Now That I'm Pregnant, Should I Stop My Zoloft?

In this episode of the Woman Made Well podcast, Dr. Candice Wood discusses the critical topic of depression and anxiety during pregnancy. She emphasizes the importance of understanding the substantial risks to both mom and baby associated with untreated mental health issues. We also discuss the complexities of medically treating depression while pregnant. Dr. Wood outlines her approach to patient assessment, the safety of SSRIs, and the necessity of individualized care to ensure the best outcomes for both mothers and their babies.

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Transcript

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untreated anxiety and depression in pregnancy can result in changes to the fetal brain morphology. These changes have been shown to result in delays in babies' development, lower academic achievement, greater emotional reactivity, and emotional and behavioral problems that persist into adolescence. Welcome to the Woman Made Well podcast. Today we're talking about something that is my bread and butter. We're talking about depression and anxiety in pregnancy, whether we should be on medications, whether we shouldn't, what medications are safe, and how I go about talking about this with my patients. Most of you guys know I'm an obstetrician-gynecologist. I did my residency in that and practiced for 20 years and still am practicing as an obstetrician-gynecologist. But about eight years ago, I became very interested in maternal mental health. And six years ago, I went to my first psychiatry conference, which I remember like it was yesterday. Lee Cohen was the director of that conference. And he's the director of Mass General and Harvard's perinatal and reproductive psychiatry program. At that specific conference, he talked about when he told his dad after he'd finished his psychiatry residency what his specialty was going to be. He told his dad that he wanted to specialize in perinatal psychiatry. And his dad laughed and said, pregnancy is the happiest time in a woman's life. You're not going to have a job for very long. I thought this was pretty funny, as did most of the people in the audience who recognized that. Contrary to some people's believe pregnancy may be actually the entire opposite. It often is the hardest time in women's life and we know that depression and anxiety are often exacerbated during this time. So deciding what to do about depression and anxiety during pregnancy is obviously a very crucial and important decision. So the first thing that I like to talk about with my patients is that deciding how to treat with or without a medication for depression or anxiety is what I like to call a risk - risk situation. That means that there's risks if we don't treat the psychiatric illness, we don't let the mom have relief from her depression or anxiety, and there's also risks for the mom and the baby with treatment. So it's a risk risk situation and what we do as I work with patients is figure out how we can balance the risk and which risk is greater. So when we first look at the risk of maternal mental health on a pregnancy that's untreated, let's talk about that. There is data now showing that maternal stress and depression dysregulates the hypothalamic-pituitary-adrenal axis. Now this is fancy things in our brain that basically control our stress response. When this is dysregulated, the corticotropin releasing hormone gets elevated. This can stimulate labor and increase the risk of preterm birth in mothers with untreated anxiety and depression. The cortisol level is also elevated because of this, which can decrease placental blood flow, which can decrease birth weight. Those are some specific scientific things we know that happen when depression and anxiety are present in pregnancy. Now, if we focus specifically on the fetus, we know that during gestation, there's programming of the fetal hypothalamic-pituitary adrenal axis. And when it is exposed to abnormal levels due to maternal stress or depression, there is dysregulation. This can cause babies to have increased reactivity to that stress and vulnerability to mood and anxiety disorders later in life. It changes their fetal brain imprinting. And this is something we didn't know several years ago, but we do now know. So these specific findings are consistent with data that we have. We have data that shows that pregnant mothers with untreated psychiatric illnesses are less likely to get adequate prenatal care. They're more likely to have a preterm birth, low birth weight babies, preeclampsia, and infants admitted to the NICU after delivery. There's also new research showing that untreated anxiety and depression in pregnancy can result in changes to the fetal brain morphology. That's actually how the brain looks. And it's typically in the area that is most important for cognitive performance, social and emotional processing, and auditory language processing. These changes have been shown to result in delays in babies' development, lower academic achievement, greater emotional reactivity, and emotional and behavioral problems that persist into adolescence. So we clearly see that there are risks to mom for not treating and specific risks to baby for not treating. So how do I go about discussing this with patients? First, I like to make sure that they understand that it is a risk-risk situation and that together we're going to work out which risk is greater for them. The goal for every patient is euthymia, which means a pregnancy that is not overrun with depression or anxiety. And ideally, I would love to be able to talk to every mother before she was actually pregnant. This unfortunately doesn't happen all the time. I typically meet patients when they are pregnant and we're already discussing these things. They potentially are suffering from depression or anxiety that's new or they had it before and as soon as they found out they were pregnant and they went off their meds or they stayed on their meds and they didn't know whether there was a risk or not and we're trying to settle that. So ideally I'd love to meet patients before [pregnancy] so that we can talk about what we will do when they become pregnant and what would be safest. Here's the first step when I meet a patient. The first thing I like to do with my patients is figure out exactly how they're doing right now. Are they currently depressed or anxious? If they are, then we are going to know that there is something that needs to be done. If they aren't, are they on a medication or are they stable because things have changed in their life, but they have a history of depression before that they're concerned about. If they're doing well and they are on a medication, and they're not pregnant, we can talk about whether they would like to try to go off that medication in preparation for the pregnancy or not. I typically like patients to be at least stable on their medication for greater than six months. And we'd like to do a slow taper off and then make sure that they stay stable for around six months as well before I'd recommend that it's smart and safe to get pregnant If a patient is not doing well and on a medication, then we can talk about how we could change medical management so that we can make sure they are doing well. So the first thing I like to do is mainly just see how a patient is doing and what her current situation is. The second thing that's really important, maybe the patient's doing really well right now, but we really need to make sure that there aren't any history of severe episodes or how severe they've been. Have there ever been suicidal attempts? Have there ever been manic episodes? That's really important to plan for because if a patient is incredibly stable and off medications, it is really good for us to have a plan in place if she has had severe episodes before because there is a risk of relapse in pregnancy that is higher than during other time periods in life. So we would like to have a potential plan in mind for if that happens. Third, I always like to have a robust discussion of any meds that have been tried by the patient. Which ones worked, which ones didn't work, which ones had side effects. And it's important, and I want all of you out there to remember that it is so amazing for you and for your provider if you can keep track of the meds you've been on and how they've made you feel. It can keep us from wasting time. Most of you guys know these medications don't work overnight. And so often when we're trying to optimize something, can take four to eight weeks. And if we knew that it didn't work or we knew that it did, it can save us a lot of time. So remember what worked for you and maybe keep it in a diary, keep it somewhere on your phone. Next, it's important to discuss their living situation. Who do they have as support? What kind of situation are they in? Because what options do they have outside of medication to support them in their depression or anxiety? or through the possibility of worsening depression and anxiety if and when they do become pregnant if they aren't already. So knowing what kind of support they have. Do they have a partner who's actively going to support them through the pregnancy? Do they have family members? Do they have friends? Do they have a great job that they feel really good about? Do they have a church community? Therapy, are they going to a therapist? Do they exercise regularly? Do they do active meditations? Are they taking supplements? These things are all super important because it helps me know how motivated they are to pursue outside options other than medication. And maybe they're motivated, but they just don't have the support. So it's important for us to know that as we make this decision. And the last thing, of course, if a mom is pregnant and needing help or if she is looking into pregnancy but needing help. What medications do we choose? And that's really kind of what the focus of this talk is about. What meds are safe in pregnancy? It's the million dollar question. Which one's the safest, right? Well, typically and most importantly, the safest is the one that works. If I have a patient who's been on five different medications, And the one that works isn't one of my top three that I really believe has the most studies in pregnancy, but she has not done well on four other medications. Really, most psychiatrists, including Dr. Cohen from Mass General would say keep her on the medication that she's done well on. Your risk of relapse coming off medications or changing medications is five times higher in pregnancy than it is normally. So you're at high risk to have issues. So one of the most important things we think about when we're choosing the safest medication is what has worked for her in the past. If we have a choice, meaning she's not already on a medication, maybe she's naive to medications and has never tried one, then what medications are the safe, the safest? Which antidepressant and anti-anxiety medication would we choose? Most of you guys probably are aware that Selective serotonin reuptake inhibitors win by default because we have the most data about them. We know that the absolute risk to the pregnancy is small and there is no evidence of malformations and we have data with SSRIs as a full class of over 100,000 exposures and that is huge. I always talk to my patients when they're asking me about medication safety in pregnancy that we don't often have good studies for a lot of things because we in medicine love double-blinded studies, meaning a group of people sign up for a study, some of them get placebo, some of them get the real medication, nobody knows, everybody's trying and they get the results. There are very few pregnant women who volunteered to be in a double-blinded study. to take the risk of exposing their baby to something versus not. And so we don't have those robust studies. So to have over 100,000 exposures in this medication class is huge. So how do we talk specifically about medication safety? And how do I talk about SSRIs when I'm about starting a mother on this? Or if she's on another class of medications, how do we think about it? Well, I like to talk about it in the frame of four different things. We first of all consider the risk of teratogenesis, which is those congenital defects like the medication would cause the baby to have a cleft palate or a heart malformation. The second is, does it affect the pregnancy outcome? Am I going to have a preterm baby? Is it going to make me develop preeclampsia? Am I more at risk for gestational diabetes? Those would be complications in pregnancy. Next, it's neonatal symptoms. How does this affect my baby right after the baby's born? Are there withdrawal symptoms? And the last one, which is probably the hardest for us to get a lot of data on, is long-term symptoms. Meaning, does this affect my baby's ability to grow and mature their brain function throughout their lifetime? And we like to look at those risks compared to the risk of not treating the mom. So when we think about this in line with the SSRIs, which again are the most common meds, so the ones we're focusing on today, we want to know that the baseline risk for that first risk we're talking about, those congenital malformations, the baseline risk in the United States is between two and 5 % of pregnancies that they will have a congenital malformation. Now we're going to talk specifically about Zoloft or sertraline, which is probably the most common medication that your OBGYN would put you on or any PCP is going to put you on if you come in complaining of depression or anxiety and you are a female that is potentially in her childbearing years. And if they did this, it's a great choice because this specific medicine, we have over 20,000 studies specifically about sertraline. And we know with that, we have no increased risk of birth defects. Lexapro or escitalopram we have the same, almost the same amount of data, about 15,000 pregnancies, and also there is no risk, increased risk of birth defects. Prozac or fluoxetine, which is probably the next most common, We have at least 10,000 cases, and it also has been shown to have no congenital defects. As far as concerning pregnancy outcomes, some studies have shown some mild increase in preterm delivery or low birth weight babies, but this also is a known risk for untreated mood disorders. And so this result is kind of unclear. As far as neonatal outcomes, if you guys have read anything about these medications, you may have heard that there was a study that showed 1 % risk of persistent pulmonary hypertension. Pulmonary hypertension is high blood pressure in the vessels that are in your lungs, and this can make it very difficult for a baby to breathe. And so this is very important. This 1 % risk was a six-fold increase from the baseline risk for any baby, which is 0.2%. However, three studies since this study was released have found no association between the antidepressant use in pregnancy and persistent pulmonary hypertension. And one of these studies actually showed a lower risk. So we don't believe that this actually is a risk. However, the one known risk that we do know is called neonatal distress syndrome, which can affect a quarter of the patients that are exposed to SSRIs, including Zoloft, Lexapro, or Prozac. This is characterized by irritability, jitteriness, restlessness, problems eating or maintaining temperature. It's mild and will pass in hours to days without any medical intervention. As far as long-term development, which is the last of the four things I like to discuss with my moms concerning any medication that they start, Our data is limited. There is one study in four to five-year-olds that showed no difference in behavior. A larger study of 135 children followed for seven years who had been exposed specifically to fluoxetine showed no difference in IQ, temperament, behavior, reactivity, mood, distractibility, or activity level. So... with the data that we have, which is the most robust for the class of the SSRIs. we know that there is limited risks, no congenital defects, no real data showing any poor pregnancy outcomes. As far as neonatal outcomes, we have that understanding of a quarter patients being affected by that transient neonatal distress syndrome. And as far as long-term outcomes, we have good data, not a ton, to show no effect on the things that most parents would be concerned about, IQ, behavior, reactivity. etc. So this is why SSRIs are what we would say considered safe. But as we talked before, it is always a risk-risk decision. No decision is perfect. Our goal is to optimize the pregnancy outcomes of the mother and of her child. There are risks of not treating the disease and there are risks with the medication. Often I feel if the depression is mild and controllable, I like to focus on lifestyle changes, diet and exercise. I encourage therapy, which I do myself, or I send a patient to get regular therapy. If a patient is actively depressed, having symptoms, you know, more than three to four days a week or actively suffering from anxiety, I often do encourage medication. A lot of patients don't want to take a daily medication and they'd rather take a rescue medication. But often this is not what's best for you because those stress hormones, dysregulation of our hypothalamic pituitary axis is still getting offset and we're just chasing it. Where when we can do a daily medication, we can find ourselves euthymic and not have that disruption. People who are actively depressed have had relapses before, have had suicidal thoughts. Obviously the risk for them is greater than the potential risks of most of the medications, specifically the SSRIs. And so keeping them or starting them on medication is obviously something really important that we would want to do. But again, this is... obviously just glossing over this topic and the most important thing for you if you're a mom who is pregnant or you're a mom who's thinking about becoming pregnant and you have had any issues with depression or anxiety in the past or currently, it's important for you to get into your physician and work through this risk-risk discussion individually. I can't stress how individual this discussion is. What's right for one mom is not necessarily right for another mom. What options another mom has for support to help her through a pregnancy that may be stressful versus another mom who doesn't have that support is completely different. And so we have to weigh those options differently. The great thing is though, we are getting more and more data for our mothers to be able to make those educated decisions. And so this again was just glazing over because we only really talked about one subset of medications. But again, these are the most common. If you guys have any other specific questions about medication safety, you can shoot me an email. send a message to Instagram and we could talk specifically about specific studies. I never know how nitty-gritty you guys want to get into the science, but I love that too. But I hope this overall has given you a way to view this discussion that there are risks to the baby and the mom if we don't treat. There are risks with medication and what we're trying to do is shared decision making with each mom about which risk is greater so that we could have the best outcome for mom and the best outcome for baby. And if we can do well during pregnancy, that is the greatest indication that we will do well postpartum. so maintaining that euthymia during pregnancy is my best bet to keep my mom's healthy postpartum when they are taking care of that baby. And so it's important when we think about it from that perspective too. I hope this has been educational for you can let me know if you want more topics like this that are a little bit more scientific And I hope you guys have a great day and we'll see you guys again soon.