Dr. Shari Lusskin joins Dr. Nathan Fox to discuss anxiety before and during pregnancy. Dr. Lusskin explains that a possible pregnancy (planned or unplanned) is something she always considers when first treating women for anxiety since certain medications are not safe for pregnant women. Fortunately, most anxiety and depression medications are safe to take during pregnancy. Even still, having a detailed pregnancy and birth plan with your mental health provider and OB-GYN can be incredibly helpful for many women, especially those with diagnosed anxiety whose symptoms might worsen during pregnancy.
“Anxiety: Before, During, and After Pregnancy” – with Dr. Shari Lusskin
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At “Helpful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Dr. Shari Lusskin, welcome back to the podcast. You were with us last week to talk about anxiety. Again, last week for our listeners, for you and me. Four seconds ago, it’s still your birthday. Thank you for coming on your birthday. Happy birthday. And we’re gonna talk about anxiety now specific to pregnancy. But before pregnancy, I wanna talk about pre-pregnancy because obviously, there are a lot of people who know they’re being treated for either an anxiety disorder, or some component of it, or a psychiatric disorder with the components of anxiety, and they’re seeing you as a patient, and they say to you, “I’m thinking of having kids, of trying to get pregnant. What do you think?” And so, how do you approach that with your patients preparing for a pregnancy for someone who’s under your care for anxiety?
Dr. Lusskin: That is something we approach right from the very beginning. So, as long as you’re treating somebody with a functioning uterus, there’s a possibility that they will get pregnant and it may not be planned. So, when I first see the patient, I wanna know, are they using contraception? By the way, big news in the contraception world. Right?
Dr. Fox: Yes. Yeah.
Dr. Lusskin: Well, I’m sure you can…
Dr. Fox: Over-the-counter.
Dr. Lusskin: Over-the-counter birth control pills.
Dr. Fox: Wonderful.
Dr. Lusskin: Very interesting. A good thing, generally speaking.
Dr. Fox: It makes a lot of sense. Considering what else you can get over the counter that’s a lot more dangerous than birth control pills, it would seem that this is wise.
Dr. Lusskin: Yeah. So let’s make a pitch for reproductive freedom and reproductive rights while we’re here. Okay? And the ability for people to access proper reproductive healthcare.
Dr. Fox: That would be wonderful.
Dr. Lusskin: Including the ability to determine when and if they get pregnant.
Dr. Fox: It would be delightful.
Dr. Lusskin: That would be very helpful.
Dr. Fox: One day, one day.
Dr. Lusskin: So anyhow, if you have… Let’s say you’re anxious, you go to a doctor, and a doctor diagnoses you as having an anxiety disorder, one that merits treatment. The treatment could be a few sessions of psychotherapy, depending on the nature of the problem, or it could be psychotherapy plus medication, or it could be just medication alone. Before you put that pill in your mouth, you should address the reproductive safety of that medication. What would happen if I got pregnant while taking this medicine, planned or unplanned? And we wanna make our choices accordingly.
So, to take most of the medicines that we use in psychiatry are safe for pregnancy if used correctly. There is one drug that everybody should know about that is not a good idea in pregnancy, if you can avoid it, and that’s valproic acid. It’s a drug used for epilepsy and it’s a drug used for bipolar disorder. Okay. Everything else can generally be used in pregnancy. Blanket statement, I can go over the data. But if it’s working and the patient is well, then you shouldn’t assume that you have to go off medicine. But really, pregnancy planning starts at the first visit. Very key. And if your healthcare provider hasn’t mentioned that, you can bring that up.
Dr. Fox: Yeah. Well, I think that’s a really important point and when you say the first visit, you mean the first mental health visit, not the first pregnancy visit.
Dr. Lusskin: No. Right.
Dr. Fox: Meaning pre-pregnancy planning. Yeah.
Dr. Lusskin: Right. The first visit with your mental healthcare provider.
Dr. Fox: Yeah, right. That we used to call doctors. Yeah.
Dr. Lusskin: Some of my best friends are doctors. Right. So, the first visit that you have with a psychiatric professional should include a discussion about the reproductive implications of your disorder and the reproductive safety of the treatment.
Dr. Fox: Yeah. And I think it’s important for a lot of reasons. Number one, obviously, am I taking something that I could continue to take if/when I get pregnant? And if the answer is yes, okay. And if the answer is no, then the question is, “All right. Do I plan on getting pregnant or how am I preventing myself from getting pregnant?” Meaning if it’s the right medication for you when you’re not pregnant, fine. It’s the right medication for you, but you need a plan. Okay. I need to either not get pregnant or, you know, figure that out, versus if it’s something you can get pregnant on. And then the same thing, if those discussions are had before pregnancy, it’s much more beneficial medically. But also, think about it. We’re treating anxiety, whereas if you got pregnant and you don’t know if the medication is safe, it’s gonna make your anxiety worse. Like, so if you’re prepared, it’s like, yeah.
Dr. Lusskin: So, what do your patients do in that situation?
Dr. Fox: So, they frequently just stop their medication.
Dr. Lusskin: And then what happens?
Dr. Fox: And that makes their anxiety worse. And then it’s a whole… Again, it’s a cascade of events. And so, when I see patients before pregnancy and I love seeing patients before pregnancy for whatever their questions are when it’s related to mental health. And usually with mental health, it’s the medications they’re on. It’s not specifically the mental health part of it, but it’s obviously all wrapped together. It’s so much better because they’ll know going into a pregnancy, “Yes, I spoke to someone. Hopefully he knows what the hell he’s talking about.” Right? “And we made a plan that because of A, B, C, and D, I’m gonna continue this medication exactly as is or before pregnancy, I’m gonna check with Dr. Lusskin if I need to increase my dose, decrease my dose, add a second medication, remove a second medication, whatever it might be. And then when I get pregnant, if/when I get pregnant, this is the plan. So there’s no additional anxiety and I’m not tinkering around the medications. At the same time, I’m nervous about being pregnant and miscarrying, and I’m nauseous, and this, and this.” It’s the safer way to go and it’s the more… Just from an experience perspective, it’s so much more secure for people and satisfying for people to have that plan in place.
So, I do that, but obviously, I don’t have any say over who comes and sees me before they get pregnant. And so, if you’re seeing someone who’s a mental health professional, talk about it with them. You don’t necessarily have to see me. You might, you might not. But if they know what they’re talking about, they’ll say, “All right, here’s our plan for when you get pregnant. I’m comfortable with this plan. This is what we’re gonna do and you do or don’t need to see Fox before you get pregnant.” And it’s the same thing. You enter pregnancy so much more confident or comfortable with the situation rather than like, “Holy shit, I’m pregnant. What do I do?” Like, that’s not a good situation to be in for people, especially those who have an underlying anxiety disorder.
Dr. Lusskin: So we said “last week,” we said that a little anxiety is good because it helps you prepare for a threatening situation potentially or an important situation. It helps you prepare. So this is an example of where a little anxiety about what you’re taking and what its impact on pregnancy would be helps you prepare by discussing it with your doctors. And by the way, I always like my patients to see you before they get pregnant because if they know who’s going to be taking care of them and they’ve met your team, you know, in one way, you know, to some extent…
Dr. Fox: An introduction. Yeah.
Dr. Lusskin: …it reduces their anxiety about the pregnancy. “Oh, I’ve met them. They’re like normal people who are bright and effective,” and all of those good things. And that makes them calmer. I mean, I think it’s better for you to meet them pre-pregnancy, better for me to meet them pre-pregnancy.
Dr. Fox: I love it. They might…
Dr. Lusskin: Doesn’t that reduce your anxiety?
Dr. Fox: It certainly… Yes. Yeah.
Dr. Lusskin: Yeah, exactly.
Dr. Fox: Yeah. Same thing, when I see someone and they’re coming to me, and they’re already pregnant, and then they start telling me all their medical problems and all the medications around, and this or this, I’m like, “Oh, man, I wish we could have planned this beforehand.” Again, it’s not… Usually it works out either way, but it’s just, I’m like, “Oh, this is gonna be a lot of stuff for her to start tinkering around with and she’s already dealing with pregnancy.” I just had a conversation with someone, literally two hours ago. I was meeting with a patient and she said, “Do I need to pick my pediatrician before the baby is born?” I said, “Well, you don’t need to, but you should.” And they’re like, “Well, why?” I said, “Because you don’t wanna start looking through, you know, websites and, you know, calling doctors, and trying to figure out who’s good, and who’s not, and who lives near me, and who takes my insurance after you’ve had a baby. Because then you’re not sleeping, you’re in pain, you’re trying to nurse. You got this crying baby. You got people visiting you. You’re dealing with all this stuff.”
Dr. Lusskin: You’re making me really nervous. I mean, you’re telling everybody about all the bad things, but it’s beautiful to have a young infant.
Dr. Fox: No, it’s… Sure. But it’s…
Dr. Lusskin: It shouldn’t make you anxious at all just because you have no idea what you’re doing.
Dr. Fox: Oh, yeah. Well, no. Yeah, absolutely.
Dr. Lusskin: Why would that make you anxious, right?
Dr. Fox: Yeah. But I’m like, that’s not the time to start deciding, “What doctor am I gonna see or is the baby gonna see?” Like, you can make that decision while you’re pregnant. And so, you just… All you need to bring with you to the hospital is their phone number or put it in your phone, and then you’re done. Like, you’ve sort of pre-planned that.
Dr. Lusskin: I have to say, based on what you just said, I have to interject something maybe a little ahead of time. When anxious patients come in with a birth plan, it’s the end of pregnancy. They come in with four single-space typewritten pages of how they want their birth experience to go.
Dr. Fox: Right. They bring that to you?
Dr. Lusskin: They bring it to me. I’m sure they bring it to you.
Dr. Fox: I definitely see them. Yeah.
Dr. Lusskin: And I metaphorically ripped those pieces of paper in half and say, “Here’s our birth plan. You come out alive and healthy, and the baby comes out alive and healthy.” And the rest is commentary because they’re very anxious. And when you’re too anxious and you try to micromanage a situation that’s not in your control, because you’re not in charge of the team, you’re not in charge of the hospital, I mean, it’s just impossible for you to control all of that, it increases the possibility that things will not go the way you want them to go. Because you’re focusing on something that’s really not essential and you may distract somebody from doing what they’re supposed to be doing. Now, of course, it’s our job as the doctors to stay focused on the essentials. But you don’t wanna kind of distract people if you don’t have to.
Dr. Fox: It’s so interesting. I never thought of… I mean, obviously, I’ve thought a lot about birth plans and we had a podcast on it, and we spoke a lot about it, and how that they’re not conceptually a bad thing and people share preferences and talk about it. But it’s mostly… The solution ultimately was it’s not about the plan on paper. It’s about a conversation with your doctor, your midwife in advance, you know, “Is this the type of person who I could trust to make good decisions? Here’s how I…” You know, “Do I want an epidural? Do I not want an epidural? These are sort of how I want it to go. Is that doable? Is it not doable? Is it safe? Is it not?” It’s the conversation. We didn’t really focus on the subset of people with birth plans who it’s sort of their treatment, their sedative, you know, for an anxiety disorder, right? Because having a birth plan does not mean you have anxiety disorder. I’m just saying that for the record. But for those who have a birth plan and it is their way to treat their anxiety disorder, it’s the same sort of solution that it’s a conversation in advance, it’s preparation, it’s talking about it, it’s knowing about these things.
So it’s interesting. Like, that’s why it would work better. But I agree that if someone is hanging on to that paper as like, this is how I’m gonna treat my anxiety over labor, it’s not gonna work because shit happens. I mean, things go left, things go right. And for most people with the birth plan, they get that. Like, my plan is this is what I want. But if things go awry, all right, we have to adjust and we adapt, and we figure it out. We do it safe and right. And that’s a very healthy way to approach a labor. But if it’s like, “This is how it has to go,” or, “I’m gonna decompensate,” that’s an unhealthy way and it’s just a manifestation of a problem. It’s not a birth plan, it’s a problem. Yeah.
Dr. Lusskin: I will encourage the patient to talk with the OB about the plan in general.
Dr. Fox: Right. And well, like I said, maybe change the dose a little bit.
Dr. Lusskin: Like you said, epidural or C-section. But, you know, I think if somebody says, “I am not having a C-section no matter what,” it really puts…
Dr. Fox: Right. Well, it’s… Yeah.
Dr. Lusskin: It traps them because very often… Forget the high rates of C-sections. There are legitimate medical reasons for having a C-section.
Dr. Fox: Sure. Right.
Dr. Lusskin: But if you put yourself in this box that you’re not having a C-section, you’re having a vaginal birth no matter what, you really can interfere with your medical care. And so, I think it’s important for patients to understand that their general wishes need to be respected. And of course, you wanna make sure the staff is listening to the patient and respectful of the patient. But as long as they understand, that part of the process is unpredictable and therefore you need to be flexible. It will reduce their anxiety in general and it will improve their experience of labor and delivery even when things go sideways. And you have to have a lot more interventions than you expected. So it’s, you know, part of the anxiety management in pregnancy. But I always laugh, when they come in I’m like, “Oh my God, how nice would it be if we could actually follow this plan if nothing happened?”
Dr. Fox: It would be great.
Dr. Lusskin: It would be great.
Dr. Fox: The medications that are typically used for anxiety, I mean, the most common ones we see are some form of an SSRI, right? So whether that’s, whatever, Zoloft or whether it’s Prozac, or whatever they’re on. Just like we spoke about in our podcast related to depression, there may be slight risk. May, probably not. And if so, it’s very, very, very low, which is what all the data says, probably zero. But ultimately you’re balancing taking a medication that you can’t study perfectly versus being well. And pretty much for everybody, we choose to be well. Right?
Dr. Lusskin: Right. Well, I think it’s taking medication versus being unwell. Yeah.
Dr. Fox: Exactly. You’re right. So again, and I think what I probably said then, what I typically tell people was every now and again I come across someone who’s on one of these medications that probably don’t need to be on it, probably never needed to be on it, it was started for some strange reason, fine, that’s the person who may go off it before pregnancy or during pregnancy. But the majority of people who have an issue, have a disorder, they have something that makes them from unwell to well, it is not a good idea to start stopping that medication because they’re gonna be unwell. And that’s generally how it goes. So, it’s the same medications.
The one medication that is more common with people with anxiety disorders compared to depression which I get asked about a lot, are benzos. So they take Xanax, for example. They take Klonopin, whatever it is, either to help them sleep, to help them get through the day, to help them get through a busy day, a bad day. They take it as needed. And I have people who come to me and say, “My doctor said I have to stop this, that this is horribly dangerous for my baby. And now I can’t sleep anymore, I can’t function.” What is your take on benzos? I could tell you my take, but I wanna hear yours first because yours will be better. I wanna make sure I’m not wrong.
Dr. Lusskin: So, benzos are benzodiazepines. These are drugs that work on the benzodiazepine receptor which by the way, is the same place that alcohol works. So, these are drugs that lead to relaxation. They’re called sedative hypnotics. So they will calm you and if you take enough of them, they’ll put you to sleep. The problem with the benzodiazepines is not that they cause birth defects or that they cause severe pregnancy effects. The problem is for the mother that you can have tolerance and withdrawal. So you need higher doses. If you’re on high doses of benzodiazepines, there seems to be a higher risk that the baby might have some neonatal complications, jitteriness, tremulousness, breathing or feeding difficulties, sleep disturbances which may reflect withdrawal in the baby. If I see somebody who comes in with a chronic benzodiazepine prescription or they’re using benzodiazepines on a daily basis for a long period of time, it’s very difficult to take them off it during pregnancy because you usually need a long time to get them off the medication safely. But it really illustrates the point that no medications is safe if it’s the wrong drug for the wrong condition used in the wrong way.
The drug in and of itself, this class of medications in and of itself is not something that can’t be used in pregnancy. So the drugs would be Valium which is Diazepam, Xanax which is Alprazolam, Klonopin which is Clonazepam, and Lorazepam or Ativan. Those are the drugs we see most commonly. But if they work and they’re used properly, then we continue them.
Dr. Fox: Yeah. All right, good. I’ll say the same thing. Gosh. Thank God. All right. That would have been bad. And I think that sometimes it comes about from not even older data, but older recommendations where I think some of it was like, people who in the 70s were, like, abusing Valium at the same time as cocaine or something, and it got mixed together. You know, but it’s not… Like you said, that’s not how it’s supposed to be used. That’s not the relevant, you know, comparison. But someone who takes it as needed for sleep or they take it as needed on a certain day, or even like you said, it’s someone who that’s what they need to get through a day, that’s part of their medication, it really hasn’t been shown to increase the risk of birth defects. And there’s a lot of data, a lot of people use it. So it’s not like these are rare medications. And also, I would say that in terms of the withdrawal side, the data is actually pretty reassuring that it’s a pretty low risk of withdrawal in the neonate compared to something like narcotics. Like, if someone’s on methadone or if someone’s on, you know, long-standing codeine or whatever it is, there’s a much higher chance of the new born having withdrawal symptoms after birth and it’s treatable. Like, they give the baby, you know, methadone also for X amount of weeks and ultimately it’s okay if it’s treated. And so, we do have people who have to take chronic, you know, narcotics or methadone, and that’s okay. We can work with that and it’s fine. But it’s less so with these medications. The risk of that for babies tends to be less. And so, I think people overestimate the risk of these medications specifically compared to the reality.
Dr. Lusskin: Yeah. I’d say a lot of clinicians overestimate the risk because this class of medicines was associated with cleft lip and palate abnormalities which is a split in the lip or the hard palate in the mouth. And that association was never shown to be a true causal relationship where taking the drug caused that relatively common type of birth defect compared to some which are much more rare. The other complication we worry about at the time of delivery would be sedation in the neonate. It’s surprisingly uncommon. Now, I’ve had…
Dr. Fox: Yes, it’s very uncommon.
Dr. Lusskin: One patient comes to mind who was on 3 milligrams of Klonopin…
Dr. Fox: That’s a lot.
Dr. Lusskin: …plus a very high dose of Quetiapine, of Seroquel, very complicated bipolar disorder, came to me on the cocktail. And there was no way, there was just no way to get her onto a lower dose of medicine. We were kind of stuck with it. If she come to me a year before she got pregnant, that would have been different. But we were stuck. And that baby came out kicking and screaming, and, you know, asking for a bottle. Basically, it was like, “No problem.” So, maybe you could answer this question for our listeners. How common are neonatal complications in general like, the transient neonatal complications? Before you answer, I want you to answer that because my medicines are always blamed for it.
Dr. Fox: Yes. Well, no, it’s easy if we could blame someone else.
Dr. Lusskin: It works for me all the time.
Dr. Fox: So, it depends on the complication. Like, for example, what’s the chance my baby is gonna go to the NICU? Right? Something like that. Because that’s, like, practical for parents. The biggest predictor of that is the gestational age at delivery. So, you know, at 37 weeks, give or take, 10% of those babies will go to the NICU, plus 8% to 10% under 37 weeks, it’s higher. Right? If you’re 28 weeks, it’s 100% and whatever. Over 37 weeks, fine. At 38 weeks, let’s say it’s about… I’m not a neonatologist, but these are approximate numbers. Let’s say it’s, you know, 5% to 6%, and at 39 plus weeks, it’s let’s say 2%, and it’s sort of stable. Okay. So those are the rates. What is the chance my baby is gonna have a complication that seems to be something that could be from a medication like the baby is too sleepy or the baby is too jittery? Like, those are the two things. Like, too sedated, not sedated enough. Right? Those types of things. It’s very low. The chance that the babies go to the NICU for those things is very low for everybody.
The main reason babies go to NICU at full term, again, is either because there’s a concern about an infection in the baby like a mom had a fever at labor and this or that, or the baby is not breathing well, or sort of working hard to breathe. That’s not jittery, that’s not sleepy. Like, they see them working hard to breathe and that’s a concern. Those are the top reasons. Or maybe low blood sugar, but also not related. So, I would say very, very low in terms of things that could be related to a psychiatric medication. And so, it’s…
Dr. Lusskin: Well, are they related to the psychiatric medication? That’s what I’m saying. I can…
Dr. Fox: As far as we know, no.
Dr. Lusskin: Exactly, exactly.
Dr. Fox: Yeah. So now, I’m gonna say… Yeah. Of that 10%, minuscule would be for something like baby is too jittery, baby is too sleepy. It’s not the types of things that babies typically get admitted to the NICU for.
Dr. Lusskin: So the point is there are complications at the time of delivery. But when a woman is taking a psychotropic medication,…
Dr. Fox: Very unlikely that’d be the cause.
Dr. Lusskin: …the knee-jerk relation, the knee-jerk reaction on the part of the doctors is to attribute it to the psychiatric medication.
Dr. Fox: Absolutely.
Dr. Lusskin: Even though…
Dr. Fox: Because otherwise they’ll attribute it to us, to the doctor. “You did a bad job.” No. The vast majority of reasons baby goes to NICU has nothing to do with the medication the mom was on or the doctor. It’s usually just how the baby’s breathing status. And again, most of the babies who go to the NICU, again at full term, it’s just for to be cautious. Meaning if they somehow didn’t go to the NICU and they went to regular nursery, the vast majority of the babies would just be fine, right?
Dr. Lusskin: Right. But we have a NICU, so we use it. Right?
Dr. Fox: Because most of the kids go… Again, the kids who go to the NICU at 37, 38 to 39 weeks, frequently they’re there just to be observed in a closer setting. It doesn’t mean there’s actually anything wrong or anything’s happening. They’re like, “We’ll watch you a little closer.” And that happens a lot. So, yeah, the class of medications where we are concerned about the effects of the baby right after birth is really, really concentrated on, like, narcotics because that is, yeah, that’s is well known.
Dr. Lusskin: Yeah. If you’re addicted to narcotics, they’re rapidly metabolized.
Dr. Fox: Sure.
Dr. Lusskin: So that means the amount that’s in the baby’s bloodstream is cleared very quickly so the baby can have withdrawal symptoms.
Dr. Fox: Yeah. So, yeah, and that’s well known, but treatable.
Dr. Lusskin: And well known. And totally treatable.
Dr. Fox: You know, well known and we know in advance. These are people who we tell them like, “All right, you’re on methadone because you’ve had an addiction. This is how you’re treating, this how you’re well. Stay on it.” Like, “We don’t want you to break your vision, but just know that we’re gonna meet neonatologists. After birth the baby is gonna go to the NICU and they’re gonna start the baby on a low dose of methadone, and slowly, over time, decrease it so the baby doesn’t have withdrawal, and then the baby should be fine.” And that is true because we know about it in advance. That is really the only situation where again, I don’t wanna say concerned because we know about it and it’s treatable, but where we sort of predict that the baby is gonna have some sort of withdrawal. We don’t predict that with your SSRIs. You don’t predict that with your benzos. It’s very, very uncommon that that is actually something that comes to fruition in the baby. Almost never. And there’s tremendous long-term data on the babies in terms of, like, neurodevelopment, neurocognitive development.
Dr. Lusskin: Correct.
Dr. Fox: And so, it’s really just that hypothetical concern of, “Oh, I’m taking medication early in pregnancy.” Studies aren’t perfect. You can’t know 1,000%. No, you can’t know 1,000% anything. But I also know it’s not good to be unwell, and it’s not good to not sleep, and it’s not good to have bad nutrition and not exercise, and avoid your life because you’re not well. That’s also bad. And so, it’s always these balances. And that’s why it’s a conversation when someone knows what they’re talking about.
Dr. Lusskin: Yeah. And what’s so important about your podcast is how…
Dr. Fox: Oh. Here we go again.
Dr. Lusskin: Oh, I know, I know, I know.
Dr. Fox: God bless you. This is why we invite you back. It’s not because the listeners like you. It’s because I like you.
Dr. Lusskin: But what’s really important, and the reason this is a great thing to do on my birthday,…
Dr. Fox: Oh, here we go.
Dr. Lusskin: I’m so happy to participate, is you’re helping to destigmatize psychiatric illness in general and psychiatric or psychotropic medication in particular so that people can get the help they need.
Dr. Fox: A hundred percent.
Dr. Lusskin: Because there are still so many people who don’t believe it’s real, who blame the mother who are taking a medicine during pregnancy if there is a complication in the baby.
Dr. Fox: Or blame her for having the anxiety even though they were gonna step over, you know.
Dr. Lusskin: Right, right. So…
Dr. Fox: Why are you depressed? You’re pregnant. You know, like, what? It’s a horrible thing to say to somebody.
Dr. Lusskin: Right. When you have somebody who hasn’t been able to conceive and they say, “You’re pregnant, you should be fine.” But of course, it doesn’t work that way. But, you know, when you look at anxiety disorders, anything psychiatric is stigmatized in the medical community, not just the wider world.
Dr. Fox: Yeah, 100%.
Dr. Lusskin: We’re still not there yet where these disorders are treated like any other biological disorder, but hopefully we’ll get there.
Dr. Fox: Yeah. I’ve said on the podcast multiple times that that is probably the thing that I’ve learned the most about unrelated directly to, you know, obstetrics, let’s say, in my career, is an understanding of mental health just in general, but also working with people who struggle with mental health and what their experience. Again, I can’t be them, but I can have so much more understanding. Not even just empathy, but just, like, real, like, insight into what they’re experiencing and to what they need, and what they’ve been through in the healthcare system. And that’s something I’ve learned the most about. And so, I notice that some doctors really get annoyed when they see someone with mental health issues. And I was like, “Would you get annoyed if they have cancer?” Like, “Does it annoy you?” Like, cancer is horrible. They’re very sick. They sometimes get better, sometimes don’t. They take a lot of time. They need a lot of medications, a lot of attention. That doesn’t annoy you. Like, you’re helping them. And why would someone with depression annoy you. Like, it doesn’t make any sense. They don’t wanna have it, you know. They hate that they have it. You know, they wanna be better.
Dr. Lusskin: The prejudice goes back. I mean, it just goes back so far. I don’t even know when it started. Well, it goes back to the fact that you can’t see it. I mean, actually, you can see depression. You can see anxiety. You can probably diagnose it looking in the waiting room.
Dr. Fox: You can’t get it on a piece of paper and a blood test. And there’s the option to blame someone for it. It’s not right. It’s wrong, but it’s doable. And you can’t blame someone for getting cancer. I don’t know how you wanna say because they… A behavior they had, but whatever.
Dr. Lusskin: Well, they smoked or whatever, but…
Dr. Fox: But that’s the exception, you know, pretty much always. And it’s just, it’s horrible. But we digress.
Dr. Lusskin: Well, we digress a little bit, but it gets back to the question of how do you treat anxiety in pregnancy? So, the conversation with your OB, with your psychiatrist is about the importance of mental wellness in pregnancy, to have good pregnancy health across the board, including all of the obstetric metrics, whether it’s nutrition or proper rest, or high blood pressure, or diabetes. Now, you can get gestational diabetes through no fault of your own, right?
Dr. Fox: Right, right.
Dr. Lusskin: But if you’re miserable, if you’re super anxious, you’re not going to manage that diabetes properly. And if you have high blood sugar during pregnancy, that leads to a host of other pregnancy complications.
Dr. Fox: Yeah. We have people who show up and they call this, you know, the white coat hypertension where they, you know, get hypertension in my office and they don’t have it at home. And some of it’s related to anxiety, some of it’s not. But we definitely have people who have known anxiety, and they come, and their blood pressure is high in the office, and then it takes time. And, you know, when they’re calmer and they’re at home, or not at home, whatever, it’s normal. And they’re like, “Should I take a blood pressure medicine?” And I’m like, “No, we need to treat your anxiety.” Like, you’re very anxious and it’s actually having a physiologic effect on you, causing your blood pressure to go up which is not good. And so, I prefer to treat your anxiety to treating your blood pressure because that’s gonna number one, work better, number two, you’ll also feel better. And that happens, that happens a lot. And they’re like, “What?” I’m like, “Yeah, take your Xanax in the morning of your appointment, so that way when you come in, you’re not gonna be… You may be anxious, but much less so, and your blood pressure is gonna frequently be better. And then I’m not gonna send you to the hospital where you have preeclampsia. Right? Because you don’t because your blood pressure was normal when you woke up in the morning. It’s just 45 minutes later in my office, it’s very high.” And so, there’s so much of that that is relevant that people don’t even realize it in that sense and how much the mental health affects even the physiology.
Dr. Lusskin: Well, especially the physiology because when you’re anxious, your stress management system is overactivated. So, you have more cortisol running through, more epinephrine, and that has direct physiologic effects. And just as I said, you can see somebody who’s depressed in the waiting room. You can see somebody who’s anxious, that’s the person who’s tense, who can’t sit still. There are actual physical components to the emotional state of anxiety. So, in case you thought it wasn’t real and it’s all in your head… There’s that famous joke about the guy who… Do you know this one?
Dr. Fox: No.
Dr. Lusskin: The guy, Sadie and Max, who are in their, like, 80s go to the neurologist. Sadie is waiting for hours. Max comes out. He says, “Oh, thank God it’s a brain tumor. I thought it was all in my head.” Right? So, for anybody who doubts that anxiety is real, look in the waiting room. Right? Look at what happens with white coat hypertension. Doesn’t white coat hypertension, isn’t that a marker for hypertension in general?
Dr. Fox: It’s interesting. It’s complicated because it seems that people with white coat hypertension have a higher chance of getting hypertension in general, but it’s also clearly related to some form of response, you know, like anxiety type of…
Dr. Lusskin: O, no, no. I mean, it’s definitely related to anxiety, but long-term,…
Dr. Fox: Yeah, it’s a little bit of…
Dr. Lusskin: …it’s actually a marker for a hyperreactive vascular system.
Dr. Fox: Yeah, exactly. Or that long-standing anxiety can actually lead to hypertension. One or the other. I don’t know. I don’t know.
Dr. Lusskin: One or the other. Well, because it’s a bidirectional relationship as we like to say.
Dr. Fox: It is. Do you find in your own patients that anxiety tends to worsen over the course of pregnancy, get better? It depends on the circumstances, obviously. What do you tend to see?
Dr. Lusskin: It depends. Now, if you have panic disorder which is panic attacks with or without agoraphobia, agoraphobia being a fear that you’ll have a panic attack in someplace where escape is impossible or help is not available, and you’ll have a heart attack, a stroke, or go crazy. If you have panic disorder, it tends to get worse in pregnancy. And instead of your panic attacks lasting 30 minutes to an hour, they can become PAN cycle panic attacks. And you can have nocturnal panic attacks whereas you might not have had those before. So, the panic can start at different times, and it can last for hours and even days. And then it can tip you into a more severe anxiety/depression type of situation. Obsessive compulsive disorder can also get worse in pregnancy because you have more things to worry about. Right now you’re worried about how everything that happens to you could affect the baby. Depression, we know, can get worse in pregnancy.
Dr. Fox: Right. And all of them can get worse postpartum.
Dr. Lusskin: And everything can get worse postpartum. And GAD, generalized anxiety disorder can get worse because I mean, not just if you aren’t aware of all the things that can go wrong. The fact that you have to see your healthcare provider doctor or whichever obstetrical provider you’re seeing…
Dr. Fox: Sure.
Dr. Lusskin: …that you have to have regular checkups. That’s like a little red flag that they’re looking for stuff. We could talk about ultrasounds for a second.
Dr. Fox: Okay, let’s do it.
Dr. Lusskin: Okay. You’re a specialist. You’re a maternal fetal medicine specialist. You guys are the ultrasound gurus of New York City and the surrounding region.
Dr. Fox: Thank you. We’ll take it.
Dr. Lusskin: Absolutely.
Dr. Fox: All right. True or not, I’ll take it. That’s fine.
Dr. Lusskin: It’s true. So I’ll never forget going into a mall and seeing a huge banner from a radiology practice that said, “Meet your baby. Come have a 4D ultrasound.” And I looked at that, and I had a panic attack. Because you’re not doing prenatal ultrasound to introduce the patient to her baby. You’re doing it to look for problems. If there are no problems, it’s nice to get a picture of the baby and maybe facilitate bonding during the pregnancy. But you’re really doing it to look for problems. So especially for anxious patients, every time they have a test, “routine screening” in pregnancy, they’re not stupid. They know you’re looking for problems, so they get anxious in anticipation of the test. And one test is good, so then they’re worried about the next test. And whenever you see people advertising ultrasounds for sort of bonding purposes.
Dr. Fox: Yeah, I’m not a big fan of those. It could be an issue. What’s an interesting subset of patients I find is people who don’t have… Let’s say, they don’t have an anxiety disorder. They don’t have anxiety typically, but almost like a PTSD since they had a bad outcome in the prior pregnancy. When they are pregnant again, they have horrible, horrible anxiety. But it’s situational, right? It’s almost like they’re always standing on the street with the bus coming at them or again, it’s normal in a sense because let’s say, they had a, you know, they had a stillbirth and a horrible thing, last pregnancy. And so, they get pregnant and they’re a little bit anxious. And then as they get more pregnant and they’re approaching the time when then the stillbirth last pregnancy, they’re getting horribly anxious, way worse than the person who has an anxiety disorder and is on three medications. But it’s also, “normal.” Like, it’s understandable. Like, it makes a lot of sense that they have crazy anxiety. And so, if someone like that is coming to see you, when they’re not pregnant, they’re basically fine, let’s say, right? They’re obviously scarred because of, you know, hurt because of what happened to them a year ago, two years ago, three years ago. But they don’t have anxiety disorder. They’re fine leaving the house. They can work. They can do those things, but then they’re pregnant, and it’s debilitating. Do you treat it the same way you would an anxiety disorder or is it different? Because if it’s very situational for the pregnancy… How do you approach… I assume you see people like that all the time. How do you approach them compared to someone who has it always, let’s say?
Dr. Lusskin: Well, we come back to the original principle that a little anxiety is adaptive and too much anxiety interferes with your ability to live your life. So, I mean, the therapeutic approach is to acknowledge that there’s a real potential threat that’s more real to them because they’ve lived through it than somebody who hasn’t had a poor pregnancy outcome before. I mean, ranging from miscarriage,…
Dr. Fox: Yeah, anything.
Dr. Lusskin: …stillbirth, or whatever, or a crash delivery that was painful, and life-threatening in some way.
Dr. Fox: Sure.
Dr. Lusskin: To then saying, well, how can we mitigate the risk of a poor outcome? It sounds like poor outcome is the wrong word, but what can you do to reduce the risk that things won’t go as planned or reduce the risk that you might not have a healthy baby? So we wanna be proactive. It means, you know, going to your OB visits, seeking a specialty consultation with the best maternal fetal medicine group in the country. I tell people, you guys are so good that you saved my patients, twins by gestational carrier in the Midwest, born in the Midwest. And it’s true, it’s true. Without even seeing them, you actually did. But anyway, get the maternal fetal medicine consults you need. And then if the anxiety is keeping you up at night or you’re not eating properly, you can’t sleep, you can’t function, we medicate it if talk therapy is not adequate. So there’s a real threat, but your body is reacting. Perhaps not overreacting, but that reaction can take on a life of its own independent of what started it in the first place. So that’s how we approach it.
Dr. Fox: Fascinating. Really interesting. And again, anxiety is something that’s actually routinely screened for postpartum because again, someone without anxiety can get…
Dr. Lusskin: Actions.
Dr. Fox: …postpartum anxiety, just like postpartum depression. Again, this is something we’ve spoken about before, but it’s just a reminder that it’s not unique to pregnancy. It can be postpartum, it can get worse. But it also, you know, happened for the first time in someone unsuspecting. Shari, thank you so much for coming on, for spending all this time on your birthday with me and with our listeners doing two podcasts back to back which I really appreciate. It’s awesome. It’s great to see you. Thank you so much.
Dr. Lusskin: You’re welcome.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at email@example.com. Have a great day.
The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.