Dr. Warner Huh (Host): Hello, everyone. It's Dr. Warner Huh, the Chair of the Department of Obstetrics and Gynecology at the University of Alabama School of Medicine, and I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh.

So, this month, we have two return guests. And I have with me, Dr. Rachel Fargason, who is the Senior Associate Director of Strategic Planning for the Department of Psychiatry here at UAB and is also the Patrick Linton Professor and Chief Quality Officer, as well as Katy Orr, who's one of our awesome Women's Health OB-GYN Nurse Practitioners who has a specific interest in perinatal health. For our listeners, you probably remember, we invited them to give us a primer on perinatal health. And if you listen to the podcast, which I strongly recommend that you do, we stated that we're going to do a part two of this. So, we wanted to make sure that we covered the fundamentals about perinatal health, but today is going to be more focused on interventions, further awareness, and that kind of thing.

So, super excited about the second part of the podcast. And I'd like to welcome Dr. Fargason and Katy back to the podcast.

Dr. Rachel Fargason: Thanks for having me back.

Katy Orr: Thank you so much.

Host: So, you guys did a great job, again, giving us that intro and primer on perinatal health. And I think it was eyeopening for a lot of our listeners. So, I'm just going to dive right into it. So, one of the things I wanted to ask you is how can partners or family members or even friends provide meaningful support to someone that's experiencing perinatal mental health challenges. I think you talked about what are the symptoms and signs of how to identify it, but how do we support individuals that have perinatal mental health challenges?

Katy Orr: Well, as we spoke about last time, very important to know how to recognize the risk factors for someone, who may be at risk for anxiety and depression while pregnant or after pregnancy in the postpartum time frame. I thought I'd just do a quick like run through of some of those again.

So, a few of the risk factors we want to watch out for as family members, significant others, or friends, if your person has a history of mental health conditions, if they're currently going through some financial stress or marital stress, if this is an unplanned or unwanted pregnancy, or if they've had a traumatic event during pregnancy or birth or something unexpected has happened and kind of thrown them for a whirl. These are some just common risk factors to be watching out for or just to know about. And then, again, some symptoms to be looking for that they may not recognize in themselves, they may be showing some lack of interest in things that they're normally interested in, like not interested in taking care of the baby as much as we would like. They may also be experiencing some anger or irritability, some hopelessness or guilt. Also, we'll see some disturbed eating and sleeping patterns.

So, I just wanted to do a quick run through of that before we get into how to support them. And that kind of leads us into like what to be looking for. So, really important for someone if you're seeing that they're struggling to sleep or they're wanting to sleep all the time, typically, it's the first thing. We're staying awake watching the baby making sure that baby's alive and breathing. And sometimes mom has a hard time just sleeping and resting. So, it's really important to prioritize that for your partner, your friend, daughter, sister, whoever that person may be to you.

And a lot of times I hear some support people say, you know, "I don't want to interfere. I don't want to overstep," and that's really kind and thoughtful. But sometimes, the mom, a lot of times actually in these situations, the mom will not know how to ask for help necessarily. And so, if you can be really creative and crafty and thinking about ways that you can lovingly approach them and say, "The baby's going to be fine. Let's take a nap." Hopefully, they'll listen and be able to do that or, you know, make a schedule of sleep throughout the night for that person as well.

Quality time, just time for self is super important. So, that's another thing that could be done. You know, take over cooking or doing the chores, paying the bills or whatever it may be for that person so that they can just go for a walk or have some time for reading or meditation or exercise. Exercise is so important. If they're physically cleared to exercise, if you can encourage them or do that with them, that would be huge. And then, one of the other things is just to know when to ask for help. If you've tried some of these things and you don't really see it going well, the friend or family member is not super easy to help or responsive, or they may be irritable with you that you're trying to do these things, or it's just not helping, it's important to know when to ask for help. And I've seen patients, support people ask for help from pediatricians, their primary care providers or their OB-GYN as well. Or if they're already in counseling or seeing a psychiatrist, of course, I would go to them for help. Lots of things that can be done for these patients as far as therapy, services, so support groups. And I think Dr. Fargason is going to get into this in a second, but helping them, going with them to a support group. Looking up how to get into one. We'll get into those resources later as well.

One thing I wanted to mention here before we move on is how important it is not to downplay someone who is struggling with their mental health. It's very important not to downplay their feelings or their experience, even though you may not understand it, it's still real to them. And so, it's just so helpful and important to validate them. Really good to tell them, you know, "I'm in this with you. You are not alone." We can get you to someone who can help you or be here with you along the way. It's always good for them to hear, you know, you're doing a great job. You're a great mom. So, those are some of the good things that they can do.

Host: So, I want to step back, kind of reframe why we're doing this podcast. And so, Katy, I think you brought up a really couple of good points. The main reason we're doing this is so that our listeners understand just how widespread and common perinatal health challenges are. And I think I have two kids. I remember this. We always know that having a newborn is super stressful. We're trying to help, but we're not trying to interfere. So, there's some boundary issues there.

But for me, one of the reasons I wanted to host this podcast was for the general public to understand that there's a difference between being tired and overwhelmed and then having a problem. I think this is like a stepwise educational process, particularly for the broader public, but for at least people to be aware of that, right? And I think sometimes intervening, and like you said, using your word, creatively, which is like the right way to look at it, is really important.

So, just for the listeners, again, just for people to be aware that, yes, we know that it's hard to separate these two, but to also realize that this may be a sign of a bigger challenge or issue. And I think you stated it perfectly, but I wanted to kind of summarize that in a more broader way to our listeners.

So, Dr. Fargason, let me ask you, I think that many of our audience is interested, like, what are the treatment options that are available for perinatal mental health and how effective they are? And I think you'll probably get into this, but normally, you know, we try to break down options into medical and non-medical, but I would love to hear your thoughts on what exactly is available for our patients.

Dr. Rachel Fargason: Well, we just heard a lot about just basic social and lifestyle changes we can add into our life. And the only thing I'll add to that is that people, when they are developing true psychiatric symptoms that, as you both say, are different than just feeling tired and stressed, but it's starting to be symptoms that the person can't control, that it really is important to try to remove as many stressors from their life as possible.

So, for example, if they're working two jobs, maybe it's time to go down to one job and cut our budget for a little bit or something like that. Taking time to do spiritual things. Whether that's mindful meditation or gratitude, using a diary to express gratitude or prayer, whatever that person's interest is can reduce anxiety and improvement. And then, there's really are some fantastic apps for sleep that people can use on their phone that make nice sounds or do meditation or mindfulness that are really helpful, and it's sort of like having your own therapist in the room.

So then, I'll jump into the psychological therapies. A lot of people aren't aware that there are some really amazing new psychological therapies that are known to be evidence-based and effective in pregnancy specifically. Many of these are called the third wave therapies. And the thing about these therapies is they're very brief, they're very engaging. The therapist is talking back and forth to you. They're not just sitting back and expecting you just to talk. And they can work very rapidly, sometimes in just a few sessions.

And I'll name some of them. There's the acceptance and commitment therapy, ACT therapy. There's DBT, which is dialectic behavioral therapy. There's mindfulness-based CBT, which is cognitive behavioral therapy. And then, there's all these specialized cognitive behavioral therapies. So, there's CBT-I, which is specific for insomnia and works on some of our distorted views about sleep and actually not liking our bed or being afraid to go to sleep. There's CBT-E if somebody has an eating disorder. There's self-compassion therapy, which is a particular favorite of mine, because it teaches you to be nice to yourself because we're all kind of very mean to ourselves. Sometimes we talk to ourselves in a way that we wouldn't talk to anybody else and it can work specifically on that. And then, trauma therapy.

And what I was going to say is, depending on where you live, you can't always find a therapist who can do some of these therapies right in your town. But in this day and age, you can go online and get some of these therapies. And even if you don't have a lot of money, you could just do a few of them and learn some good principles. So, that kind of covers therapeutic experiences. And those can often be a first-line treatment for mild to moderate psychiatric symptoms. But for more severe or chronic psychiatric symptoms, we probably are going to be moving into the biologic treatments like medication.

So first, I want to say that psychopharmacological agents are, in general, very effective for psychiatric conditions. And most psychopharmacologic agents are very safe in pregnancy. Now, the decision whether or not to use medication in therapy during pregnancy or when breastfeeding is going to be a very collaborative decision between the obstetrician and the psychiatrist or prescribing provider and the patient with a lot of risks and benefits discussed. And in a sense, there's no completely risk free decision because-- we'll get to this later-- there are some risks of untreated psychiatric conditions. But I will say this, that most psycho-pharmacologic agents are considered to be extremely safe in pregnancy. Some are safer than others, and there are some nuances with breastfeeding. My recommendation to people, if people are planning a pregnancy, is that they speak to their clinicians, speak to your obstetrician or your psychiatrist, and get as stable as possible. And what you're going to work on is you're going to work on a couple things. You're going to try to simplify your regimen and get it down to what we call monotherapy, which is taking only one medication whenever possible. You're going to try to reduce doses because the effect on the fetus is dose-related with most medications. And really, all women of childbearing age who are even contemplating becoming pregnant should consider getting on folate, and maybe higher doses of folate if they are on an anti-epileptic drug. In general, our recommendations are that, if a patient with a very chronic condition is on medications, we're usually going to recommend that they stay on them because it's very important that they stay stable.

Just to say something specifically, the serotonin reuptake inhibitors, the SSRIs, are one of the most commonly prescribed medications during pregnancy. And in general, they are not considered to be major teratogens. So if somebody gets pregnant and they're on an SSRI, don't panic. Call your doctors. Talk to them. But it's probably going to be okay. We have the second for bipolar disorder, very severe depressions and psychosis, there are the second generation antipsychotics, which are also considered overall very safe. There are some small risks that need to be discussed. And then, when necessary, and again, it's always a risk-benefit discussion, the risk of treatment versus the risk of no treatment. Even for ADHD, some people really do need to stay on their meds. some people with very severe insomnia may need some medications. There's a few studied in each of these categories that are considered safe.

And finally, I don't want to forget to mention substance use disorders. Those can be very risky both to the mother and to the unborn child, and there are several very safe and effective treatment options.

Katy Orr: And I'd like to just add on a couple things. The first thing, I love how, when I've been, working with Dr. Fargason in the past, the way that you put, trying to describe how important it is if you're on one kind of therapy. Like if you're taking medication, how important it is to also be working on some of those non-medical, non-medication therapeutic treatments as well.

And I think that you said the marriage of these two things works really well together. And so, I just want to reiterate that it's really important. You don't have to just do one if you are prescribed medication. Keep on doing the exercise and keep on doing the meditation or the prayer, giving yourself the self-love and the time that you need, because all of those things work together really well.

Dr. Rachel Fargason: Absolutely. All the studies show that joint treatment works better than any individual treatment.

Host: What I'm hearing from you is that they compliment one another and they should be used in conjunction, not either or, basically, right?

Katy Orr: Correct. Yes.

Host: That's awesome. So, could one of you just comment on what resources are available to our patients and their families and friends, you know, either general resources and/or resources that are specific to UAB Medicine. I'm pretty sure that our audience would like to know what they are.

Katy Orr: So first of all, we have recently started a perinatal mental health clinic over the past few years at UAB, as a part of the OB-GYN department. And this right now is offered to low-risk OB patients or postpartum patients and specifically is there for the management and treatment of anxiety and depression.

We have our patients who are maybe a little more high risk. They may have more complex mental health conditions such as ADHD or bipolar disorder. We have the UAB Psychiatry Department and they will be offering a clinic that has some spots specifically for these patients as well. So, ask your provider if you're interested in learning more about that. Also to address those with a current or past substance use disorder, we have the UAB Comprehensive Addiction in Pregnancy Program, and this program provides help for new or expecting mothers with substance use disorder history or current use.

Dr. Rachel Fargason: And I will add for the addiction treatment, there's a connection to Beacon Clinic, which is an addiction resource center, and they have fantastic group therapy groups that people really enjoy and feel connected to other people and accepted and not shamed. And so, there really are great resources out there.

Katy Orr: Some more international and national resources that you can look up on your own. One is Postpartum Support International. This is a huge organization that trains perinatal mental health providers. There's a certification that we get through that organization. They also have many, many, many support groups online. You can also look up a catalog of therapists and providers who are certified in perinatal mental health specifically in your area. That's a great resource to find. If you need to go online to find a therapist, that's a great resource to go to.

And then, if we're having questions or an emergent situation where you don't know who to call or who to go to, Alabama has a maternal mental health hotline. It's also national, but it's available in Alabama 24/7 to call. And I believe that we'll be able to list all of these resources on the show notes.

Host: Yeah. We'll get these websites and the links and we'll definitely post them in the show notes. And so, I'll get that from you guys after we talk. So, this question may eventually lead to another podcast down the road, because I think it's an important question and, you know, one that I don't know as much about, but what impact if any does a mother's mental health have on both infant and early childhood development? I would suspect that there's probably some linkage there, but I thought, you know, it'd be interesting for you all to comment on that.

Dr. Rachel Fargason: Allowing psychiatric symptoms that are significant to go untreated has some definite consequences on a growing infant and on maternal-child bonding after the baby is born. What is known, and there is still a lot to be known, but what is known at this point is that the risk is the risk of chronic stress in mild to moderate psychiatric conditions such as anxiety or depression. The risk is the risk of chronic stress. So chronic, even low level stress does have an effect on what we call the HPA axis, the hypothalamic-pituitary adrenal axis of the mother's brain, and can cause the release of stress hormones that can affect the placenta, which, as you know, what attaches the fetus to the mother, and cause dysregulation. And this can have two effects.

One effect is the stress hormones can stimulate early labor and lead to a preterm infant, which is not desirable. And second of all, they can decrease placental blood flow. And you can end up with a baby that's small for gestational age. The other kind of category of things that can happen is that an excessive release of stress hormones by the mother alters the programming of the fetal hypothalamic-pituitary axis. And down the road, there's some early evidence that this can lead to behavioral outcomes in the child. And most of what is being found right now is not affecting IQ, but is affecting what's called externalizing behaviors, be it acting out or temper, things like that. These are still in the very early childhood areas.

But I want to emphasize leaving very severe psychiatric conditions untreated is far more risky. First of all, a mother needs to be able to meaningfully interact with her baby for the baby to thrive and grow after the baby's born. So, treating the psychiatric condition is very important, but I just want to point out that psychiatric conditions have their own risk. Suicide is the 10th leading cause of death in all adults. There's risks of accidents in the car if people are emotional, they're not paying attention. There's a risk of substance use disorder. There's risks of accidental overdose. And when there's psychiatric conditions, there can be fighting and violent behaviors too.

One thing I really do want to emphasize is that people come and tell us that they don't want to take any medications, but they just want to take their CBD gummies, their cannabidiol gummies, because you can buy them in a gas station and they look like candy. So, they're safe, right? Well, that's not what the studies are showing.

What the studies are showing is that women who use regular doses of CBD, there are some outcome studies in the children, and they're showing that the children's brain size is smaller, has decreased connectivity, and there are also these externalizing behaviors that I just described. Not to mention that CBD can cause hypotension, vomiting, paranoia, and psychosis in the mother, none of which are desirable. And we have had people admitted to our hospital who'd never been psychotic before, who uses CBD.  

Host: I'm actually really glad that you mentioned that. it's becoming a progressively important topic, but I'm actually really happy that you mentioned, you know, your thoughts on CBD just because we're seeing a lot more of that, not just in the perinatal space, but all in women's health, actually really all of medicine for that matter. But I think that's really, really a fantastic point.

Any closing thoughts from you guys? This has been fantastic. Again, I'm so appreciative that you guys came back for part two of this. There's so much more to talk about, but what we'll do is we'll try to make sure that these resources are available on the show notes. There's so much more to be aware of this, but at least what's promising is that we do have treatment options, and then also resources as well. But going back to what I said in the very beginning, this is about level setting for the audience to make sure that they understand that this is a diagnosis that we have some options, but I think these earlier interventions are really important, particularly for the partner, the spouse, the family, friend that wants to provide support. And so, for me, that's equally as important as the medical interventions that we provide.

Dr. Rachel Fargason: I just want to second that thought. Do not ignore these symptoms, psychiatric symptoms. If they are caught early, they're much easier to get a handle on and get under control. If somebody's psychiatric condition is allowed to go on, they can really develop a lot of secondary problems, like with relationships in school and their job. So, we don't want that to happen.

And while on a related topic, people worry a lot about stigma. They say, 'Well, I don't want anything to do with any psychiatric treatment, because I don't want to be embarrassed." Well, first of all, I'm going to say, that in the northeast and on the west coast, the Gen Zers and the millennials all think it's cool to have a therapist and they're all talking about their therapist all the time.

But if you're a private person and we're here in the south and people are a little more private, I just want to remind you all that your confidentiality is going to be protected in a healthcare system. And one thing I always remind people I treat is that a treated psychiatric condition stays far more private than an untreated psychiatric condition. So, think about that.

Katy Orr: That is such a good point.

Host: That's a great, great point. I'm going to write that one down actually. Again, I'd like to thank Dr. Fargason and Ms. Katy Orr for participating in this podcast on perinatal health. It's really one of the best podcasts we've done, so I'm always deeply grateful that you guys participated in this.

And to our audience as always, please rate the podcast and we welcome any comments, particularly on topics that you all are interested in. And if you're interested in any of the women's health services as well as the mental health services here at UAB, check out uabmedicine.org. And until next time. We'll see you next month. Have a great day. Take care and peace out. Bye-bye.