Perinatal and postpartum mental health is a topic that has received growing attention over the last several years, but we still have a long ways to go in better detecting, diagnosing, and treating mood disorders in pregnancy and the postpartum period. Specifically, we need to raise more awareness, banish stigma, and create more resources for families and pregnant people. I was thrilled to talk to the wonderful Callie Dauler on The Upside Podcast about mental health in pregnancy and psychiatric medication. (Link to episode here!) It’s a topic I’ve wanted to post about for a long time, but knew the Instagram caption limit would not suffice.

Over on Instagram, I have posts on postpartum depression and anxiety and lots of re-shares of my favorite mental healthcare professionals in my “Mental Health” highlight. This post is going to talk about using psychiatric medications to treat mood disorders in pregnancy and postpartum.

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💙Mental Health Awareness Month: What your OB doctor wants you to know: . 💙 I want you to know to know that depression and anxiety symptoms can be postpartum AND during pregnancy. . 💙 I want you to know the symptoms. Common symptoms are feelings of guilt, shame, unworthiness of motherhood, anxiety with consuming worry, not sleeping well due to worry and unpleasant thoughts, not eating well, thoughts of hurting yourself, thoughts of hurting your baby. . 💙 I want you to know that it’s not your fault. Antenatal and postpartum depression are hormone-driven, biological processes. You have done nothing wrong, you are not to blame for feeling this way. . 💙 I want you to know that treatment is SAFE. There are many of ways to address depression and anxiety in pregnancy and postpartum, but a major treatment is medical therapy. Taking these medications while pregnant and breastfeeding IS SAFE and recommended. The healthiest pregnancies are those where the mental and physical health are at their best. Medication has low risks. . 💙 I want you to know to tell someone. I want you to tell ME. As your doctor, I care deeply about maternal mental health. I want to know how you’re doing and how you feel. If you can’t tell your doctor, tell your partner, a friend, a family member. Ask for help. . 💙I want you to know perinatal depression is comon. 1 in 8 women are have perinatal depression. Raising awareness will eliminate stigma and bring more women to treatment. . 💙 I missed Maternal Mental Health Awareness Day by a few days, but this topic was just too important to my heart not to post about. 💗🤰🏼🤱🏼 Mom, my inbox and heart are open to you anytime, even if I’m not your doctor. 💙

A post shared by Your best friend OB-GYN (@dr.martaperez) on May 4, 2019 at 5:06am PDT

Taking a psychiatric medication is a mainstay, along with counseling and therapy, of treatment of many mental health conditions including anxiety, depression, bipolar disorder, obsessive compulsive disorder, schizophrenia, and more. Psychiatric medication works in alleviating the suffering from mental health conditions. There are a variety of different classes and types of psychiatric medications, and most of them are acceptable and safe in pregnancy and breastfeeding. The few that are not safe can be identified by your mental healthcare provider or OB-GYN and usually substitutions to similar medications can be made before pregnancy.

The most common mental health conditions are generalized anxiety disorder and major depressive disorder. Both of these are typically treated with what is colloquially known as “antidepressant” medication – though they work for anxiety too. The most popular SSRI class – like citalopram (celexa), fluoxetine (prozac), sertraline (zoloft), etc. Many people take these medications before entering pregnancy to help manage their mood disorder. Other times, pregnant people may be diagnosed with a mood disorder for the first time during pregnancy. Of course, postpartum anxiety and depression can affect many who never have previously experienced mood disorder. I’m going to address some of the frequently asked questions about psychiatric medications and the reproductive journey. Don’t forget to listen to my podcast with Callie (linked here) for even more information and how wonderfully she shares her experiences, how she talked to her OB doctor about the treatment choice that was right for her, and why she chooses to stay on her medication.

“Should I stop my antidepressant when trying to conceive?”

First, congratulations on thinking about this before conceiving! It breaks my heart when I see patients for their first OB visit and they’ve stopped taking their medicine abruptly at a positive pregnancy test. Second, the answer is… it depends. Like I said above, most of the common medications are safe in pregnancy (see below), so I usually recommend staying on them. Problematic medications can be switched to other, safer medications. My blanket recommendation is to stay on your medication. But for women who who’s mood disorder was primarily exacerbated by a specific life situation or event that is now over and who want to try to stop it, working together we can monitor symptoms, understanding we may restart the medication if symptoms worsen. There are no harmful fertility effects of these medications, so they are safe to be on when trying to conceive as well.

“Is it safe for my baby to take my psychiatric medication while pregnant?”

A great way to think of this is a risk see-saw. On one side, we have the risks of medication to the fetus/infant and on the other side, we have the risks of inadequately treated mood disorder to both the maternal and fetal/infant health. The risks of untreated mood disorder are a bigger set of risks and have more potential harm than the risks of medication exposure. It’s healthier for the pregnant person AND the baby to opt for treatment.

Why? Because stress is a physical experience, and the stress of mental health does have real negative outcomes on a pregnancy, from trouble with ideal nutrition to preterm birth and low birth weight. If mental health is treated successfully with medication, these outcomes are avoided. Most research on psychiatric medication and pregnancy is with SSRI class and (with the exception of paroxetine, which does have small elevated risks of birth defects) the risks of neonatal withdrawal symptoms are small. They only happen a small percentage of the time and include some symptoms that last a few hours to a few days (poor tone, jitteriness) with no lasting negative impact seen yet in research studies.

I love this graphic and caption from my friend @womensmentalhealthdoc because it gets at a commonly felt misplaced emphasis on the risks of medication (which are minimal) instead of the risks of untreated mental health issues (which are bigger). Medication is safe and effective.

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When women come to see me, they are often scared that I might recommend antidepressants. I get it. It’s not an easy decision to take meds when you’re pregnant or nursing. But, what many women don’t know is that UNTREATED depression can have serious consequences for the baby, lasting well beyond childhood.⁣⁣ ⁣ This post lists some of the conditions that we worry about. One that I find very interesting is the higher levels of cortisol. Cortisol is a stress hormone, and is elevated in people with depression. Studies show that children who have mothers with untreated depression during pregnancy or postpartum have higher levels of cortisol than kids whose mothers do not have depression. Even more importantly, research shows that treatment of maternal depression during pregnancy can help normalize cortisol levels in infants. ⁣ ⁣⁣ Ultimately, the importance of this post is to show that it’s always a RISK versus RISK equation when deciding how to treat depression (or anxiety) in pregnancy or during breastfeeding.⁣ ⁣ Please follow @womensmentalhealthdoc for more women's mental health information!⁣⁣ ⁣⁣ All information here is for education. It is not medical advice.

A post shared by Pooja Lakshmin MD | Psychiatry (@womensmentalhealthdoc) on Jul 10, 2020 at 10:17am PDT

“My psychiatrist told me they do not treat pregnant women and would not refill my medication, what should I do?”

I’m pretty disappointed when I hear this, but I think it comes from a culture of malpractice litigation. This is called defensive medicine and can really hurt patients. As an OB-GYN, I feel completely comfortable managing most anxiety and depressive disorders in pregnancy and for those with a more complicated mental health history, usually have a list of psychiatrists and mental healthcare providers who not only feel comfortable, but specialize in the peripartum and postpartum period. Major shoutout to my friend Dr. Pooja Lakshmin who is a leader in this field and offers tons of resources on social media, visit her page here. All over the country, there is a growing focus on women’s reproductive mental health and I. AM. HERE. FOR. IT. Talk with your OB about if they know of any in your area or use google. Mental healthcare via telehealth can be a huge life-saver for many as it decreases barriers to access.

“What are the medications I should avoid when pregnant or breastfeeding?”

As I mentioned above, some medications are safer than others, and finding the safest medication in a way that controls mental health symptoms is ideal. The class of medications called benzodiazepines, which are sometimes used for acute anxiety (brand names like xanax, ativan, klonopin) are less preferred than SSRI’s for management of anxiety, both because they are less effective in treating anxiety symptoms and because there are some increased risks of neonatal withdrawal symptoms. Some anti-epileptic medications that are also used for some psychiatric conditions can cause birth defects, and there are safer ones within a similar medication class. Working with your mental healthcare provider and OB-GYN can optimize care before and during pregnancy to keep the balance weighted towards maximum maternal and fetal health.

“Will taking my antidepressant affect breastfeeding?”

Breastfeeding is healthy for the parent and the baby. These medications have not been shown to affect breastmilk supply. Many medications do cross into breastmilk, but their detection in the infant bloodstream is at very low levels that are unlikely to have any effect at all. Just like with pregnancy, there are a few medications (like lithium) where we may try to avoid infant exposure, so always talk with your physician to double check.

If you have more questions about mental healthcare and the reproductive journey, I’d love to hear them! This topic needs so much attention so we can reach those who feel isolated, lonely, or suffer in silence.

**All information is intended for general education and is not personal medical advice and does not replace the recommendations from your healthcare provider. Please always speak to your healthcare provider about your diagnostic and treatment plan before making any changes to it.**