TCPR: Dr. Burt, you’ve spent much of your career in psychiatry treating women and teaching about reproductive psychiatry. How do you do your evaluation of pregnant or postpartum women who have psychiatric disorders?
Dr. Burt: Typically, when a patient calls to schedule an appointment, she’s been referred to us by an obstetrician, reproductive endocrinologist, internist, or psychiatrist. She may already be pregnant or hope to become pregnant or is postpartum and possibly breastfeeding. I spend time speaking with her on the phone to assess her current state of mental health and functioning, particularly her stability and safety. It’s now pretty widely recognized that pregnancy does not protect against mental illness, and the postpartum period is certainly a time of very high vulnerability for women, especially if they’ve had a history of psychiatric illness.
TCPR: What if a patient does not seem stable or safe?
Dr. Burt: If she appears to be unstable or unable to function, I will have her seek emergency psychiatric intervention, usually by going to an emergency room, and will not have her wait for an outpatient appointment.
TCPR: And if she seems stable, how do you proceed?
Dr. Burt: For women who are stable enough to wait for an appointment, I send them a detailed questionnaire so that I have a head start before the initial consultation, which is generally a 90-minute appointment. Some patients find it useful to consolidate their history in a way they’ve actually never done before. I have them describe everything from current symptoms, emotional state, and behavior functioning, to details about past psychiatric history; current health providers; current and past medications, both psychiatric and non-psychiatric, including over-the-counter and alternative agents; substance and alcohol abuse or use now and in the past; medical history; obstetrical history; and of course social and development history. Also, there is the well-validated Edinburgh Postnatal Depression Scale, a 10-item screening instrument widely used to screen for depression both in pregnancy and postpartum which patients can take themselves (Cox JL, Br J Psychiatry 1987;150:782–786).
TCPR: So if during your screening process you determine that a patient is high risk, what’s your best practice in terms of working with the referring doctor?
Dr. Burt: One of the things I do is provide patients and their health care providers (with the patient’s consent) a written copy of the final consultative report, which summarizes the patient’s clinical status as well as my recommendations. I also include relevant citations from the current literature that support my treatment recommendations. Referring clinicians are often worried about incurring liability for making such recommendations, so I feel that this is the best approach to address any of their medical/legal liability concerns. An important part of that report is a written case formulation. It puts together my understanding of the patient psychodynamically in terms of her psychiatric diagnosis so that my treatment recommendations reflect my best understanding of what will work for that particular patient.
TCPR: And then do you take over the treatment?
Dr. Burt: It depends on the situation. Some referring clinicians prefer that I follow and treat their patients through pregnancy and postpartum, and then refer them back after six to 12 months postpartum once everything is stable and the patient and her baby are doing well. Other times, we just provide that one-time consultation. Many clinicians feel very comfortable following our recommendations, and we are happy to provide clarification or additional consultations as needed.
TCPR: What’s your thought process like as you evaluate whether women wanting to become pregnant should be on antidepressants?
Dr. Burt: When I see patients who want to know the risks of antidepressants in pregnancy, I always start by addressing possible risks and benefits of not using antidepressants in pregnancy. The main risk, of course, is relapse. For example, let’s say I’m seeing a patient who is in her 20s or her early 30s. She’s been on antidepressants for a long time, and she’s stable. It’s reasonable for her to defer pregnancy for a while so that we can taper her off her medication, and we’ll follow her, say, for six months or so. If she continues to be fine off the antidepressant, then she can become pregnant without exposing the fetus to medication, which is the best approach, other things being equal. But if she relapses, I’ll generally recommend restarting the medication to keep her stable.
TCPR: What about the woman who is older and feels like the “clock is ticking” on her fertility? Do you make different recommendations?
Dr. Burt: Absolutely. If a patient is in her late 30s or maybe her early 40s, we don’t have as much time to wait to see if she’s stable off medication. Continuing the antidepressant she’s been on may be the wiser plan. No two cases are the same, and the best treatment approach is always individualized for a patient’s specific circumstance.
TCPR: That brings us to the crux of the matter, which is the risks of being on antidepressants during pregnancy. There are plenty of studies, and it can get pretty confusing. Can you summarize where we are with antidepressants right now and what are the things we need to think about?
Dr. Burt: Antidepressants in general may be associated with an increased risk for somewhat shorter gestation—about 3 days or so, certainly less than a week, which is generally not clinically significant. With regard to birth weight, antidepressants may be associated with a reduction in birth weight of about 75 grams, which is about 2–1/2 ounces or so, which, again, is generally not of clinical significance.
TCPR: What about SSRIs specifically?
Dr. Burt: As a group, serotonergic agents—whether we’re talking about SSRIs or SNRIs—are not considered major teratogens, certainly nowhere close to drugs like Accutane or thalidomide. If you do a literature search, individual articles suggest specific malformations with one SSRI or another. The problem is that most of these studies have flaws because ethically you can’t do the gold standard studies that would give us definitive answers. Specifically, we can’t do randomized controlled trials in which we assign pregnant women randomly to antidepressants vs. placebo. The potential risks to the fetus are too great.