were wondering how to manage that. I got another call recently from another psychiatrist who was asking about Depakote, about what to do about a patient who was looking to be on Depakote and how to manage that. And also, many of them do referrals to the community as well. There are now 29 of these programs across the country, so they cover the majority of the births in the country at this point. You'll see, hopefully, if your state is one of the green ones, that means that you do have an access program in your state. If you want information about whether your state has one, then on our website, Lifeline for Moms, we have a list of all the access programs across the country, and we also have their phone numbers so you'll know how to call them. And also, there's a PSI national line whereby, this is on the Postpartum Support International, is PSI, that's the acronym PSI. And any of you can go on the website for PSI. If you Google it, you'll find it very quickly. And they have a national line also that anybody can call if your state doesn't have an access line. And also, the VA has one as well. So there's also a veterans line. So there's 31 total. So, why do these programs exist? They exist because I'm sure all of us, many of us here, probably most of us psychiatrists, know that it's really hard that people, we often have really long wait lists, and it's really hard for people to be able to see us. It can be really frustrating to practice as a psychiatrist when we wanna, our goal is to treat people and be able to have people access us. And often, there's months wait, particularly if people have public health insurance. So I'm gonna use an example here about how this can be frustrating for people and how these are, the access programs aim to help. So if you have a practice, for example, of 1,000 patients, an OB practice that has 1,000 patients, which you see, oh, there's no, okay, there's no clicker, but that's the first box. So if you have 1,000 patients in the practice, if 20% have mental health symptoms or experiencing mental health or substance use disorders, you have 200 patients who need care, right? Or 200 patients who have symptoms. Of those, let's assume that 150 of them need treatment and treatment is indicated. And let's say that 100 of those accept their referral. And then 100 need treatment. The available treatment is not 100. So you have less available treatment than those that need it and people are cycling waiting for treatment and you have a bottleneck. What access programs aim to do is to intervene in between patients needing treatment and the referral. So rather than referring people for pharmacotherapy to psychiatrists that probably have a really long wait list or may not take their insurance or what have you, they consult with the access program. The access program builds their capacity to manage themselves. Many of the access programs primarily serve perinatal care providers, for example, obstetrician providers so they can treat them themselves. And this is consistent with what's being recommended by ACOG and the professional organizations are expecting obstetricians to manage these illnesses. So the goal is that by calling, we build their capacity to treat themselves. The OB or PCP keeps calling the access program and then when they treat the treatment, we increase the amount of available treatment. And then ideally, no wait for treatments, as I'm looking at the slide again, it's probably overly ambitious but at least there's less wait for treatment. I don't know if we'll get to a point where there's no wait. And also, as I mentioned, any of you can call a psychiatrist as well because as we heard from our speakers earlier, from Amanda and Reid, there's challenges in that many psychiatry programs don't necessarily have, it's not required as part of training right now and many psychiatrists may not feel comfortable doing this. That's probably why we have so many people in this room. This is really hard. I did a fellowship in this, right? There's a reason these programs exist across the country and they exist because this is challenging. I know before I became a perinatal psychiatrist, when I was a resident, I remember a pregnant patient came in and I was like, oh no, they're pregnant, what do I do? I felt anxious about it myself. And that's natural. There's a reason there's a fellowship and there's a reason we have these programs. This stuff is really hard and it's hard to keep track of all this data. So we're here to help you and we're happy to take calls and I know we have a network of these access programs across the country. I know they want your call, so please call them. Their time is protected to provide consultation. So the resources don't end here. Any of you can have access to people like us who do this work all the time. And there's also some community resources to let you know about. As I talked about with, I was focusing on pharmacotherapy but there's major challenges with access to psychotherapy as well, right? And also other psychosocial supports. I always worry, I know in our program, even if we do a referral, we always talk about the worry we're sending people on a bridge to nowhere because it's so hard to access evidence-based therapy, particularly with people with public health insurance. So Postpartum Support International has resources available on their website. They have peer support groups, they're all free. They also have a maternal mental health hotline. These are all resources that you can offer your patients and they also have, they have the consult line, as I mentioned, and they also have a helpline for patients. So these are all things that are available to anyone across the country and they're excellent resources So thank you all for being here and thank you to Amanda and Reid for leading this. We're gonna have a Q&A, so it's not ending, to be clear, but we're gonna have Q&A now, but Amanda and Reid really led this and did a fantastic job and we're gonna have time for Q&A because we figured there'd be a lot of questions and so we're gonna start that now. I'm gonna sit down and then we'll moderate from there. So. Thank you. So any questions, please come to the mic with any questions. We'll just do it from here. Yeah. Hello, thank you for a great talk. One of the things that I see most commonly is alcohol use disorder in expecting mothers and so I was thinking about that as a topic and substance use more broadly and also the safety of neuroleptics, antipsychotic medications. Yeah, that's a great question. So the first, you asked about substance use disorders and neuroleptics, yep. I'll do that. So with neuroleptics, with antipsychotics, there's emerging data for antipsychotics. When I was a resident, I'm aging myself, I'm a lot older than these guys, they were like Haldol, the only thing you can do is give Haldol and that's what we did. That was in like the early 2000s and now there's a lot of data about both typicals and atypicals. There's really, most of us that practice this, you know, are perinatal psychiatrists, feel comfortable giving atypical antipsychotics. The evidence overall, I would say, outweighs the risk. Amanda and Reid alluded to this earlier, the question I was asked when a psychiatrist calls our access program and a psychiatrist calls about asking what to do, the first question I ask is, what would you do if the patient wasn't pregnant? And often that's the same thing, with the exception of a couple things, as we heard about. But with atypical antipsychotics, the main things that you worry about are the similar things you'd expect for an adult you're treating. So, metabolic syndrome, you would worry about the baby being born large for gestational age and the increased risk of gestational diabetes. And then there's the postnatal adaptation syndrome. But overall, they have not been found to be major teratogens and, you know, if I'm treating someone and they're on an antipsychotic and it's working, I would typically continue it. And then you asked about substance use disorders. So, for substance use disorders, I would say that, I mean, it's a broad topic, but I'll just give a couple of high points. Medication for opioid use disorders like buprenorphine and methadone, the short story with that is that the benefits of giving those medications during pregnancy clearly outweigh the risks. Because the risk of someone using, the risk of, you know, opioid misuse, the risk of overdose, and the risk of fluctuating levels of the baby far outweigh the risk of using those medications in pregnancy. So, there's a very strong evidence base for using medications for opioid use disorders during pregnancy and postpartum. And that would be the standard. And there's an increasing evidence base for using buprenorphine as well. A long time ago, we were more comfortable with methadone, buprenorphine was a newer med, but really, I think people are really feeling very comfortable with buprenorphine at this point as well. Yeah. Hi, thanks for a great talk. I think you might have just answered my question, but I specifically was interested in your experience with clozapine in pregnancy. I understand it's not suitable for breastfeeding, but if you'd had any direct experience. Oh, clozapine. Yeah, that's a little more specific, so I do think that's different. Do you guys, do you want me to answer? Do you want me to answer? Go ahead. Sure. Go ahead. So, yeah, there was a case like that recently in our hospital system. And actually, things went quite well with the pregnancy, and the outcome for the fetus on clozapine, there's less data with clozapine. So, you have to just be aware and also guide that there isn't as much data surrounding clozapine during pregnancy as there are for SSRIs and things like that. But the outcomes for the fetus were quite good. Mood was stable during pregnancy. Decompensated quite a bit though postpartum and still trying to understand why. I think the best practices in that regard are still evolving. And I defer, though, if there's additional thoughts there. Yeah, I think, I'm glad you asked because I sort of was being very broad about atypical antipsychotics. I do think clozaril's different. It's a great med. It also has a lot of side effects. So, just as we think about that, I mean, there isn't anything, as I'm aware, showing that it's a major teratogen or anything. But, you know, we know that we have to monitor things with clozaril, so that would wanna be taken into account. But I would still say if it was working and someone was on it, and usually people are on clozaril for a really good reason, I wouldn't, I don't think, it can be used in pregnancy with additional monitoring given that it's clozaril. And then I do wanna add that MGH has a national pregnancy registry specifically for antipsychotics that they hold that it's amazing for patients and providers to learn more about. And so you could just go right to womensmentalhealth.org and enroll that patient in those studies. Right, because there's so few cases right now. That way it helps keep track of them all so that we have the most up-to-date data. Thank you, first, for how educational this has been. It's awesome. It's a great topic. When you showed the network of consultative services across the United States, I'm a psychiatrist in Alaska, and I noticed that Alaska's not part of that. Yeah. It's kind of a bummer. But I work for the military, and I wanted to know if these types of services apply for people that are in a federal insurance program like Tricare. Yeah, definitely. So most, it's a great question, so most of these, and I would like to see Alaska have a program. You can call the national line, but yeah, so all of the programs are insurance blind. So most of these programs are either, all of them, are either federally funded through federal grants or they're funded through state legislature through those funds. So you don't have to worry about insurance. They're all free for who calls. So I'm really glad you asked that question. So they're completely insurance blind. So, and even if sometimes the program sees someone for one-time consult, many of them don't bill for that because they don't run as typical direct care services. They're funded through other sources. They buy out the psychiatrist's time to provide the consultation for whoever calls. So, yeah, I'm glad you asked. Thank you. Yeah. Hi, thank you so much. It was such a wonderful talk, and you guys really boiled it down to make it more accessible. I was curious about your recommendations regarding tapering medications. So if you had someone who was on valproic acid and they become pregnant, would you recommend you just stop it immediately or is there a taper down? And similarly for the antidepressants and lithium, if the patient had a preference to stop, is it okay to just stop them or would you taper in all cases? So because I am a reproductive psychiatrist, I do not prescribe a Depakote usually. So I don't really have much to say about that, but you could definitely answer later on that. In terms of SSRIs, however, I will say that tapering is best and really going slowly because SSRI withdrawal or serotonin withdrawal can be quite devastating for a patient, right? And it just depends on the patient's physiology, but I've seen across many different patients about whether they suffer from chills, night sweats, mood swings, irritability, insomnia, even suicidality. So you wanna be safe in tapering. Yeah, I would taper if it's safe to do so. So for the Depakote, I would lean towards stopping it immediately and dealing with that and have close monitoring, be starting something else that's going to be supporting their mood because when we talk about things being dose dependent, that's not just the daily dose, it's also the total cumulative dose. So the less that the fetus is getting exposed to the Depakote, the better. For other medications, I would taper also in part because if someone is experiencing, oh, even just going down on the dose slightly, now I'm having a reemergence of mood symptoms. I think sometimes when people have been well for a long time, they're like, maybe this is a good moment, maybe I don't even need the medication anymore. And so if they taper and they're doing well, then okay. But if they're starting to go down and then they're already noticing that worsening, sometimes they'll actually be like, yeah, I guess I do actually want to stay on and let's go back up. So it makes it a little bit less cut and dry, but ultimately, patient autonomy is gonna rule the day and you're gonna just give your recommendations, of course, and help them on that path. Yeah, I agree with all that. I think the other thing I would add, that actually for the data that you guys presented on the study where they looked at lithium discontinuation, they actually found that the slower they tapered the lithium the faster they tapered the lithium, the more it increased. That was proportional with the relapse rates. So the faster you taper, the more you're going to increase the risk of relapse based on that data. So I would definitely say with Depakote, that's different because it's like that is the true teratogen of the psychiatric meds that we just really want to avoid. But I would say for lithium and most other psychiatric meds, if you're tapering them, because sometimes patients really want you to, and of course you have to work with the patient and if that's what they really want you to do, sometimes that is the situation, you'd want to really do that slowly because the risk of relapse will be less the slower it's done. And I think in general with Depakote, it really, in my opinion, shouldn't be given to women of childbearing age. And if it is given, they should be on contraception. It's actually illegal to give Depakote in France, for example, to pregnant individuals. So that one is something that's special. Does that answer your question? It does. And just to clarify, say you have someone on lithium in the first trimester, would you taper if they wanted to come off or would you just stop lithium and if they became pregnant? I would still taper, I think, because the risk of relapse, because Depakote's different because that's a true teratogen. So we just want to stop it, right? Lithium is, I wouldn't say that is, I mean, these all have risks and benefits, but lithium I would say is the treatment of choice for someone with bipolar one in pregnancy or of reproductive age. So it's a drug, it's a treatment of choice in my opinion usually if someone's got you know the benefits often outweigh the risks so I would taper because you want to work with the patient because they want to go off but I would try to work with them to at least taper slowly ideally they would stay on it but if they really want to go off you at least minimize the risk of them disconcerting by tapering it slowly and I would recommend revisiting it with them also later in the pregnancy of once they're out of that first trimester would they be more open to re yeah yeah because it's it like stopping meds and like lithium in pregnancy if someone needs it is not patients don't always want us to do what's evidence-based but it wouldn't be evidence-based to do that yeah yeah you're welcome thank you for a great talk and one piece of advice is if you do this talk again you have to ask for a bigger room I know thank you give that feedback to the APA as well yeah so if you have a patient who's a first episode bipolar patient a woman young woman and you haven't prescribed anything so she's carte blanche would you choose lithium or and you know she's gonna want to become pregnant in a few years you know that so so would you choose lithium or would you choose an antipsychotic in that case knowing that antipsychotics are maybe a little bit safer what would you choose well I guess each of us speak for ourselves but I would still prescribe lithium because I feel like that question of what would you do if they weren't pregnant what if you what would you do if they couldn't get pregnant or couldn't be pregnant I mean lithium has much better data for bipolar one in terms of preventing mania especially so I wouldn't give someone a second line treatment on the idea that they could become pregnant in the future but that's just antipsychotics are considered first-line some of them in in for example circle exactly it's considered by Ken guidelines so yeah there are other first-line treatments yeah I mean it's a good I hear what you're saying I mean I think that I agree with Amanda that like you know we generally think of lithium as first on treatment it's always depends on the situation so I don't think there's a hard and fast answer so for example circle has a ton of weight gain associated with it right so you have someone who's if you know they're gonna stop it because of weight gain then you know you that might not be the best medication so I think it's really it's very individualized lithium is a great choice but there's definitely people that if I see someone who's bipolar type one that might not be my first choice with that individual for a specific reason right and also for lithium it does require monitoring and maintenance and that's not for everybody right and so and it also depends on you know I would recommend discussing the risk and benefits of the meds and the options with the patient and deciding together and it may be a lithium and it may be an antipsychotic depending on what their values are what they're you know if they can participate in the monitoring for lithium or if they want to they might say I'm willing to take something that maybe has a little less data to support it during this time period but that might be less sort of higher maintenance as far as monitoring and so forth and there's a toxicity with lithium so lithium does have a lot it's a higher maintenance medication thank you so much for this like interesting topic and the controversial actually so my question is about patients in this acute settings if a pregnant lady got agitated and required or warranted I am medication usually for other non-pregnant we give to 550 to at event 50 of mineral and five held on how does it work for pregnant ladies I think that that's you know what we would go to as well right but making sure that an OB consult is put in so that they can see them on the late on the inpatient psychiatric unit making sure that we can bless you and we could stage the pregnancy right and making sure that we understand you know what else is going on but yeah no I agree I mean I think however you I mean it's not like you're gonna give them Depakote for agitation acutely right so most of these meds I think you I think treating the agitation from a pharmacotherapy standpoint in a similar way is reasonable yeah I think it's reasonable yep I think also like benzodiazepines you know do get a bad rep among some of the OBGYN colleagues were in our field but I think that you know it can be very effective for people and as long as it's not like right before delivery right it's it can be okay yeah I agree the other thing to consider is of you know of course the the goal is always to be avoiding like physical restraints but harm reduction in that regard of that you want to be minimizing compression to the aorta especially like later in pregnancy so you can have like a hip elevator but I mean ideally you've not you're not getting to that point at all but just something to note there as well okay thank you thank you echoing everybody else's remarks on how great the talk was really appreciate it my question actually comes back to case three with the Depakote and the patient who is going through IVF and thought that I had with her age being 39 like an ovarian reserve being a factor in egg retrieval for a patient who's stable on Depakote would you then like take them off prior to egg retrieval is there any evidence for that or would you maintain them on that so they could get the egg retrieval and then spend that time getting them optimized prior to the implantation I guess that might be depend actually once you get into the nitty-gritty of how they intend to do the IVF whether it's just egg retrieval and egg banking for much later on versus supposed to be like for like creating the embryo and implanting like sort of all more at the same time because that's going to really change your plans but it sounds like what you're saying is assuming they'd be banking it for way to a way later would that change the plans I mean I don't think that there's data on any of any psychiatric medications affecting say like the success of egg retrieval which sometimes people have questions about like especially if it's a costly procedure they're like well I still get the same number of eggs if I do it I don't want to have anything affect that yield that might already be low so there's no risk for the medication in that regard but I think you were kind of going the other direction of would it be safe would they need to come off of it I think it has more to do with once they're pregnant rather than the eggs themselves yeah I would just add to that that I think if someone is on Depakote what you want to think about preconception planning so ideally you don't want to wait till somebody gets pregnant to change their medication because that's not pregnancy is not the best time to change medication period it's not so in addition to what Amanda was saying I think we also you ideal I think just for general for any medication if there's if there's a change that happened you want to get people as stable as you can on the regimen that they can stay on in pregnancy before they conceive so if someone's going through IVF regardless of the egg retrieval I would want to think like while they're going through that process I think you want to think about well Depakote is not compatible with pregnancy so let's change let's get you on a regimen that's stable ideally before they even start the IVF so I'm sort of backing up even further that I think you'd really want to you always want to get people on a stable as a medication as you can ideally and plan that before they conceive and even before they start trying if if if possible 50% of pregnancies are unplanned so that is not always possible half the time it's not possible but you know when you can I would add that piece too I just want to add that but you bring up a great point about continuing other medications until the embryo transfer instead of you know during that whole process and I have had patients be on a medication until the time of embryo transfer so they could be on like Adderall let's say until embryo transfer even though it's during egg retrieval but that's part that's their personal decision thank you so much no everyone first of all thank you again for the excellent presentation and congrats on the full house I'm sure the overflow is also full hi Amanda so I had a quick question so you mentioned that generally in pregnancy we tend to prefer second-generation antipsychotics what about Seroquel specifically like I've often heard that Seroquel is like the preferred medication during pregnancy is there a specific reason for that like is it because it's like the lowest EPS risk or like are there other I think in a lot of cases it it mirrors for for non-pregnant individuals you know first generation for the second generation in terms of some of those side effect profiles that's that's the biggest aspect of it and of course which of the antipsychotic classes are better for which diagnoses then I think a lot of times that ends up sort of converging on Seroquel as a very reasonable treatment choice right and you can I totally agree and I and I'm not aware of data that says the Seroquel is less has more you know more data or it has less association with any of these you know potentially Tritogen effects and other antipsychotics and I think part of it is that like if you're if you want to minimize using multiple meds and pregnancy and Seroquel is often a nice way to do that because it's FDA approved for so many different you know different indications versus like other meds where you might have to have multiple meds at once I think that's part of it similar to what we might do with another patient that wasn't pregnant or postpartum like Amanda said thank you yeah you're welcome hey thank you for the great presentation and before I ask my question big shout out to your artists that's impressive yeah I know so my question is this is kind of a gray area for me there's certain patients with bipolar disorder who don't do well with lamictal don't do don't do well with lithium but they do well with carbamazepine they want to get pregnant what do I tell them yeah that does have some teratogenic potential it's sort of in between lamictal of course and valproic acid is still much higher than that is that gets tough I mean that's a tough medication pre prescribed for like a variety of reasons it's almost like clozapine in that regard and that like if that's where you've ended up you probably tried a lot of other things and you are doing your best so that risk risk discussion becomes different because there's probably aren't so many things to switch to that have worked in the past and at the same time I think you have to advise that there is an elevated risk and have that discussion in that way and what else would you add to the I agree I mean I think that oxycarbazepine and carbamazepine are similar in that way like they're not like the Motrina lithium benefits often outweigh the risks you know Depakote is like really a no and then those are sort of like I try to avoid them they certainly wouldn't start him if they could be on other things but I'll give you a case example I once saw someone in the ER actually who came to the ER her psychiatrist was tapering her meds and what this was oxycarbamazepine but I still think of it in a similar way and and and they I called her psychiatrist actually and said please you know please don't stop all these meds like let's taper them or like we're happy to do a consult long story short they still precipitously stopped all the meds the woman ended up in my clinic like about four months later pregnant still pregnant she was now you know mid pregnancy after all this happened and she or maybe towards the end and she had and she had been in jail because she got really manic after they stopped her medication she lit fire to her home and ended up in jail and then ended up in my clinic after she got a jail that's a good reason to keep one of these meds on right I kept her on that medication all during pregnancy she did fine the baby was fine for her the benefits clearly outweighed the risk I mean that's an extreme example but these illnesses are really debilitating yeah we worry about teratogenicity but in this particular patient she put on all the other mood stabilizers like she put on everything this was the only med that worked and it was just okay the benefits outweigh the risks you know and I think that we discussed it and we when it stopped it was much worse than her being on it I thought so that's like a you know an example of when we would continue one of these you know like carpe mezzapine or oxcarbazepine yeah yeah you're welcome I thank you for the lecture so we've long known that ECT is safe for pregnancy but I did a rotation for one month at the second largest ECT Center and I did not see one pregnant patient there so have you seen cases where ECT was used what helped it uptake and then kind of a second question have you seen any use of TMS for depression yes I like I thank you for bringing that up because we didn't address that and ECT is safe in pregnancy sometimes there are there are often additional modifications like I know at our institution like that past a certain gestational age they'll intubate just because there's so much additional like weight compressing things like that so it's not always like the exact same process there but it is doable it is safe if somebody has that severe depression it may well be very appropriate I we haven't used TMS as much in our clinic yeah yeah I mean there's studies on TMS and pregnancy like you know not huge studies but there is studies Simone to go does a lot of this work in Toronto and you know I think if someone if TMS was indicated I would absolutely use it in pregnancy I think it can be used I don't think the uptake is much but it can be a nice option for people because you know it's not as if it has more risk than for example these like lithium limoges like some of these other medications we're talking about and it has an emerging evidence base for use in pregnancy so I think if someone needed it and that was a minute that was the treatment that they wanted it can be a good option thank you Oh again the first answer so still thinking about alcohol use and alcohol is a teratogen I want to be non-specific about a certain patient but one who's optimistic about stopping alcohol use but I'm thinking also if it's not stopped is there a relative difference that you're aware of in the safety of say naltrexone versus a campers eight versus disulfiram as a potential treatment so I will be candid that I don't know offhand and I'll tell you what I do when I don't know offhand which is I go to repro talks which is a really helpful website and app that keeps all of that information up to date for every substance and medication and so I will often if I see something as a console question I'm like oh that's not the one that I've done in a while I'll look that up as a as a good place to get accurate literature review on the spot so repro talks talks yeah and there's also mother to baby org for fact sheets that you can give out to patients that have like frequently asked questions and I I love that I also think that when we go into like breastfeeding as well thinking about lact med like I said it's a great resource that has all the latest data and yeah and oh yeah you said lack men right okay yeah yeah and thank you sir I just want to say thank you Amanda for saying like hey I don't know the answer to that and that's like such good modeling because like see we're up here talking about this we're experts and there's still stuff we don't know this stuff is really hard right like I think it just speaks to how complicated this can be I would say that most of those medications used for for those alcohol use disorders can be used like naltrexone there has been recent data on naltrexone that it can be used my understanding is similar with a camper say I don't know that one is necessarily better than the other but you know I think people are generally becoming more comfortable using medications to treat alcohol use disorder during pregnancy and postpartum and the data that's coming out is not is isn't suggesting that they're you know that there's a they're dissociated with major teratogenicity thanks so much hi everybody thank you so much um so your question about the the woman undergoing egg retrieval during an allen valproic acid made me think about there's some questions I've had from a patient which I never really thought about but I looked into where they were worried about whether the medication they were taking even before conception would damage their sperm or the genetic material I've had to turn with women also I do know there's a little bit of data about valproic acid and sperm counts but as far as I know the situation with most psychiatric medications is very poorly studied to what extent do you include that in your like how much of that in your practice do you talk to patients about how do you include potential damage of psychiatric medications to sex cells in your decision-making during patients considering consumption that's a great question the only thing that I would say and I really don't honestly and I should and kind of promised me to do more of that probably I will say that you know when I looked into Depakote and PCOS because I was giving a talk on PCOS they the research shows that when Depakote was given in 1993 they found that there were ovaries of those patients just had a PCO morphology and it wasn't necessarily that these people had this syndrome so it's hard to say but again we're not going to start giving reproductive age females Depakote to then study those patients yeah and I would just add that I would weigh that it's a really interesting question I also don't talk about it with people and I think you're weighing that with like I was giving a talk earlier this morning and someone said well what how do you talk about this I'm like actually the first thing I do is I ask people how much they want to know because I saw a patient a couple weeks ago and I when I first started doing this I would have this long list and I would document that I discussed everything in the Sun and all the stuff because I was like managing my own I could suppose anxiety around prescribing these meds and this person said to me I said you know how much do you want to know and she said I don't want to know if you think that this medication the benefits outweigh the risks I don't want to know the details she said I'm so anxious I overthink everything the more information you give me the more I'm gonna overthink it and then I document that the pit you know we discussed it the patient didn't want the additional information and I sort of weigh with them like so someone's asking you and they really want to know this and then there's a point where you know sometimes with anxiety like the more you feed into it the more of the bigger it gets so like it's it's a balance with that too so I wanted to add that piece because we don't have to disclose everything and we want to tailor that to what the patient what's gonna be helpful to the patient what they're asking for and also what you and your clinical judgment think would be most helpful it is interesting though how little research there has been surrounding the male factor like yeah male factors in terms of infertility and how psychiatric medications may or may not play play into it so I can tell you like there really isn't much that's studied there is some research that suggests even for SSRIs there's some sperm fragmentation but then like what does that mean practically I don't think we're actually necessarily at a point where we can truly advise people and that we understand what to make of some of that data and I haven't seen more information kind of coming through the pipeline about it there's a little bit more surrounding egg quality and amounts like retrievals in IVF and psychiatric medications on the female side and it's very reassuring in that regard but even then there's like two studies total yep yeah thank you it's a good question okay I think we have time for one more because you're here and that's good timing because you're now it's three o'clock I just want to know if there's any sleep aids you do or do not recommend during pregnancy maybe what you're like first line second line third line options would be yeah I will say doxalamine is a great sleep aid and it's also really good for nausea and pregnancy so that is my first line usually when it it really depends on other factors like mirtazapine trazadone they're okay again refer my patients to mother to baby org to really learn more and then when thinking about you know benzodiazepines if patients have been on them for a long period of time and really can't foresee themselves coming off of them I mean it does become a trickier discussion yeah yeah I just didn't hear and then I do always refer them though to CBT I there's a great app through the VA CBT I coach it's wonderful it's free downloadable on people's phones so I just always say that as a first line as well I agree I think pregnancy sort of forces I think us as practitioners to do things we should do when people aren't pregnant to like do CBT I first before we like is that in the long term the data is pretty clear that Benzo is like and all these sedative hypnotics in the long-term artists you know see we really the CBT I is really pretty of can be quite effective if people can engage in it but I agree and also the other options like hydroxyzine is very reasonable and not that it's the you know great for sleep but it's it's we don't worry about like typically hydroxyzine and pregnancy or Benadryl like obese I see use those a lot but I totally agree with everything Reid said as well and then also just asking some more questions about the nature of their insomnia or exactly what's going on like is it that their anxiety is actually worsening a lot is kind of the driver of why they're not sleeping as well or if there is it like that there's a lot more physical discomfort like they're in the third trimester everything hurts they can't find a good position sometimes like pregnancy positioning pillows are different things like it may be factors like that that are non-pharmacologic at all you can help give some guidance yeah and one last thing is that I think if you also like I've seen people who were come in so anxious and it's all because of sleep and like they came in that you PDS was high you would have thought they were maybe even had an anxiety disorder they get a night's sleep because in this case OB had given them a benzo and then there they were like completely asymptomatic so like in that case maybe what you know giving them something to really get them to sleep in the context of when sleep is driving everything else meds can be really helpful and really the benefits can really outweigh the risks so we are out of time but thank you for your questions and thank you all for coming we appreciate it

psychiatric medication management

pregnancy

perinatal mental health

SSRIs

lamotrigine

lithium

Depakote

teratogenic risks

pharmacokinetic changes

consultation programs

Postpartum Support International

maternal mortality

evidence-based data