Maternal Use of Antidepressants
Dr. David Silver discusses treatment recommendations for depression and anxiety in pregnancy and postpartum.
Featuring:
Dr. Silver is Board-certified in Obstetrics & Gynecology, Gynecologic Oncology, and Psychiatry. Dr. Silver is a Gynecologic Psychiatrist with Women's Behavioral Health Specialists-UPMC. In his spare time, Dr. Silver enjoys spending time with his family and drawing, especially architectural drawing.
David Silver, MD, MBA
Dr. Silver completed a fellowship in Gyn Oncology at Roswell Park Cancer Institute in Buffalo and his ob-gyn residency at The Union Memorial Hospital in Baltimore. He earned his medical degree at Thomas Jefferson University’s Sydney Kimmel Medical College in Philadelphia. He completed a psychiatry residency at the University of Pennsylvania. To broaden his training, he also obtained a Master’s in Business Administration (Healthcare) at DeSales University in the Lehigh Valley.Dr. Silver is Board-certified in Obstetrics & Gynecology, Gynecologic Oncology, and Psychiatry. Dr. Silver is a Gynecologic Psychiatrist with Women's Behavioral Health Specialists-UPMC. In his spare time, Dr. Silver enjoys spending time with his family and drawing, especially architectural drawing.
Transcription:
Bill Klaproth: Everyone's mental health is important but when it comes to treatment recommendations for depression and anxiety in pregnancy and postpartum There are more questions to answer so here to help us answer those questions especially when it comes to maternal use of antidepressants is Dr. David Silver UPMC Women's Behavioral Health Specialist in Camp Hill PA. This is Healthier You, the podcast from UPMC in central Pennsylvania. I'm Bill Klaproth. Dr. Silver, thank you so much for your time. So, let's jump right into this. In general, how do treatment recommendations differ when depression or anxiety occurs in pregnancy or in the postpartum period?
David Silver, MD, MBA (Guest): Yeah. Interestingly in general, treatment recommendations are very similar. There's two broad types of treatment. There's either talk therapy or we call it psychotherapy and there's medication management.
Host: What should a patient expect if they choose psychotherapy or talk therapy if you will?
Dr. Silver: Yeah. So, I like to let my patients know that talk therapy or psychotherapy is not the same as talking to a friend or a loved one about your problems. It's a guided conversation with a trained therapist who can help to reframe some maybe irrational thoughts and feelings and help to improve the symptoms that patients are having. And also a therapist can provide skills in coping with the symptoms that patients are having. It requires repeated visits. So, it's not just a one or two time therapy session. It usually requires weekly visits up front. And then as patients feel better, the time interval spaces out a little bit over time.
Host: And then on the flip side, what should patients expect if they choose medication management?
Dr. Silver: So, what's interesting, and I think lot of patients come with preconceived notions about medication. When we think about medication for depressions and anxieties during pregnancy, we select medications that are safe both for the pregnancy, the patients, the newborn child, if they're breastfeeding and interestingly, most of the standard antidepressant medications, that those are known as SSRIs or SNRIs are safe in pregnancy and breastfeeding. So, we do have a fairly large selection of medications. They should be followed closely in pregnancy. The priority would be to maximize a single medication if possible, but if needed, we can combine medications also safely.
Host: So, then let's talk about a woman who is pregnant. Are there any risks to mom and or baby with using antidepressants during pregnancy?
Dr. Silver: Like any medication, we balance risks versus benefits, risks of treatment versus risk of not having treatment. And I think that's what's really the most important thing to consider in pregnancy is we know that symptoms of anxiety and depression are a high risk factor that affects pregnancies, that affects newborns, and affects children longterm. So, when mothers have symptoms, pregnancies and their children are affected significantly. We also know that many of the antidepressant medications have very few, if any side effects that are significant in pregnancy or in breastfeeding. So, on balance, the review of risks of taking versus risks of not taking certainly side with treating the symptoms.
Host: Okay, well, that is good news to hear. And then as we're trying to cover all ground here, what about a woman who is on antidepressants and then becomes pregnant? What changes should be made to their medication? And how do you determine what changes to recommend?
Dr. Silver: Yeah. So, thank you for asking that question. One of the biggest risk factors to depressive or anxious symptoms in pregnancy is the discontinuation of treatment that had kept the patient stable prior to pregnancy. People come to us frequently after either self-discontinuing their medication or even having their primary care providers suggesting they should stop their medication due to perceived risks in pregnancy, which are really not there. So, I think the main message is if you are stable on a medication, before you consider discontinuing that medication for pregnancy related reasons, talk to a psychiatrist that specializes in this type of patient population. Most patients can continue on with whatever they were taking prior.
Host: Really good advice because I'm sure that question comes up a lot and I'm sure women are wondering, gosh, what do I do in this situation? So, great advice, Dr. Silver, thank you for that. So, then how about toward the end of pregnancy, in preparation for delivery? Do medications need to be adjusted in that case? And what about if breastfeeding is planned?
Dr. Silver: There are some medications that you would consider increasing and decreasing dosing towards the end of pregnancy and postpartum. But those are few and far between. So, in most instances, a medication can remain at a stable dose throughout, keeping the patient intact with their symptoms of anxiety and depression, and protecting the pregnancy and the newborn the best. On those rare instances where patients are on medications that needed to be adjusted, they should be seeing somebody who specializes in this area so that those appropriate adjustments can be made. When we're considering what, when to adjust, generally it's about symptoms the patient herself is having or side effects. But in a rare instance, there are medication levels that we follow that may change towards the end of pregnancy and after delivery, that would trigger us to want to change the dose of the medicine.
Host: So, it sounds like the message is always consult with your physician before making any changes, because after an evaluation, it sounds like there might need to be an adjustment, but you don't want to do that on your own. Is that correct?
Dr. Silver: I think that's exactly right. And I think it's really good for patients and providers to understand that this area is really quite specialized and it has been an area where we have had a lack of understanding for a long time. This specific subspecialty now of maternal psychiatry, really addresses the lack of complete understanding of the OB GYNs about what is safe from a psychiatric standpoint and from the psychiatrist about what is safe in pregnancy. I would encourage people to seek out providers who really have a comfort level with this area.
Host: Yeah, such good points there. I think finally, in this country, we're starting to recognize mental health and trying to accept it and understand it better instead of just writing it off. You know, or people hiding it. It's really important that we talk about these things, especially when it comes to women who may be on medication or feeling depressed or anxious and becoming pregnant or being pregnant. So, I think this is really an important discussion. So, thank you so much for your time. We really appreciate it.
Dr. Silver: Thank you.
Host: That's Dr. David Silver. And for more information, please visit upmc.com. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier You, a podcast from UPMC. I'm Bill Klaproth. Thanks for listening.
Bill Klaproth: Everyone's mental health is important but when it comes to treatment recommendations for depression and anxiety in pregnancy and postpartum There are more questions to answer so here to help us answer those questions especially when it comes to maternal use of antidepressants is Dr. David Silver UPMC Women's Behavioral Health Specialist in Camp Hill PA. This is Healthier You, the podcast from UPMC in central Pennsylvania. I'm Bill Klaproth. Dr. Silver, thank you so much for your time. So, let's jump right into this. In general, how do treatment recommendations differ when depression or anxiety occurs in pregnancy or in the postpartum period?
David Silver, MD, MBA (Guest): Yeah. Interestingly in general, treatment recommendations are very similar. There's two broad types of treatment. There's either talk therapy or we call it psychotherapy and there's medication management.
Host: What should a patient expect if they choose psychotherapy or talk therapy if you will?
Dr. Silver: Yeah. So, I like to let my patients know that talk therapy or psychotherapy is not the same as talking to a friend or a loved one about your problems. It's a guided conversation with a trained therapist who can help to reframe some maybe irrational thoughts and feelings and help to improve the symptoms that patients are having. And also a therapist can provide skills in coping with the symptoms that patients are having. It requires repeated visits. So, it's not just a one or two time therapy session. It usually requires weekly visits up front. And then as patients feel better, the time interval spaces out a little bit over time.
Host: And then on the flip side, what should patients expect if they choose medication management?
Dr. Silver: So, what's interesting, and I think lot of patients come with preconceived notions about medication. When we think about medication for depressions and anxieties during pregnancy, we select medications that are safe both for the pregnancy, the patients, the newborn child, if they're breastfeeding and interestingly, most of the standard antidepressant medications, that those are known as SSRIs or SNRIs are safe in pregnancy and breastfeeding. So, we do have a fairly large selection of medications. They should be followed closely in pregnancy. The priority would be to maximize a single medication if possible, but if needed, we can combine medications also safely.
Host: So, then let's talk about a woman who is pregnant. Are there any risks to mom and or baby with using antidepressants during pregnancy?
Dr. Silver: Like any medication, we balance risks versus benefits, risks of treatment versus risk of not having treatment. And I think that's what's really the most important thing to consider in pregnancy is we know that symptoms of anxiety and depression are a high risk factor that affects pregnancies, that affects newborns, and affects children longterm. So, when mothers have symptoms, pregnancies and their children are affected significantly. We also know that many of the antidepressant medications have very few, if any side effects that are significant in pregnancy or in breastfeeding. So, on balance, the review of risks of taking versus risks of not taking certainly side with treating the symptoms.
Host: Okay, well, that is good news to hear. And then as we're trying to cover all ground here, what about a woman who is on antidepressants and then becomes pregnant? What changes should be made to their medication? And how do you determine what changes to recommend?
Dr. Silver: Yeah. So, thank you for asking that question. One of the biggest risk factors to depressive or anxious symptoms in pregnancy is the discontinuation of treatment that had kept the patient stable prior to pregnancy. People come to us frequently after either self-discontinuing their medication or even having their primary care providers suggesting they should stop their medication due to perceived risks in pregnancy, which are really not there. So, I think the main message is if you are stable on a medication, before you consider discontinuing that medication for pregnancy related reasons, talk to a psychiatrist that specializes in this type of patient population. Most patients can continue on with whatever they were taking prior.
Host: Really good advice because I'm sure that question comes up a lot and I'm sure women are wondering, gosh, what do I do in this situation? So, great advice, Dr. Silver, thank you for that. So, then how about toward the end of pregnancy, in preparation for delivery? Do medications need to be adjusted in that case? And what about if breastfeeding is planned?
Dr. Silver: There are some medications that you would consider increasing and decreasing dosing towards the end of pregnancy and postpartum. But those are few and far between. So, in most instances, a medication can remain at a stable dose throughout, keeping the patient intact with their symptoms of anxiety and depression, and protecting the pregnancy and the newborn the best. On those rare instances where patients are on medications that needed to be adjusted, they should be seeing somebody who specializes in this area so that those appropriate adjustments can be made. When we're considering what, when to adjust, generally it's about symptoms the patient herself is having or side effects. But in a rare instance, there are medication levels that we follow that may change towards the end of pregnancy and after delivery, that would trigger us to want to change the dose of the medicine.
Host: So, it sounds like the message is always consult with your physician before making any changes, because after an evaluation, it sounds like there might need to be an adjustment, but you don't want to do that on your own. Is that correct?
Dr. Silver: I think that's exactly right. And I think it's really good for patients and providers to understand that this area is really quite specialized and it has been an area where we have had a lack of understanding for a long time. This specific subspecialty now of maternal psychiatry, really addresses the lack of complete understanding of the OB GYNs about what is safe from a psychiatric standpoint and from the psychiatrist about what is safe in pregnancy. I would encourage people to seek out providers who really have a comfort level with this area.
Host: Yeah, such good points there. I think finally, in this country, we're starting to recognize mental health and trying to accept it and understand it better instead of just writing it off. You know, or people hiding it. It's really important that we talk about these things, especially when it comes to women who may be on medication or feeling depressed or anxious and becoming pregnant or being pregnant. So, I think this is really an important discussion. So, thank you so much for your time. We really appreciate it.
Dr. Silver: Thank you.
Host: That's Dr. David Silver. And for more information, please visit upmc.com. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier You, a podcast from UPMC. I'm Bill Klaproth. Thanks for listening.