Fertility Forward
Fertility Forward
Ep 134: Mental Health Medication and Pregnancy with Dr. Marlee Medora
One of the most common topics facing doctors today is the issue of mental health medication and pregnancy. If you are a soon-to-be mother with a mental health condition, getting the right information may be an arduous and complicated task. So today, we’ve asked Dr. Marlee Medora to join us on the show and help us unpack safer ways of finding the right care for pregnant women with a mental illness. Dr. Medora is a Women’s Health Psychiatrist with her own private practice in New York and she begins our conversation by laying out three important tenets that govern how doctors treat pregnant patients who also have ailments to consider. Then, we discuss the dangers of starting a new medication or finishing a chronic course in and around pregnancy, why many women are still unaware of the options that are available to them, our guest’s process for assessing medicinal safety during pregnancy, and how patients can find the right doctors and resources for their particular plight. We also learn about the importance of dismantling stigmas relating to mental health and substance abuse and after taking a closer look at the infertility struggle and the value of self-care, we close with today’s moments of gratitude.
Hi everyone, we are Rena and Dara and welcome to Fertility Ford . We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Ford podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate. I am so excited to welcome to Fertility for today, Dr. Marley Madora . She is a women's mental health psychiatrist in New York City and an assistant professor of Obstetrics Gynecology Women's Health and Psychiatry at Montefiore Medical Center and also as a private practice in New York City. She received specialized training in reproductive psychiatry from the women's Mental health fellowship at Brigham and Women's Hospital, Harvard Medical School, and a clinical elective at the Motherhood Center. She focuses on promoting wellness during reproductive changes in life, transitions with psychotherapy and psycho-pharmacology and is licensed in New York, Massachusetts and New Hampshire. Thank you so much for taking the time to come on today. I'm so excited to have you on. I was connected to you through another RMA physician and so excited to have someone kind of in the family to talk about so many things that I know my patients struggle with and to be able to kind of cross collaborate in the mental health field. So thank you so much for coming on.
Speaker 2:I really appreciate the invitation. Here's a shout out to Dr. Kerry Bergen for putting us in touch and it's really nice to meet you in this type of way. I love podcasts and this is really an exciting opportunity.
Speaker 1:Yes, well when she did the intro I said this would be great if you could come on because something that we've had on before, but it was a while ago and I always like to refresh our episodes and new research comes out and to get new perspectives is specifically the topic of mental health, medication and pregnancy. So as an LCSW , I do not prescribe medication. I collaborate with people like you who do prescribe, but so many of my patients always ask me about medication and either going on it, coming off of it while trying to conceive while pregnant postpartum and it is such a hot topic. So I'm so happy to have you on to give your expert advice and guidance.
Speaker 2:Yeah, it's a great topic. We can jump right in. But you know, it's a complicated one that I think everyone struggles with and in some ways it's often the first parenting decision that one needs to make of are you going to take medications or not while you're trying to conceive while you're pregnant. So you know, it's not something to take lightly. I understand why a lot of your patients are approaching you with that question.
Speaker 1:Sure. So something I kind of always defer to when talking to patients is, well the mother's mental health is the most important. So kind of that guideline of well you should never try to conceive or be pregnant or postpartum if your mental health is going to suffer. So how can we keep your mental health good? Does that mean you stay on medication? Does it mean you do other sort of self-care things? But sort of that idea that you don't need to suffer nor should you to achieve your goal of having a child.
Speaker 2:You bring up so many good topics right there and there's a lot that we can really unpack in what you just said. And as a reproductive psychiatrist, what I share with all of my patients are these three key tenets and you really named one of them, which is healthy mom equals healthy baby. So we want a mom's mental health to be optimized because that is what is gonna make her the best mother for her baby and that matters, you know, that happy mom is going to have a positive impact on the development of her baby, whether it's during pregnancy or postpartum. So that is really important. The other one is, you know, do what works. Pregnancy isn't the time for experimentation because we really want to minimize exposures. So exposures we often think about medications . So you might think about like SSRIs, you might think about benzodiazepines such as like Ativan for anxiety or panic. So those are things of as exposures and anytime you are taking a medication, you know, that is an exposure. But we also think about the exposure of mental illness and that could be depression, anxiety, A DHD, substance use, you name it. And it's important to think about your exposures and decide, okay, how can I minimize the impact that this is gonna have on me and my baby? Do what works and not add a bunch of different exposures that you don't need to. For instance, say somebody has depression, they are on an SSRI, such as Prozac, they're doing really well, their depression's in remission, they feel completely, you know, their best selves before trying to conceive and they have this exposure of the Prozac and they did have depression, but right now that depression's in remission so they actually don't have that exposure anymore and they might ask, oh, can I get off my medication? And you know, that's a hard decision because if you take away that exposure of the Prozac, it might mean that that exposure of the depression, you know, it can no longer be in remission. You know they can have a relapse after discontinuing the medication and then you're actually having two different exposures. You're having uh , exposure to the medication and an exposure to the depression. So it's really important for people to, you know, think about it's not just the risk benefit of the medication, it's actually what are the risks of the medication and then what are the risks of the mental illness. And you know, that's something that like I can't say enough to all of my patients, you know, different providers who are asking because you know, we tend to only think about what you know sometimes like what we have control over and like whether we are gonna take a pill every day. But you know, there's so many things that like we aren't controlling and so many things that we don't think about and take for granted. And one of those things is like if a medication's working, that's great, you know, you're doing something positive actually for you and your baby.
Speaker 1:I love how you phrased it like that and termed it as exposure and sort of this looking at, well it's sort of this risk assessment, right? Okay, if I take away one variable, will that then increase another variable which may not be so positive, I guess I would ask. So it sounds like if you are someone that wants to think about, you know, being on an antidepressant or an anti-anxiety, it doesn't mean necessarily that you have to be on that the rest of your life, but it sounds like the time to think about either tapering down or getting off of that would not be while you're then introducing another variable such as pregnancy. So if you are someone that's on one and you wanna think about getting off of that before pregnancy, then you should do that well in advance, not at the same time.
Speaker 2:Exactly. That's another point that, you know, I always like to tell reproductive endocrinologists or obstetricians is, you know, I love to see patients in the preconception phase. That means while patients are still kind of on, whether it's long-acting contraception, still using condoms because that's the time that we can really optimize their mental health treatment with pharmacotherapy and psychotherapy to get them them to the best place possible before they're going into that like pregnancy or assist a reproductive technology journey. So yeah, I think when somebody is off contraception as well, because 50% of pregnancies are unplanned, I'm often thinking about okay, I'm gonna pretend this patient's pregnant right now . I'm gonna use what works, I'm gonna maximize monotherapy and I'm gonna try to make mom as well as possible without introducing a lot of other variables.
Speaker 1:That makes so much sense. Sorry, I wanted to get through this podcast without having to explain away my voice, but it sounds so bad so I'll acknowledge that It sounds terrible. I lost my voice and still trying to record this episode so I apologize to our listeners for
Speaker 2:The You're such a trooper <laugh> . Yeah , my
Speaker 1:Voice . Let's talk about maybe the classes of medication because I think it's important for people to understand that there are different classes of medication and that doesn't even just apply to mental health medications, it applies to anything you may see in a drug store as well that that some are safe during pregnancy and some are not. But it's the same too with the mental health family and that some are deemed safe for pregnancy and then some are not.
Speaker 2:I'm really glad that you bring up that point. And it's interesting because you know, after kinda doing this work for a while and having these conversations with hundreds of patients, I actually never say, oh this is safe during pregnancy because it's not that simple ever. It's really about what are the risks of the medications, what are the risks of your mental illness and how do you and I talk about that and make an informed decision about what feels right to you. And you also bring up kind of this idea of the FDA pregnancy categorizations and in 2014 the FDA actually got rid of that pregnancy categorization because it was confusing, you know, it was overly simplifying these, you know, very complex questions and it was making it even harder to communicate the risk of certain medications during pregnancy and lactation. So for instance, sometimes you might see, oh this medication is pregnancy category B and this medication is pregnancy category A, or sorry, usually we have like B and C that we're talking about for psychiatric medications and often you'll be like, oh, I might as well pick category B because you know, B is better, but really often category B just doesn't have as much research behind it doesn't have as much evidence for that kind of nuanced decision making . So I think if you're looking at those classes, you know, it's more nuanced than that. The FDA now has kind of taken back those letters and it's really important to, you know, talk about this because you know, women, they're often feeling ashamed, guilty about having mental illness, about being on medications when trying to conceive. And it's a really hard thing to go through. And I really recommend for patients to talk to their partners, talk to their friends family, talk to their obstetrician, their internist, their therapist and you know, we we're around, you know, look for a reproductive psychiatrist if you have a very nuanced question to ask and you know we're gonna make the recommendations by learning a lot about you and having an informed consent conversation about you. The other thing I wanted to mention is, you know, when thinking about what is like the risks of the illness, I think it's really important to do a , a very comprehensive evaluation of the symptomatology. And so for any patient who steps into my office, you know, I'm gonna ask them a lot of questions. <laugh> , they know that they're gonna be there for a long time. It's gonna be an intensive appointment, but we're gonna talk about their current symptomatology, past psychiatric history, past family psychiatric history, their experience with medications, their experience with non-pharmacologic treatments, like all different types of therapies if they've worked, if they haven't worked, obstetrical and medical conditions and also the patient's preference, like that's really important, the patient's preference, the partner's preference, and then putting it all together for you of, you know, how that kind of fits in line with your goals and then talking about the specific risks of the medication and then coming together of like what feels right for you during this journey.
Speaker 1:I love that you brought all that up. And that brings me to a question I was going to ask too, which is I always tell people, you know, and I always refer out and I say, if you can, you should see a reproductive psychiatrist because that is someone that knows what's safe or I guess we're not using the word sort of safe in pregnancy. I like that you sort of reframed that, but they're knowledgeable about what may be acceptable for you during pregnancy. Who do you recommend patients see in terms of practitioner, right? You know, you mentioned a lot of healthcare professionals then , you know, from OBS to internists and I always say, you know, if possible see a repro, a reproductive psychiatrist, what would you sort of recommend if that's not accessible? It's
Speaker 2:Not possible. Yes . So yeah, I'm in New York City and you know, New York City is a hub for mental health care , so there are a lot of reproductive psychiatrists, but you know, I was just in New Hampshire actually, and there I think are two reproductive psychiatrists and , and it makes it really hard to have these conversations with people. What I will say is that the reproductive psychiatry community wants to also train other psychiatrists, primary care doctors, obstetrics, pediatricians so that they can also have these conversations. And we know that there are not enough of us, so there's different like access lines for your provider to call a reproductive psychiatrist for a consult. You know, there's one in New York, there's one in Massachusetts called MCP for moms, which is incredible. And so there's different ways that you can bring a question to your doctor and then your doctor can find a very good answer for you and they can kind of be your doctor and work together with you while also having that expert opinion in their ear.
Speaker 1:Okay, that's super helpful. And it, so it sounds like this is another sort of field where it is important to advocate for yourself though, and it may involve really speaking up for yourself, asking questions, doing kind of a lot of the legwork or groundwork to make sure that you get to where you need to be.
Speaker 2:Yes. And also there's a lot of amazing resources for patients, for providers. So I was talking about providers, the access lines. Something else I wanna mention is this curriculum called the NCRP, the National Curriculum of Reproductive Psychiatry. So they have like amazing courses for kind of all different providers to learn more about this, but there are also other websites and a lot of them are more patient centric. So one of my favorites is Mother to Baby and this is a website where you can look up all different medications and it gives you this beautiful one page pamphlet , um, where you can kind of get summaries of this is the key data on this medication. So like this talks about the risks of the medications and they usually break it up into these really nice categories, which I also break it up to when I'm counseling patients and that is usually congenital like are there any congenital anomalies associated with this medication obstetrical. So that is usually if there is some like medical obstetrical issue that is more risky on a medication such as gestational diabetes, gestational hypertension, preeclampsia, things like that . Then there's neonatal, which is you know, the first, the beginning of life, you know, does the baby have an increased risk of being in the nicu? Will they maybe have something called postnatal adaptation syndrome? Are there certain kind of things that the baby, especially in like the first month, maybe even first year that you're gonna see. And then the other one is long-term developmental issues. So this is where the category of like autism, A DHD, those types of long-term neuro behavioral things get brought up. And so this website mother to baby, it usually can break the medication down, it can cite some of the major studies in that. And then it also talks about whether something is safe during conception, so like whether it influences fertility and also if it is safe during lactation. There are other websites especially that providers can use like LactMed Reprotox that talk a lot about lactation with medications. But I think Mother to Baby is like really amazing for patients.
Speaker 1:Okay, that sounds like a fabulous resource and we'll list that in the show notes and everything. I guess my only concern with sending people to the internet is that they then get sucked into this Google rabbit hole and their minds go to all places.
Speaker 2:Exactly. The Google rabbit hole is very dangerous. <laugh> .
Speaker 1:Yes . So I I
Speaker 2:<crosstalk> and that's why I love this website. You know, you just look up the medication, it's simplified, it's right there. I love it. And then if you know you want a little more information, the other favorite of mine is called women's mental health.org and that is um, the mass general , um, hospital kind of research center , um, for women's mental health. And they publish a lot of amazing articles about topics just like this. You know, they'll do like a roundup of the most recent literature and you know, this is for providers but also patients and it's just an amazing wealth of knowledge.
Speaker 1:Okay, fabulous. Well I'm excited to share these. I mean I think the other important thing to talk about is, you know, you sort of mentioned how important it is for patients to share with partners or family or friends and I think what is so prevalent with mental health in general and then you add in the nuance of trying to conceive or pregnancy with that is the stigma around it and that people are really afraid to share. Maybe they're afraid of judgment, maybe they're afraid that they'll be told, you know, you can't handle being a parent. So to really work to break down the barriers around the stigma and shame around mental health.
Speaker 2:Yeah, and I will say even within the past 10 years, you know, you do see a shift. I think it's interesting how when I was in medical school when into psychiatry was really unpopular. Like I had a emergency medicine doctor who told me, why are you doing that? When I said that I was applying into psychiatry, you know, a lot of physicians like didn't even like recognize it as a real medical specialty. And now there's just so much more like interest, so much more kind of value that is given to this really important field. And I think, you know, that's represented in like how we think about mental health providers but also like mental health generally. You know, we don't want patients to feel ashamed, we don't want it to influence their self-esteem. It's something that like really it's something that should be celebrated and you know, it's really hard to do that, but it's kind of all of us, you know, not just providers but also for patients to speak out about and you know, be an advocate for like, you know, how do we kind of change the cultural way that we think about these things , whether it's mental health, infertility, all of those things that like have a lot of shame attached to it because of our specific cultures. But it's important to kind of question that. Right,
Speaker 1:Absolutely. And I think something else you touched upon as well, sort of in the, you know, which is A-A-D-S-M diagnosis is substance use disorder. And I actually just finished um, a pretty intensive post-grad program on that. And so I've been thinking a lot about tying that into the infertility work that I do because I think that's another niche sector here that people really don't talk about and sort of, you know, those that present with substance use disorder and are trying to conceive or pregnant and how to manage that. Which again, that ties into mental health since A DSM diagnosis and the importance of really speaking out about that as well. You know, I find that people who struggle with any sort of DSM diagnosis, whether it's depression, anxiety, wherever you are there or substance use disorder, they just often they don't wanna share about it and maybe then they feel unworthy of trying to become a parent or being a parent. And I just hate that people feel that way and think that it's so important to get support if you are struggling with any of those things.
Speaker 2:Yeah, exactly. And I'm glad that you brought up substance use because that is so much tied to shame and you know, I've seen situations where, you know, patients don't talk about substance use that they're currently dealing with and you know, they have kind of a lot of different tests, evaluations for things to kind of help them conceive, but generally it's because they were so ashamed to bring up the substance use, you know, that was really the underlying issue. And you know, I think that you see that time and time again and just having that like open relationship with patients too so that they feel comfortable talking about it. You know, a lot of times when they first meet you, that's not gonna be the time that they're going to bring up something that they're ashamed of that they haven't told their family and friends it might take, you know, a few weeks, a few months, but it's really important to like put in the time to build the relationship, you know, for, you know, not just women with substance use disorders, but really all of our clients because you know, these things can be hard to talk about. There is kind of a long history of shame and guilt that goes along with being a patient with a mental health condition and that's something that we need to work really hard to kind of dispel in a way.
Speaker 1:Yeah, absolutely. And I think, you know, I've seen patients where it goes both sides, whether it's male or female struggling with substance abuse and both can have an impact on fertility. And so I think it's so important to start talking about this even more and encouraging people to be honest and knowing that they won't be shamed . It's just very valuable information to know to help with somebody's case and to help give them the supports that they need. And it doesn't mean that you're not worthy or deserving of family building.
Speaker 2:Yeah, exactly.
Speaker 1:So a lot of important topics before we wrap, is there anything else that you think is really important to share with our listeners? I don't wanna subject people to hearing my terrible Yeah,
Speaker 2:I think, you know, we were talking a lot about like mental health in general, but also just the concept of, you know, if you're struggling with infertility, like that is really hard. There are actually studies showing that the emotional distress from infertility is comparable to a cancer diagnosis. And that's the sounding
Speaker 1:Yes. I always throw that one out there the same as cancer. It's huge.
Speaker 2:It's huge. And in some way because of like that shame and guilt that we've been talking about, the reaction that patients can have to the diagnosis of infertility is sometimes the opposite to a cancer diagnosis with infertility. You know, they might shut down, they might not wanna talk about it, they might be really embarrassed because of kind of some of like those cultural views that we have in society and they can isolate. Whereas with cancer, you know, a lot of times like you'll, you'll talk to people, you'll say, oh I could, you know, really use a friend to come with me to chemotherapy, those types of things. But you know, just like those difference of someone turning inward versus someone turning outward. And I think with infertility we need to kind of work on creating kind of the language, the relationships to kind of learn how to turn outward to get the support we need. You know, whether it's struggling through infertility, through a miscarriage, postpartum depression, you know, it's really important to realize that it takes a village <laugh> , you know, to raise a baby. It takes a village to kind of overcome a lot of these difficult psychological issues that can happen during this period of time. And it's important to really never go th through these things alone.
Speaker 1:Absolutely. And I'm so glad you brought up that comparison because I think I use that one a lot too because I think that really resonates with people when I say, okay, infertility is the same levels of stress as cancer. If you had a friend or a colleague going through chemotherapy and radiation, would you expect them to be operating at the same capacity that they are now? No. You would say, how can I help you? Can I provide a meal for you? Can I take some work off your plate? You should rest. But unfortunately our society has not caught up to the understanding of infertility that we're at in terms of cancer. And so I think that so many of my patients struggle when they're going through treatment of trying to be the same person they were before. And it's so hard. And so I always say it's so important to give yourself grace, you know, again, and and back to that example of if you were going through cancer treatment, you would give yourself grace and try and make your life easier. People would understand. It's just our society hasn't caught up with that yet and it's so, so hard.
Speaker 2:That was so well put . <laugh> . Yeah, exactly. Calling
Speaker 1:My voice
Speaker 2:To really give ourselves grace and , and also like remember what brings us joy. You know, like keep doing the things you love. Keep kind of remembering. Okay, what's your menu of self-care I think is a really important thing to work on with all of my patients, especially perinatal patients. You know, things can get hard and like what are those easy things for that you can always reach? Is it listening to your favorite song? Is it going to get your favorite cookie? Is it kind of dancing by yourself, singing a bad tune in the shower, you know, whatever it's gonna be. But those things are really important to remember and you know, taking it easy on yourself.
Speaker 1:Absolutely. Menu of self-care. I love that.
Speaker 2:And the menu can be all food. That's okay.
Speaker 1:Oh that , yeah. What am I gonna order today? Is it a massage? Is it ice cream? Is it a manicure? I love that.
Speaker 2:Exactly.
Speaker 1:Well thank you so much for taking the time to be on . We'll have to do a part two when my voice can maintain a longer discussion. But you are such a wealth of information and I think this episode will be so helpful to so many people.
Speaker 2:I really appreciate the invitation and it was so lovely getting to know you a little bit and speak in this forum. And yeah, I hope to meet you in person sometime soon and I really wish you was Speedy Recovery and I hope that your voice gets better.
Speaker 1:Well, thank you so much and um, the way we like to wrap our episodes is with sharing something that we are grateful for. So something that you are grateful for today.
Speaker 2:I'm really grateful that I just moved back to New York City and today I was able to take my dog to the East River and play with her for 30 minutes and it was just really beautiful.
Speaker 1:Oh, I love that. That is just so simple and in the moment and pure. I love that so much. I'll say that I'm grateful for healthcare and I'm grateful for healthcare. I'll say right before we recorded, I tested positive for Covid, which is why my voice sounds so tense ,
Speaker 2:<laugh> .
Speaker 1:But I've been thinking about this as we've been talking and in this day and age, like I'm still up and working and my voice sounds bad, but I'm still busy. I'm able to show up, be and I'm so grateful for just healthcare, for, for letting this just be an annoyance and not a life stopper. So super grateful for healthcare and the ability to work from home, have telehealth because it really is a game changer. So really happy to be able to still be able to show up with you today.
Speaker 2:Yeah . Look how far we've come in almost three years, right?
Speaker 1:Yeah, it's really incredible. So to our listeners, I'm really sorry for my voice, but I'm really happy to be here and be able to share the information that Dr. Marley Madora presented to you and we'll share all of her contact information in the show notes. And thank you all for tuning in.
Speaker 2:Thank you again.
Speaker 3:Thank you so much for listening today. And always remember practice gratitude, give a little love to someone else and yourself. And remember you are not alone. Find us on Instagram at Fertility underscore forward . And if you're looking for more support, visit us@www.rmany.com and tune in next week for more fertility .