Clinical Pearls in Perinatal Psychiatry

Hi! You’re listening to the Psychopharmacology
Institute podcast. I’m your host, Dr. Wegdan Rashad and this
is the show that aims to help you, the mental health clinician stay sharp on psychopharm! Today our episode is focused on perinatal
psychiatry. Did you know that in the US, July and August
are the months with the most births in the year? We thought we’d make this podcast for you
to prepare you for the wave of babies and amazing mothers who might need extra care
during this time. We have with us Dr. Vivien Burt, she is a
Professor of Psychiatry at the David Geffen UCLA Medical Center and also the Director
of the Women’s Life Center at the Resnick Neuropsychiatric Hospital. The peripartum period is defined as the time
from pregnancy to 12 months after giving birth. This is a vulnerable time for women in general
and especially for women who suffer or have a history of a mood disorder. Let’s kick off with a case that Dr. Vivien
Burt shared in her presentation with us. I’ll go ahead and start it. Tuck in everybody. We have Rosa, a 36-year-old, married, mother
of a toddler. She has been depressed three times, once in
college, once after the birth of her 2-1/2-year-old son, once one year ago after a 10-week miscarriage. Sertraline was effective for her depression. Cognitive therapy was tried but she was non-adherent
due to a lack of commitment, motivation and time restrictions. And she is now concerned because her toddler
is developmentally delayed. She is worried and says. “I’ve been told that antidepressants in
pregnancy cause congenital defects and autism and other problems. But without this medication, my depression
and anxiety come back and I’ve such a hard time functioning. I am so confused. What I read is scary.” And that is understandable. So how would we approach a case like this,
Dr. Burt? So looking at a basic treatment program for
Rosa, we decided on a team approach, patient, primary, referring psychiatrist, a perinatal
psychiatrist, myself, the husband, the obstetrician. And the recommendation was to continue sertraline
at the minimum effective dose, in this case, 100 mg daily, now, during her pregnancy and
during the postpartum. Psychotherapy was encouraged to address miscarriage,
bereavement issues and to augment antidepressant treatment and to provide lifelong tools for
anxiety. And close psychiatric follow-up was stressed
as very important. So first, working in a team. Second, considering keeping sertraline at
a minimal effective dose and encouraging psychotherapy. And then we follow her up closely. Nice! That sounds straightforward, but what about
obstetric monitoring? We recommended that by gestational week 18,
she have a high-resolution ultrasound. Postpartum, we encouraged surveillance by
a pediatrician for neonatal adaptive difficulties. And we encouraged that the patient and her
baby be hospitalized for 48 hours postpartum. Neonatal adaptive difficulties. Hmm, we will revisit this later in the podcast. Alright, so medications, psychotherapy, psych
follow up and obstetric surveillance. What else do we need to keep in mind? We listened to the patient and her concerns
and those of her partner and we addressed her personal, her obstetric and psychiatric
history, her symptoms with and without medication and their effect on functioning, how Rosa
and her husband understand their son’s developmental difficulties and how this might impact their
decision for future pregnancies on and off medication. So taking the satisficing approach and weighing
both Rosa’s illness and her history and the data on sertraline in pregnancy, Rosa
and her husband decided to continue with sertraline treatment. So not only did we address Rosa’s current
pregnancy, but we also addressed her son and future pregnancies. It is basically forming a coalition with the
patient and her family…discussing issues beyond medications with them. Dr. Burt mentioned satisficing, interesting
word and even more interesting concept…and it all started with a man named Herbert Simon… He was a behavioral economist of the 1950s
who won both the Nobel Prize and the Turing Award for his work in understanding how people
make decisions in the real world of unknowns. It combines the words satisfy with sufficing. For him, satisficing was a suitable goal,
perhaps the optimal goal, when forced to make a decision when a lot is unknown, unsure. In the past, our goal has been, when choosing
treatment options in pregnancy, to aim for the perfect outcome which generally means
to safeguard the health of the fetus in such a way as to aim for the perfect baby. But today, we do things a little differently. We still follow the perinatal psychiatric
literature very carefully. We still decipher, in other words translate
the data for our patients but we remind them that no one study is perfect. After all, patients are never completely randomized. Often, the numbers in our studies are not
that great and confounders abound. And we also remind our patients that to expect
perfection is in fact to guarantee disappointment. So now, we talk to our patients about satisficing
that is to choose among treatment options that will safeguard their health and optimize
the health of their babies in a way that they can live with. So for one patient, the idea of a tiny risk
of speech delay in her baby may be intolerable and she may rather wish to take a chance that
she will avoid a recurrence of serious, maybe even suicidal depression even though her past
history has suggested that she has not done so when she has gone off her medication. On the other hand, for another patient, risking
depression is a far greater threat to her pregnancy and to the well-being of her offspring
and other children than the remote possibility of speech delay which could be addressed with
a bit of speech therapy. So satisficing is aiming to satisfy the important
needs and sufficing with some aspects that might not be perfect…but ones that she can
tolerate. It is a balancing act and I think as well,
it is one step further to tailored therapy. Let’s jump back to Rosa. We made all these recommendations…what actually
happened in real life, though? So let’s look at what happened. Rosa did continue sertraline initially at
a dose of 100 mg a day and she started CBT or cognitive behavioral therapy. By the second trimester, she became more dysphoric,
more irritable. Sertraline was increased to 125 mg daily and
then to 150 mg daily with good effect. Note that with pregnancy as it proceeds, there
is an increase in extracellular fluid volume so there was probably dilutional effect of
the sertraline which is probably a part of the reason that we had to increase the dose
to 150 mg a day. By the middle of the second trimester, she
experienced fetal movements and she was psychiatrically stable on sertraline at 150 mg a day. By the third trimester, at 28 weeks, she developed
gestational diabetes and she was started on insulin. The decision, however, was to continue sertraline
at a dose of 150 mg a day. This was discussed with her OB who agreed
that psychiatric stabilization was a high priority. The pediatrician was alerted to maternal and
fetal issues and said he would follow closely. Her psychiatric status was stable. She had weekly cognitive behavioral therapy
which was increasingly helpful and the fetal parameters remained stable. Interesting. So there’s something to note here, sertraline
at the regular dose was less effective because of a dilutional effect most likely, so we
needed to increase her dose from 100 to 150 mg. To continue the story, at 37 weeks Rosa gave
birth to a healthy baby by vaginal delivery. Shortly after the birth though, they noticed
a transient increased breathing rate and occasional jerking. He was placed in a special unit of the nursery
for observation and 12 hours later he stabilized and had no more breathing problems. Phew. For Rosa, 1-week postpartum, her gestational
diabetes had also resolved. Remember when I said earlier that later we
will elaborate more on the phrase “neonatal adaptive difficulties”? Well, the time is now. This occurs in about 15% to 30% of cases where
there has been exposure in the third trimester to antidepressants particularly serotonergic
antidepressants. And what we see sometimes is transient perinatal
adverse events, things like jitteriness, poor muscle tone, weak cry, respiratory distress,
sometimes hypoglycemia, difficulty feeding and very rarely seizure. This is usually mild, temporary, dissipates,
it says, within two weeks but really generally within hours. What we recommend is that infants exposed
to antidepressants ought to be monitored after birth for 48 hours for additional care as
needed. So, up to about a third of women exposed to
serotonergic agents in the last trimester can have babies with transient neonatal adaptive
difficulties. Interestingly, studies have shown that babies
affected are no different from unexposed babies in terms of intelligence, depression or anxiety
even at ages up to age 4 or 5. What are other neonatal concerns regarding
the use of antidepressants in pregnancy? What about miscarriage risk? or risk of a
teeny baby? First of all, with regard to miscarriage,
there is no increased risk of miscarriage and this is a result of large systemic reviews
and meta-analyses of pregnancy and delivery outcomes after exposure to antidepressants. There is no increased risk of stillbirth,
neonatal mortality, postneonatal mortality with antenatal SSRIs. SSRIs and untreated maternal depression do
not cause clinically significant lower birth weight. And there is a small statistically significant
but probably not clinically significant reduction in the length of gestation of about three
days with antidepressants and/or depression exposure in pregnancy. So apparently there is little evidence to
say that mothers who take SSRIs during pregnancy are more likely to have a miscarriage or stillbirth
etc. There is some evidence that antenatal SSRIs
though, can reduce the length of gestation by about 3 days. Another thing I read about was the risk of
persistent pulmonary hypertension of the newborn (PPHN). That was thought to be possibly associated
with SSRI use in the last trimester. It can occur even with no exposure to anything. But in 2011, the FDA updated their statement
on the internet to say that after reviewing different studies “it is premature to reach
any conclusion about a possible link between SSRI use in pregnancy and PPHN.” They recommended that healthcare professionals
not alter their current clinical practice of treating depression during pregnancy. So, again not enough evidence to alter practice. The discussion on psychotropics in pregnancy
is an interesting one…we have a presentation with Dr. Marlene Freeman on postpartum depression
and how to approach it. Check it out! Let’s revisit Rosa and see how she’s doing
now. During the postpartum, the patient continued
sertraline at 150 mg a day and overnight baby nurse was secured for four weeks. Mother-in-law and mother provided additional
daytime assistance with the older child and the baby for three afternoons a week for the
first three months. Mom breastfed for three months with supplemental
feedings and we discussed with her the safety of sertraline in breastfeeding at that time. She did decide to wean after three months
due to the effects of sleep deprivation. CBT or cognitive behavioral therapy helped
her appreciate the breastfeeding she did accomplish while not blaming herself for stopping at
three months. At six months, the baby and the older child
were all meeting developmental milestones. Rosa relaxed. She was happy. She was able to care for her two children
with the help of her husband and a babysitter three afternoons a week. An IUD was placed because she no longer wished
to have any more children. She now had her family of her husband and
two children which is what she had wanted. So we kept Rosa on the dose of sertraline
that worked for her during pregnancy and we still continued with postpartum CBT. Notice how her family circle was involved
in this formulation. Now, sleep deprivation can be a big precipitating
factor for depression in women in the postpartum, so arranging effective ways to feed the baby
at night can make a huge difference. And so on the subject of sleep deprivation,
we can talk about breastfeeding. Breastfeeding issues were discussed and the
patient was encouraged to breastfeed if she wished but we also gave her permission to
supplement with formula and also to stop at three months because she was so sleep deprived. And then we did what we could to address the
need for child care help both privately and in terms of what she could afford. We can’t assume that the mother will want
or can breastfeed. It is a discussion, essentially. As you see in the case of Rosa, 3 months in,
she discontinued because of sleep deprivation and how it was affecting her. Providing alternatives and keeping the satisficing
approach in mind, can help. Next, I asked Dr. Burt if she had any take-home
messages for us. What can we say? Well, first of all, maternal stress and depression
during pregnancy are associated with serious maternal illness. Secondly, stopping antidepressants in pregnant
women with serious depressive illness is associated with a relapse of depression. Third, depression during pregnancy is associated
with an increased risk for poor obstetrical outcomes. Four, depression during pregnancy increases
the risk of postpartum depression. And five, the expectant mother’s health
is important for the health of both mother and baby. I will conclude by reminding you that we have
published two articles in the Washington Post, one in January 2017, the other in March 2017. The first, The Good Enough Mother Begins in
Pregnancy and the second, Doctor Says: When It Comes to Breastfeeding, Your Health and
Happiness Matter as Much as Your Baby’s. Both excellent, I think, lay articles for
patients who are considering using antidepressants through pregnancy and the postpartum. OK thanks very much Dr. Burt! You can find the links to those articles she
mentioned in the transcript. Annd that’s about it for today’s podcast! What, are you sad it’s over already? Well..not to worry we will be back soon with
more on perinatal psych. We will cover teratogenicity, autism and other
long term concerns with psychotropic med use in pregnancy. Also would you do us a huge favour? if you
have a case you’d like to share with us that you’d like to see discussed on the
podcast, let me know…email us at [email protected] Now brace yourselves for the key points. Satisficing is to choose among treatment options
that will safeguard the mother’s health and optimize the health of their babies in
a way that they can live with. Psychotherapy should be an integral part of
the treatment plan. Depression in pregnancy is associated with
an increased risk for poor obstetrical outcomes. Transient neonatal adaptive difficulties may
occur with antenatal antidepressant exposure, it is however, transient and has no long term
implications. Breastfeeding is a choice and conversations
about sleep deprivation and pharmacotherapy during this time are important. Did you know that a lot of today’s content
was extracted from our CME presentation entitled “Perinatal Psychiatry: Helping Patients
Make Decisions About Psychotropic Drugs in Pregnancy”? Check it out on our website. Visit and become a premium member
already! We have a bunch of CMEs and SA credits for
you to collect! If you’re a premium or premium plus member
and you refer a friend to join our platform, you will receive a $50 Amazon gift card. The following people participated in this
episode: Dr. Flavio Guzman as the general editor, Andy Rhode as the audio engineer,
Pamela Gonzalez as the project manager and myself, Dr. Wegdan Rashad as the host. We’d also like to thank Dr. Vivien Burt
for being with us. Thank you for joining us in today’s podcast
until the next episode, goodbye!

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