In this podcast, Crystal T. Clark, MD, MSc, discusses the treatment of perinatal patients with mood disorders, including challenges clinicians face, pharmacological strategies, and nonpharmacological approaches. Dr. Clark was scheduled to present on the topic at the 2020 American Psychiatric Association Annual Meeting, which was not held because of the COVID-19 pandemic.
Dr. Clark is assistant professor of psychiatry and obstetrics and gynecology at the Northwestern Feinberg School of Medicine and Memorial Hospital in Chicago, Illinois, and current president of Marcé of North America, an organization focused on perinatal mental illness. She is board-certified in adult psychiatry with a specialty focus in mood and anxiety disorders. Her current research aims to improve dosing guidelines for pregnant women with bipolar disorder.
Read the transcript:
My name is Crystal Clark. I am an assistant professor of psychiatry and obstetrics and gynecology at Northwestern Feinberg School of Medicine and Memorial Hospital in Chicago, Illinois. There, I also am a researcher and the associate program director for our adult residency training program. Given that perinatal and reproductive psychiatry have been long‑term passions of mine, I am excited to share that this year, I am the Marcé of North America president, which is an organization focused on perinatal mental illness and women's families.
I chose to speak at the APA Annual Meeting on perinatal disorders and mood disorders, because this continues to be a very important topic even in our current pandemic. We are seeing the need for specialized or specific research related to the perinatal population, as it relates to not only just outcomes and what are best treatments, but also related to mental health and how to best care for women who are dealing with stress during pregnancy and postpartum or dealing with changes in emotions. Whether that's anxiety, whether it's triggered by something like a pandemic, whether it's a preexisting disorder that is now needing to be managed due to pregnancy and postpartum or now exacerbated as a result.
It's just not a topic that we have exhausted yet, and I don't think we ever will. Every year, I try to find ways to bring the latest information in my symposiums and talks around the country. I was really looking forward to doing that this year. Unfortunately, we are all sheltering in and social distancing, but I'm happy to have this opportunity to share with mental health professionals and anyone interested in this topic.
Risks and Risk Factors
The risks that are associated with mood disorders during and immediately after pregnancy are the risk for an onset of mental illness, so new-onset anxiety, depression, bipolar disorder—during pregnancy and postpartum—are the major risks.
Risk factors, there are many risk factors that are associated with having a worsening or onset of a new episode. Those risk factors during pregnancy and postpartum include having a history of a mental illness. Sometimes, there's a subthreshold, sometimes that people haven't appreciated. Sometimes, people have mild illness prior to pregnancy, and it gets exacerbated or recurs. Those are significant risk factors.
Postpartum, some of the risk factors include lack of support or a first‑degree relative, like a mom, who's had a postpartum depression, psychosis, or another mood episode. Also, risk factors might include if a person has had a prior illness that they've been treated for. Stopping treatment is a major risk factor for recurrence, especially in the postpartum period.
The unique challenges that clinicians face in treating patients with perinatal mood disorders is really the challenges related to research. What I mean by that is there's been tons of research thus far and medications, such as SSRIs, lithium, Lamictal, and other commonly used medications for women with depressive or bipolar mood disorders. These medications have not been researched in terms of randomized controlled trials. These have been observational studies, and we've learned definitely a lot from these studies. Our challenges continue to be that, without that randomized controlled trial, there's some guesses that we must take from the data that we're presented and that we do have.
The other thing that are unique challenges is trying to determine what's the most effective treatment for the mom, especially if the mom has a new onset illness, nothing prior to pregnancy, and is in the midst of pregnancy. What's the best medication to pick for that women so that you don't end up in a trial and error situation and exposing that mother and her unborn child to multiple medication trials? Those are some of the things that are still challenges for those in our field, particularly those of us who specialize in this.
Similarly, in the postpartum period, those who are breastfeeding. That continues to be a challenge for some women, and how to navigate and how to advise the woman, the best way to breastfeed while also getting enough sleep, which is not normal for any family with a newborn.
Trying to manage around getting enough sleep and enough self‑care that they can maintain a stable mood if they are interested in breastfeeding. Also, managing the medications and medication exposure to the newborn. We have lots of great data on SSRIs, but more limited data on mood stabilizers such as lithium.
Those continue to be some of our challenges that we face, and we continue to need more research, and definitely the ability to get more creative and do more randomized controlled trials on these patients who are already being treated, but we don't have the same type of data to back up our recommendations and guidelines.
A few things I recommend for, or strategies I recommend for, clinicians treating the perinatal population with mental illness is to, one, know your patient well as far as their course of illness prior to them coming to you.
Really exploring that, what's their risk factors? Have they been hospitalized? Have they attempted suicide? The things that we normally get to know about our patients. That is very important in this vulnerable period of time. Because that helps to inform—what's the risk of them coming off of their medication?
We know that discontinuation of medication for many perinatal women increases their risk of a mood episode recurrence, but you might still choose to support a woman's decision to not take medication if you know that her history of symptoms have been very mild, she's never been hospitalized, never had a suicide attempt.
Really, that's part of that risk‑benefit assessment. Completing the risk‑benefit assessment would be most important on managing these patients. Deciding whether or not continuation of medication is best for that women, and in many cases, it will be.
I would add that not being afraid to continue medication and to continue to treat that woman the best way possible, as you would treat them if they weren't pregnant. The caveat would be to stay away from medications that are teratogenic, which there aren't many, thankfully.
Depakote would be one of them, but our SSRIs are pretty well‑tolerated in pregnancy, and none of them are considered teratogens. It’s pretty common to continue a medication that a woman has been taking prior to her pregnancy throughout the pregnancy and postpartum, and not change that medication.
That would be my other recommendation. Don't reinvent the wheel in pregnancy. Continue was has best worked for that woman, again, unless it's a teratogenic drug, and monitoring. Just continuing to monitor more frequently during pregnancy and postpartum.
Often, I will meet women who are working with a psychiatrist or their PCP, and they're used to not seeing their doctor at baseline, prior to pregnancy, if they're doing well. They may not see their doctor for 6 months at a time. More commonly, maybe it's every 3 months. I recommend monitoring monthly for these patients. Definitely no longer than every 3 months to check in on symptoms that might be changing, given the changes in physiology of pregnancy.
We see increased metabolism of drugs, and that can lead to ineffective treatment, thus having a recurrence of symptoms. I definitely recommend to follow the patients more frequently so that that could be intervened on quickly if a patient is having a recurrence of symptoms.
It can be explored as to whether or not that's due to pregnancy, or is that due to their mental illness? The other thing is not being afraid to increase the dose if there is some worsening of symptoms, and it's not related to pregnancy independently.
Then being OK with bumping the dose, and doing that before adding another medication, which is another exposure to the baby. Those things are very important. People get scared about bumping the dose, especially if the person's at the max dose of their drug.
I just continue to remind them that the dose does not equate to what the baby is seeing in the mother's serum during pregnancy, because the concentration in the serum decreases. We have to bump the dose sometimes to get an adequate concentration to continue the therapeutic effect of the drug.
Nonpharmacological interventions that can be most useful for perinatal women with mood and anxiety disorders continues to be psychotherapy and determining the modality that's best for the patient.
It's very much individual, but cognitive behavioral therapy, behavioral activation, insight‑oriented therapy, all of those are great tools for the woman. Depending on her mood disorder or anxiety disorder, that can be tailored appropriately.
The other things I encourage, and that I just think is universal for any person, but definitely can help during this vulnerable time, is continuing to exercise, adequate nutrition, having a support system.
If they don't naturally have one, trying to help the patient find a community that can be supportive. Even if that means NAMI or DBSA or programs at their hospital for postpartum depression or new moms, all of those things are very important.
I can't say enough about combining psychotherapy and that being an effective nonpharmacological and tried and true option for patients during this vulnerable period of time.
The Psychiatry and Behavioral Health Learning Network is providing readers coverage of content that was scheduled to be presented at the APA’s 2020 Annual Meeting, which is not taking place because of the COVID-19 pandemic.