Dr. Shari Lusskin joins Dr. Fox to discuss Reproductive Psychiatry, or psychiatric treatment for women during pregnancy. In this episode, they review topics including treatment options, when medication can be used, and research into psychiatric treatment for pregnant women.
“Mental Health in Pregnancy: We Need to Talk About It!” – with Dr. Shari Lusskin
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics and 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 “Healthful Woman” I speak with leaders in the field to help you learn more about women’s health, pregnancy and wellness. I’m here with Dr. Shari Lusskin, who is a clinical professor of psychiatry, also has an appointment in the department of OB-GYN, a reproductive psychiatrist, and an expert in medications in pregnancy related to psychiatry and expert in psychiatry. We work together a lot. I’m so happy you’re here. Thank you for coming.
Dr. Lusskin: You’re welcome. Thank you for inviting me.
Dr. Fox: Fantastic. So just so our listeners understand a little bit about you, who you are. So tell us a little bit like you know, where are you from? How did you get into medicine, psychiatry, this line of work, and anything you wanna tell us?
Dr. Lusskin: So I am a native New Yorker, and I’m actually the third generation of physicians in my family.
Dr. Fox: Very nice. I am too.
Dr. Lusskin: Oh, I didn’t realize that.
Dr. Fox: I’m also, yeah, third generation.
Dr. Lusskin: What did your ancestors do?
Dr. Fox: So my father’s father, who I’m named after, Nathan Fox also, was an ophthalmologist. And then my father is a neurologist, and then me, I have a brother who’s a physician, and also on my wife’s side. She’s also a third generation. She’s not a physician, but her father, her grandfather, her uncle, another uncle, all physicians.
Dr. Lusskin: Fantastic.
Dr. Fox: Yeah, a lot of doctors, a lot of opinions.
Dr. Lusskin: Yeah. Well, my grandfather was an orthopedic surgeon, and my grandmother was an orthopedic surgeon.
Dr. Fox: Wow.
Dr. Lusskin: Yeah.
Dr. Fox: Here in New York?
Dr. Lusskin: Here in New York. She trained at Bellevue in 1918 to ’19. And just a little bit of an aside on that one, she was one of two women in her intern year class.
Dr. Fox: I can’t imagine there are a lot of Orthopedic Surgeons who were women in 1918.
Dr. Lusskin: There weren’t even a lot of women doctors, let alone surgeons. Up until 1918, women were not allowed to work as doctors at Bellevue.
Dr. Fox: Really?
Dr. Lusskin: That’s right. They could be nurses, but not doctors. The only reason they took in women physicians in 1918 was because all the men were off at war.
Dr. Fox: That makes sense.
Dr. Lusskin: That’s right. So she did her internship at Bellevue. And then she went on to become an orthopedic surgeon.
Dr. Fox: So that was the only benefit of World War 1.
Dr. Lusskin: And then my father was an orthopedic surgeon. My uncle was an orthopedic surgeon, and I kind of broke the mold.
Dr. Fox: And you thought they were all crazy. So you went into psychiatry?
Dr. Lusskin: Not exactly, I tried to explain it to my dad that if you drew a line with psychiatry at one end, and surgery at the other, when you bent the line and brought them together in a circle, we had a lot more in common. Because a psychiatry dealt with internal medicine. So he actually bought that which was great.
Dr. Fox: Okay, so that’s fair. Or maybe just didn’t understand it and he didn’t wanna fess up to that. So you’re New Yorker, third generation physician, that’s amazing. So you sort of had a sense that maybe you’re gonna do this from childhood.
Dr. Lusskin: I think it was genetically programmed.
Dr. Fox: Okay, that’s nice. And so how did you pick psychiatry specifically?
Dr. Lusskin: Well, I really have made a lot of career decisions based on the mentorship I received. And in our first year of medical school at NYU, we had a really great professor who actually took us out into the field to meet with patients who were chronically mentally ill and also introduced us to the concept of multifamily groups and peer support. It was very interesting, very exciting and just seemed like a great opportunity to have kind of hands on involvement somewhat analogous to surgical medicine. And I got hooked. So that’s how it happened.
Dr. Fox: And when did you start, I guess, focusing on reproductive psychiatry or women who are pregnant, or getting pregnant, or whatnot?
Dr. Lusskin: That is an interesting story. I had always been interested in the overlap between general medical illnesses and psychiatric disorders. So I did a lot of consultation liaison psychiatry, both as a medical student and as a residents and I did my residency at Bellevue. And then that was the early part of my career. I focused on that. So I worked with patients who had cardiac disease and neurologic diseases like multiple sclerosis did a lot of that. And in 1996, I went to a conference at the American Psychiatric Association, where I met a group of doctors from Vancouver in British Columbia, who had started a program in women’s mental health, which was the reproductive psychiatry program there so, their expertise was in treating pregnant and postpartum women. So I attended their course nobody was doing this in New York. We had no training in it at Bellevue, Bellevue, if you were pregnant, psychotic treatment was three hots and a cot that was it. And maybe restraints if you were agitated. Nobody wanted to medicate them. They suffered through pregnancy terribly. One of my very first patients as a medical student on psychiatry was a pregnant woman with schizophrenia who was completely delusional throughout the whole pregnancy. It was really awful.
So anyway, I make the group of psychiatrists who have developed an expertise in using medications in pregnant women in addition to other therapeutic modalities like psychotherapy, focus psychotherapy, and the light bulb went off. And I went up to them afterwards and I said, “Can I come see your program?” And they said, “We’ll pick you up at the airport, when are you arriving?” And that was the start of my career in reproductive psychiatry. So I still work with that group. In fact, we’re doing a conference. We’re doing a virtual conference…
Dr. Fox: Of course.
Dr. Lusskin: In October at the…
Dr. Fox: Conference in quotes.
Dr. Lusskin: Conference in quotes at the Canadian Psychiatric Association annual meeting in October. It’s been a very long and productive friendship that I’ve had with them.
Dr. Fox: And it’s not that you just became interest in it. I mean, you really, I mean, you jumped into the deep end, you’re doing this, you’re writing on it. You’re talking about it. You’re publishing on it. You’re all over it. I mean, and is it something that you’ve just built on because it was interesting, or because people just started coming to you because you were the only person really doing this?
Dr. Lusskin: I think it was really interesting. And I was very fortunate to have an excellent mentor at NYU in the form of Charlie Lockwood, who is the chairman of OB-GYN who said, “This is important you should be doing more of this. I’m gonna give you an appointment in our department.” And having that kind of backing from somebody who was so talented, so well respected, was really, really important in fostering my career. And then our chairman of psychiatry at NYU, Bob Kangra [SP], was also supportive. But the support from the OB-GYN department is really what got me heavily involved in this.
Dr. Fox: Right. I mean, Dr. Lockwood Charlie is a great guy. He’s one of the world renowned OB-GYNs and maternal fetal medicine doctors, and he’s a really forward-thinking type of person. And so he was actually he and Andre Barber, my current partner, he was in his group, his partner, and yeah, he was able to see things before they became, a big deal to everybody else. And I think that it’s looking back it’s not so extraordinary to say, “Hey, like, this is a really important topic,” but it was a big deal then because people were not focusing on it. And I love the fact that he brought you into the OB-GYN department and that’s where I guess how our relationship it was like, the preconception of our relationship because at that group who was at NYU and got to meet you when they came over to Mount Sinai, and then you shortly followed…
Dr. Lusskin: Well, I came to Mt. Sinai because Andre called me up and said, “We need you at Mount Sinai nobody’s really doing this at Mount.” And so that’s how I ended up on the faculty at Mount Sinai while I was still at NYU. And then I eventually transitioned to full time voluntary faculty at Mount Sinai. I think Charlie got me involved in one of my…well, Charlie gave me my first writing assignment to do something for one of the Bellevue journals it’s sort of an in house journal. And then I got on a research project with Min Jin Lee who is now heading up MFM at University of Hawaii. So I think connected with your group from 1996 it’s been a long and productive collaboration.
Dr. Fox: And just so everyone understands our listeners, the idea of there’s two concepts with mental health or in women who are either pregnant or thinking of getting pregnant. There’s one just understand the disease process and what’s gonna happen in pregnancy, When are they gonna get better, when are they gonna get worse, and how do they get treated? But then the medication piece, which is just huge, because so many women are treated with medications, if they’re not pregnant, which is sort of the mainstay of…not the mainstay, it’s a huge part of psychiatry, and they’re getting pregnant. And like you said, in the past, people would just tell them, “Well, go off your meds, because they’re gonna harm the baby.” And that was the prevailing thoughts, and then it was just a disaster for them.
Dr. Lusskin: It was that was a recommendation based on very limited evidence. So as I like to explain to patients when you come to me or to your internist, with a sore throat, the doctor has the ability to take a throat culture to check what kind of bacteria is growing in your throat, and then figure out what kind of medication is going to kill that bacteria. So if you have strep it could be penicillin. It could be amoxicillin, it could be any one of 10 different antibiotics. But there’s a way to decide in the laboratory, what’s wrong? And how do we treat it? And those decisions about how to use antibiotics are based on trials with tens of thousands of people, not just looking at the efficacy of the drug, but also the dosing of the drug and the duration of treatment. So in psychiatry, we do not have that kind of information available, especially where perinatal psychiatry is concerned. So people would base their recommendations on a single case or the small case series experience, which really isn’t very good. One person can have an adverse reaction to almost anything, that’s statistically likely, even if it’s rare, rare things happen rarely, but to be able to really assess the safety of drugs, you need a very, very big clinical trial. We didn’t have that.
So instead of acknowledging that we didn’t have a lot of data, the default mode was just stop taking your medicine, we were talking before about a phrase that physicians often use OB-GYNs have used this a lot. “Stay on your medication if you really need it.” In the absence of large scale clinical trials, doctors often rely on their “gut” and clinical gut is useful in driving you to seek out more information. But it’s not always useful in making clinical recommendations because as the information changes, your clinical gut may not have changed unless you reeducated yourself. When a woman takes a medication, she may not be in a position to decide whether she actually needs it. It has to be a collaborative decision made between the treating physician and the patient and whatever other physicians are involved and it can sometimes be very subtle.
I don’t have a test like, a throat culture, to say, “Hey, this is what’s wrong with you. This is the treatment you need for it,” it’s a lot fuzzier when it comes to psychiatry. There’s unfortunately, more art than science involved in the selection of medication for patients. One thing I can tell you is if you find something that works, and the patient can tolerate it going off, it is not always a good idea.
Dr. Fox: Right, I mean, it’s so hard because also there’s so much overlap like you said, with diagnosis. For example, you can have the diagnosis of depression, which is their criteria and this and, but someone could also be depressed, right, and you could be depressed because you lost a loved one. Now it doesn’t mean you have clinical depression and you need medication necessarily because that’s something that should be temporary and go away in a few weeks. But if you have a major depression, you have mental illness, that’s not just gonna go away. And I think a lot of times doctors and not just doctors, but we’re talking about doctors here get it wrong and they think that someone’s has depression and just means they’re sad and they’ll be better in a couple weeks or they’ll be happier because they’re pregnant. But like, no, they’ve disease. Like you wouldn’t say that about someone who has diabetes, like, because you’re pregnant, you don’t take your insulin anymore. It doesn’t work like that, but for mental health, and some of it is just our culture, our society, some of its medical training. Some of it’s just, it’s hard, but I think we’ve gotten a lot better, but we’re understanding of all this.
Dr. Lusskin: I think one way to get around that problem is to change the terminology from mental illness to neurobiological disorder, which really makes the point that this is a brain based condition. And it has nothing to do with your moral fiber, or your inherent resilience, or character, or your strength as a person. It can happen to really successful people, it can happen to people who were never successful. It happens to poor people. It happens to rich people, but it’s a real biological addition. And it may sound a little facetious, but I’ll say it anyway, “If I take out your brain, you’re cured,” absolutely it works every time. There are some people who function quite well without a brain. But…
Dr. Fox: I remember when I started in practice, the one of the first patients I saw was a woman who had horrific depression. And she was nearly catatonic. She would come into the office, she couldn’t lift her head up. She could not smile, she couldn’t carry out a conversation. The patient herself was in her 40s, her mother who was in her mid-70s, would bring her in. And it was horrifying to see. I mean, just I don’t know if I’d ever seen someone who wasn’t in the hospital look like that. And ultimately, she did get through the pregnancy and she delivered. And about two months later, she came for a postpartum visit. I literally did not recognize her. She’s apparently right. She’s a partner in a law firm. She’s highly successful. She has like several graduate degrees. She is funny, she’s outgoing, and it’s just what’s difference is that finally they got the right treatment and they realize who she was. And if you had met her, originally, you would never know any of these things. And like you said, it’s a real disease that could happen to anybody. I wouldn’t say at any time. You know, it doesn’t just like, come out of nowhere. But it can happen to anybody.
Dr. Lusskin: It can. That’s the bad news. The good news is we do have treatment available
Dr. Fox: Yeah.
Dr. Lusskin: Sometimes as a psychiatrist, they’ll say to patients, “If I get it right the first time, I’m a genius.” But it doesn’t always work that way. Sometimes there’s a real trial and error process. I spoke with somebody this morning, who’s going to see me for a pre pregnancy consultation, somebody who had a history of substance abuse and anxiety, and depression, and is finally feeling better, ready to have a baby. So she wants to know about the safety of the medication in pregnancy. And I said, “By the way, are you using any form of contraception?” And she said, “No.” I said, “Well, I can see you in three weeks. Maybe you could use some contraception till I see you then.” And here’s the point I’m trying to make. Because it’s a lot easier to have the discussion about what’s safe in pregnancy, what’s the best treatment for you and your family before you’re pregnant. Once you’re pregnant, it’s a whole different ballgame. When women get pregnant, they are kind of a moving target, their hormone levels are changing on an hourly basis, let alone a daily basis. And that can have an effect on the brain because estrogen and progesterone are neuroactive steroids. They’re not just about sex. Although sex starts in the brain.
Dr. Fox: It’s all there.
Dr. Lusskin: It’s all there. It’s all in the brain. That’s a good example of why it’s so complicated. First, finding out what’s wrong, second, finding out a treatment. And thirdly, what’s the reproductive safety data. And fourthly, if you’re already pregnant, then I don’t wanna tinker with too much because I may not be able to get you stable again.
Dr. Fox: I think also people overestimate the risks, they assume these medications are gonna be much more dangerous than they actually are. And I know that one of the hats you wear is helping this Reproductive Toxicology Center, which is essentially a group that looks at the potential harmful effects of medications in pregnancy, and you are specifically related to the world of psychiatric medications. And I mean, they have a great website, reprotox.org, which is…I mean, we use it all the time to get up to date data. So, and this is part of your expertise, but how would you explain to our listeners, why is it so hard to do a study, like, just let’s take a simple, not simple, but medications used all the time, let’s say Prozac, right? Why do we not really know for sure what is the risk of Prozac in pregnancy?
Dr. Lusskin: I’m happy to say that we have a really good idea about what the risks are now. But the reason we don’t have the kind of data we really like, which is live studies, in live patients, as opposed to studies using healthcare databases is that pregnant women are routinely excluded from pharmacology trials, whether it’s antibiotics, chemotherapy agents, or treatment of neurobiological disorders like, generalized anxiety disorder, major depression and bipolar disorder. So there’s actually legislation that was passed recently that mandates the development of research protocols, which will include pregnant women. Obviously, the problem with having a pregnant woman in a trial with something you don’t understand terribly well is you don’t want to expose the baby to an unknown risk. But there are ways to mitigate the risk in terms of how the studies are done. So eventually, we’ll have more data. Now what we have on Prozac, the generic of which is fluoxetine and similar drugs is we have healthcare databases collected from around the world, where pregnancy outcome is correlated with medication exposure based on prescriptions filled.
So we don’t have this in the United States, except in certain systems like the Medicaid system where they can really track prescriptions and clinical outcomes. But in the Scandinavian countries, for example, and in Canada, there are large…you basically have…you’re tracked from cradle to grave with an ID number. And everything that is done is fed into a computer one way or another. And eventually you can look at a given individual’s clinical history and the prescriptions they filled. Now, here’s the problem. If somebody filled a prescription, it doesn’t mean they took the drug, nor does it mean they took the drug the way it was prescribed. And it doesn’t tell you what else they took…
Dr. Fox: Exactly.
Dr. Lusskin: …that was not prescribed. Specifically, we worry about drugs, tobacco and alcohol. Turns out that amphetamines like, methamphetamine may have some effects on brain development, but it’s not hugely Teratogenic. But cigarettes are really bad for babies. Alcohol is really bad for babies and even in assessing the dangers of methamphetamine abuse, in terms of does it cause birth defects? You can’t really adequately control for exposure to cigarettes, to tobacco, and to alcohol and alcohol is a known Teratogen. So it’s all very complicated. Anyway, but we have a lot of data we have hundreds of thousands of exposures to fluoxetine, or Prozac, as well as the other serotonergic antidepressants like, paroxetine, and sertraline, which are Paxil and Zoloft, other drugs like venlafaxine which is effects are, you know, and things like that. There is one drug for anybody who’s listening there is one drug that should be avoided in pregnancy if at all possible. And that is a valproic acid which is also known as Depakote. This is a drug used to treat epilepsy and to treat bipolar disorder. I always recommend if a patient is taking that drug, they be on some really reliable form of contraception like an IUD, to prevent unintended pregnancy. Now, risk tolerance is very much dependent on context. So if you talk to a neurologist who has a patient that has really bad epilepsy and could die from it, and valproic acid is the only drug that is effective in controlling the epilepsy. Then the neurologists might say, “Well, 90% of the babies are okay. It’s a 1 in 10 chance, 10% that there would be a problem.”
So if you wanna have a baby, while you’re on this medicine, those are the risks. A psychiatrist will say, “Well, 10% of the babies could be affected. We don’t recommend you take that instead, I’d rather you take a drug like lithium, or perhaps quetiapine, or one of the other drugs that’s used as a mood stabilizing agent, because the risks are much lower with those drugs.” So it’s all depends on perspective.
Dr. Fox: Yeah, no, it depends also it’s individualized, which is why it’s hard to say that this medication is good, this medication is bad, or whatever. I mean, there’s some medications, they’re sort of, and these are the exceptions that have a really high risk to the babies. I mean, you’re mentioning, valproic acid, which is like the worst one, and it’s still the risk is 5% to 10% right? So that we consider that very, very high. But like you said, that means that 90% to 95% time, everything’s fine. I mean, there are a few medications where it’s more like 25%, but that’s not really related to psychiatry or anything, there are medications that are bad, but not in sort of the world we live in. So we’re talking and most of the medications we’re talking about, and when I tell patients is the kind of risk we’re referring to here is 1%. You know, like some number under 2%, or even less or this. Those are sort of the numbers thrown about potentially. And so it’s important because I people think it’s 100% when they take these medications.
Dr. Lusskin: So, I came up with a slide about five years ago, that I really, really like. It’s the simplest slide I ever made. But I think it’s the best. And I came up with the slide when I was speaking to a panel of FDA experts, and representatives from pharmaceutical companies to discuss the new FDA labeling the new pregnancy categories. So my job was to explain why this mattered. This is not some esoteric, academic, and or legal discussion. There are real people at the end of these regulations. So you need to be aware of that. The slide I came up with was this, it said, or I wrote, “One in a million, equals 1 in 100,000, equals 1 in 1000, equals 1 in 100, equals 1 in 10, equals 1 in 1, equals me.” And that’s how anxious physicians and anxious patients perceive the risk benefit analysis.
Now, as I have said to you in the past, rare things happen rarely. So you could take a medication and you could have an adverse outcome and that adverse outcome may be 1 in 40,000. But you could be that one. The chances of you being 1 in 40,000 are actually 1 in 40,000 which is a pretty low risk. Now the background risk of birth defects in the United States is 3% to 5% this is why MFM exists as a specialty. Because when I delivered my kids, lo those many years ago, there were no MFM specialists as a subspecialty of OB-GYN, good OB-GYNs did a lot of MFM counseling.
Dr. Fox: Correct.
Dr. Lusskin: Those are the first ones to have ultrasounds do amniocentesis genetic counseling. And as the amount of knowledge has increased, the need for a specialists has increased kind of like in my field, there you have it, if you understand that the background risk of birth defects is 3% to 5%. And maybe a medication is associated with a 1 in 1000 chance of something happening, what you see is that the background risks of problems with the pregnancy are much greater than any potential risk from medication.
Dr. Fox: Absolutely.
Dr. Lusskin: Now, as I said that one in 1000 figure, I can’t even think of a medication in psychiatry other than valproic acid, where there’s an increased risk of anything bad happening in terms of birth defects. Not when you look at the studies really careful.
Dr. Fox: Yes, yes.
Dr. Lusskin: Okay, because that’s the key. Anybody can write anything, but it’s the methodology and it’s the way the data is analyzed, that makes the difference.
Dr. Fox: Yeah. I mean, what I tell people is sort of what you’re saying before, the only way to know for sure, if a medication causes birth defects, and these studies aren’t done for obvious reasons as you take 20,000 women, randomly divide them into 2 groups, give 10,000 the medication, and 10,000 something that looks just like it, but it doesn’t have the medication. From the start, that’s not gonna get done. You never get numbers like that, you’re not gonna get people to sign up to take a medication or not take medication. Plus what dose you give? All these things, okay. But if you did that, then you would also after birth have to do a full head to toe exam and scan and ultrasound and MRI or whatever it is in all 20,000 babies count the number of birth defects. And if it’s really more in one group with the medication, that’s your difference. Okay, so that’s not being done, it’s not done. So what they do is they go back and they look at the 10,000 women who took the medication that compare them to 10,000, who didn’t, and they look at the difference in birth defects, which is a problem for 2 reasons. Number one, they’re different, right? The women who took it, as you said, may be more likely to be drinking alcohol, or smoking, or maybe they’re older, or maybe they have medical problems, or whatever, maybe their prenatal care isn’t as good. There’s a lot of reasons things can happen.
And the second thing is their babies get tested more, so they get diagnosed more. And so what I tell women when either I show them a study, or they pull a study or we discuss the studies I say, “Look, this study showed an increased risk of like 1%.” I say that’s like, the maximum, and it’s probably something much lower than that, and maybe zero, it’s hard to say for sure. And I’d say okay, like, maybe there’s some risk, but going off, it has risk, and it’s probably greater if she needs the medication to go off the medicine. And what ends up happening is most people and they sort of realize what we’re talking about here. And the likelihood of a problem happening might be higher just from her taking the subway to my office. And so it’s generally they’re pretty reassured under that circumstance, that if I’m not so worried, they shouldn’t be so worried.
Dr. Lusskin: Well, I like the way you explained it. I’d say you ticked all the boxes. There’s a concept called confounding by indication. Which means that the reason the person took the drug may account for the adverse outcomes. So it’s not the drug. That’s coincidental, it’s the illness.
Dr. Fox: It’s like saying insulin is related to birth defects. No insulin is in diabetes.
Dr. Luskin: Diabetes it is especially if it’s not well controlled right? So it’s challenging. I would agree with you though, that when it’s explained carefully to women who are contemplating pregnancy or are already pregnant, patients get it. Now you mentioned reprotox.org, which is I’m very proud to be associated with it and kind of keeps me on my toes because we’re constantly reviewing the world’s literature on both humans and animals to see if there are indications for problems related both to pharmacologic agents like antibiotics, antihypertensives, antidepressants, and to other exposures like jet fuel, or anesthesia for dental procedures. But we have another website that the contributors of reprotox also contribute to an organization called mothertobaby.org. So mother to baby is produced by the organization for teratogen information specialists. So these are the genetic counselors that you can call up their many 800 numbers. “Hey, I had a dental X ray, is my baby gonna have a birth defect?” You can call various hotlines and you’ll get to mothertobaby.org. We produce fact sheets that are aimed at the general public. So it’s kind of a simplified version of what you might see in reprotox. But we’ve really boiled it down to the essential points, and we have, let’s say, 6 or 7 or maybe 10 references maximum on that fact sheet, which you can print out compared to 100 references in reprotox. It’s a great resource for patients, it’s highly refereed. And I would say it’s basically accurate and it’s something you can take to your doctor and say, “Hey, I read about this, do you know more about this? Where can I find more information?” And there’s nothing like a patient showing up in your office with an article in hand to get you to do your due diligence as a physician, right?
Dr. Fox: Yeah, it’s a good lesson there’s nothing better than an informed patient because then you’re having a high level discussion and you’re really talking about what matters and not trying to sort of like diffuse all of the erroneous things that are coming out left and right, if someone’s really understands what’s going on and has a good sense like, that’s a great conversation. Because then we can come to a decision about what she wants to do and what I think is the option right or wrong, I mean, it’s just a much better way to go. And it’s that kind of information certainly a lot better like, “Oh, yeah, I saw on Google something once somewhere.”
Dr. Lusskin: I saw a great coffee mug it said, “Don’t confuse your Google search with my medical degree.”
Dr. Fox: I actually had that in my office, it was given to me as a gift. You’re seeing a lot of women, hopefully before they’re pregnant, who are, you know, have for whatever reason are on several medications 1, 2, 3, medications. In your experience when they’re talking about pregnancy are most of them trying to get off their medications to get pregnant? Or most of them are trying to look for reassurance that it’s okay, to stay on. I mean, where are they in this process?
Dr. Lusskin: Well, I get both. I wanna go back to something you said before quickly. You know how I said, you ticked off all the boxes, in discussing the literature?
Dr. Fox: Right.
Dr. Lusskin: I would say the OB-GYNs have moved much further than the psychiatrists in understanding the risks of untreated illness in pregnancy. And therefore…
Dr. Fox: Yeah, and we have to take care of them.
Dr. Lusskin: Right, you’re getting the calls at 2:00 in the morning from the highly anxious patient or the one with obsessive compulsive disorder or severe depression. I’m really pleased that that has happened that OB has led the charge for acceptance of safe treatments within pregnancy, psychiatrists who tend to be anxious as a group to begin with, are still kind of hesitant. And I still have patients calling me up and saying, “My doctor said I have to go off my medicine. I’m worried about doing that. I feel so much better on my medicine.” Well, like I said before, I never argue with somebody who tells me the medicine is working. Unless it’s valproic acid, but in which case, I’m like, let’s see if we can find an alternative that works. You know, I get both. I get patients who are desperately afraid of being on anything. These are the same people who will not have a diet coke during pregnancy, won’t have a cup of coffee and they have wine because they think that’s good for anxiety, but wine is not good in pregnancy, not good sorry, but I have to disagree on that one.
They’re the ones who if you say, “Well, there’s a 1 in 40,000 chance.” They’re like, “That’s me.” And then I have the other ones who really know that medicine has helped them and they may not even be able to articulate the ways in which it’s helped them, but they know they feel better. And so they’re the ones who want permission to stay on medication. And I had an interesting situation arise once when I saw a woman who was postpartum or maybe she was just at the end of her pregnancy. It came to me on medication, doing very well had been treated for anxiety and depression. And she said to me, “My husband wants me to breastfeed, but I can’t breastfeed. I’m taking sertraline” which is all off. I looked at her and I thought…
Dr. Fox: There are several odd parts about that statement.
Dr. Lusskin: Exactly.
Dr. Fox: I’m gonna breastfeed because my husband wants me to.
Dr. Lusskin: Go on, go on. Go on.
Dr. Fox: That’s like, “Oh, okay.”
Dr. Lusskin: Okay, and what else?
Dr. Fox: I can’t imagine that happening in my marriage. I’m not sure how that comes out. And the other thing, “But I can’t,” that’s sort of statement of fact, I can’t do it. Because I’m nursing. It’s dangerous for the baby and it’s like, two wrong facts.
Dr. Lusskin: And when we did the in-depth consultation, it was clear that she felt so much better on medication and was worried she’d be very depressed and even suicidal if she went off medication…
Dr. Fox: Yeah, and it’s worse postpartum. That’s our highest risk time.
Dr. Lusskin: That would be a very high risk time. And I you know, the conclusion was, don’t impugn the medicine, the medicine is not the problem here. Your husband deciding whether you should or should not breastfeed is the problem. You don’t wanna…
Dr. Fox: Any husbands listening are probably like, “I wouldn’t be able to say that.”
Dr. Lusskin: Yeah, exactly. I wonder how long that would last, right?
Dr. Fox: Yeah.
Dr. Lusskin: I said that the issue is really you need to own up to the fact that you just don’t wanna breastfeed for a whole variety of reasons. Sometimes breastfeeding works great for people and they really love it and other times, it just doesn’t work for them. And that’s okay. That’s why we have formula. It was an interesting discussion. But the issue is not the medication. In fact, the exposure during pregnancy is much higher than the exposure through breastfeeding.
Dr. Fox: Right, you’re absolutely to the baby correct.
Dr. Lusskin: To the baby?
Dr. Fox: Yes.
Dr. Lusskin: Right. So when you take a medicine when you’re pregnant, the baby receives exactly the same amount of medicine almost as the mother does. But the mother metabolizes the drug for the baby. So the mother clears the medicine from the baby’s bloodstream, and the baby’s brain. And in the nursing baby, let’s say less than 10% of the mother’s dose gets into the baby, sometimes even less than that, 1%, and after 6 weeks of age, the baby’s liver is like, an adult liver and it like, clears out the drug rapidly. And even in those 6 weeks, the exposure is still that one nanogram per ml at less than 10% of the mother’s exposure. And there so far, there’s no damage done from even that small amount of exposure.
Dr. Fox: It’s what you said before also so interesting about OBS, or MFM’s and psychiatrists I mean, I’ve had this I mean, countless times, or I’m meeting with a patient, and I asked her about a medical history and I asked her, she said, “I have a medical history of anxiety and depression. And I was told I have OCD and I was on this medication, that medication, I was hospitalized, three times as a teen.” And she goes ahead and I say, “Okay, how are you doing?” She goes, “Well, I’m doing okay. But my psychiatrists thinks I should do this, and this, and this. Many of the times it’s stopping medication.” And I’ll be like, “I disagree.” I mean, like, “I’m not a psychiatrist, but I don’t think that’s a very good idea.” And she’s like, “Why?” I said, “Well, what do you like when you’re off your medication?” She’s like, “Well, I haven’t been off like, three, four years.” Like, what were you like?” he goes, “Well, I was a wreck. I couldn’t function. I was suicidal. I was depressed.” I was like, “Well, that’s not good for pregnancy.” I said, “We don’t want you in that place. It’s just not…A, is not good for you. I don’t want her to suffer. But it’s not good for the entire pregnancy.” And I’ll say, “You know what? Let me call your psychiatrist.” And frequently because I ask the psychiatrist, they wanna do well by their patients they’re good caring people. And I’ll say, “Listen, this is what I do. I am comfortable with her being on these medicines, I’m okay with the risk. I’m gonna scan the baby out, I’m okay.” And they go like, “Well, if you’re okay, I think it’s great.” And then it usually just happens. And it’s out. I don’t really know why maybe they don’t follow up the psychiatrists in pregnancy when this… I’m not sure why it’s sort of been that while you notice that.
Dr. Lusskin: I think there’s a problem in psychiatry that many psychiatrists have not been trained well in collaborative care. So I told you when I was at Bellevue, as a medical student and resident I did a lot of Medical Psychiatry, a lot of consultation liaison psychiatry, that means going in to see patients who had other medical conditions and treating their psychiatric condition, neurobiological condition in the context of their medical illness, whether it was heart disease, lung disease, infectious disease, cancer, or fractures, and trauma. So there are a lot of psychiatrists who once they leave training, don’t speak to other doctors. Would you ever refer a patient to a cardiologist without calling that doctor first? I mean, you wouldn’t right?
Dr. Fox: Right.
Dr. Lusskin: You, would pick up the phone, “Hey, I want you to see this patient of mine. I’m concerned about a heart murmur.” And psychiatrists don’t always do that. Now, I’m happy to say that and in more recent training, there’s been an emphasis on collaborative care. So I’m hoping the field will improve in that way. But you’re talking about doctors who didn’t think to pick up the phone and call the OB, to discuss it and with a lot of things in medicine, as long as the risk is shared, the medical liability, the malpractice liability is shared with other providers and they’re fine if there’s an adverse outcome, they’re on the hook for it. I think it sends people off to the moon.
Dr. Fox: Yeah, do think it’s an issue of people are afraid from a liability perspective, that they’re like, “Well, it’s probably okay, but I don’t wanna be blamed for anything or is it that they honestly believe it’s the wrong thing to be in this medicine in pregnancy.
Dr. Lusskin: Right, I think you see both, you know, I think it’s hard to separate the two. But I’m curious to hear you say since you articulated the analysis of the literature so beautifully. I’m curious to hear you say what you tell patients about the risks associated with depression, and anxiety, and pregnancy.
Dr. Fox: They’re huge. So I tell people in general, there’s things we know and things we don’t know right? I said things we don’t know is probably huge, right? In terms of how much your brain activity and behavior and how things are functioning affect your overall health. I mean, a lot of people suggest that and suspect that and have some studies to show it and believe it and there is definitely this concept and so people will buy that, but I think it’s real. And I mean, there is some data about stress and anxiety and pregnancy causing adverse outcomes. But like, I said it’s gonna affect your nutrition, it’s gonna affect your ability to exercise, it’s gonna affect your ability to make good decisions.
In significant cases people could have self-harm. I mean, it can get dangerous for certain people. And I said the other thing is you’re also gonna feel miserable. There’s no goal to feel miserable in pregnancy. And I said, it’s gonna be worse after you deliver. Now you’re gonna have to do this with a baby, your life stressors, if you can’t sleep, right, and there’s so many things that are just not gonna go well. And so most people, they know that I think most of them I would say that the most interesting thing for me is, as I’ve gone through medicine, I would say that the under not the understanding of the biology, but just the understanding of people who struggled with neurobiological disorders, or also called mental health. I just understand it better. I don’t wanna say it’s empathy. It sounds like, so much empathy when like, I feel bad for someone. I just sort of get them a little bit more.
You know, when you’re younger and you’re training and you see someone who comes into your office or to the hospital, and she’s got OCD and anxiety and the first thing you think is, “Oh, God, like, this is gonna be so hard she’s gonna ask 1000 questions because she’s gonna be so nervous, it’s gonna be very difficult.” Yeah, listen, if I see someone with very bad hypertension, it’s also gonna be hard, but I don’t like complain about it. You know, you say, “Yes, she has anxiety.” So you have to explain it again, and you’ll have to be calm, and you’ll have to reassure her and you’ll have to take her phone calls. And it’s just part of it. And I just, I don’t know, maybe it’s because I’m older. Maybe it’s because I see more people or, in general in society, I think we’re just better at understanding these things. And recognizing that there are real, like you said biologic conditions and not, a judge on someone’s character. And so I’ve been much more comfortable over the years, taking care of women who are on multiple medications and multiple complications from neurobiological disorders than I was when I started for sure.
Dr. Lusskin: What comes with experience also as an OB is understanding that the better treated the underlying disorder is, the easier it is to manage the patient and the more likely she is to follow your recommendations. In severely ill women, we definitely see that they don’t keep their prenatal appointments regularly. They’re not as likely to follow dietary recommendations. So if you have a patient with gestational diabetes, she really needs to follow a strict diet, or she’s going to end up on insulin. And if she still doesn’t follow a strict diet, she’s gonna have poor glucose control. Anyway, same with high blood pressure, same with women who have to be on bed-rest. If you’re nervous and fidgety and depressed, it’s very hard to comply with all of that.
Dr. Fox: We wouldn’t prescribe bed-rest anymore. That’s out so no worries.
Dr. Lusskin: Oh, no, there’s no more bed rest?
Dr. Fox: The rest is out.
Dr. Lusskin: Oh, I see. This is why it’s fun to do…
Dr. Fox: I would actually it would be the opposite. I would be concerned that since she’s suffering, let’s say it’s depression. She’s gonna end up in bed all day and I’d say that’s bad. So we flipped it….
Dr. Lusskin: So now that you have what 115 minutes of cardiovascular exercise and moderate intense a week.
Dr. Fox: Yeah, absolutely.
Dr. Lusskin: That current?
Dr. Fox: 150 a week it’s give or take something like that.
Dr. Lusskin: Yeah.
Dr. Fox: Yeah, it’s give or take depends on who you read, but somewhere like, that it should be. Yeah. And women can’t do that. If they’re, you know, or maybe they ae gonna start turning to get treated in other ways like, alcohol is great, you know, yeah.
Dr. Lusskin: Self-medication. I mean, I’ve always said their drugs work better than my drugs. That’s why it’s very interesting. There’s a drug called haloperidol, which is an anti-psychotic drug. If you have really severe psychotic symptoms, like hearing voices and having visions. Haloperidol was a game changer for many people, but it has a really serious side effect profile. The only time it was abused on the street was during the crack cocaine epidemic, when people would get really psychotic. And so dealers had haloperidol with them, okay.
Dr. Fox: It’s good for business.
Dr. Lusskin: It’s good for business.
Dr. Fox: Yeah.
Dr. Lusskin: But when people are depressed and miserable, they self-medicate. And sometime we self-medicate with prescription drugs like, prescription narcotics. And I think your audience for the podcast is probably pretty educated listens to podcasts. But there are lots of people who don’t have access to really top drawer medical care around the country. There are people who have illnesses that are so severe they could barely listen to a podcast and concentrate on it. And everything we’ve said today is that much worse for the group of patients who have those challenges.
Dr. Fox: So let me ask you a question. So you’re here you have an audience, people are listening. What is it you would want someone to know who has a diagnosis or has a symptom is on a medication or isn’t on a medication and she is thinking about her future about having a family about having kids? What are the things you wish you could say to everybody before that happens?
Dr. Lusskin: I think I would start with happy mommies make for happy babies. The better you are feeling emotionally, the better the outcome will be no matter what challenges you have to face. So some women will have to face difficulties getting pregnant. And they may go through infertility treatments, which I guess have been renamed as fertility treatments.
Dr. Fox: Right, exactly. Look at the positive side.
Dr. Lusskin: Look at the positive spin, they may have to deal with that challenge. There is, of course, a risk of pregnancy loss in every pregnancy. And if you’re not in good shape to begin with, it’s gonna be that much harder to deal with a pregnancy loss whether it’s an early miscarriage, or a stillbirth, which about 1 in 200 among Caucasian women and 1 in 100 among black women in the United States. So it’s really quite a significant did I get the numbers, right?
Dr. Fox: Yes. I mean, they’re very close depends on your definitions of all these things. But basically…
Dr. Lusskin: Well, the same, loss of a baby after 28 weeks.
Dr. Fox: And give or take. It’s a little bit less after 20 weeks, that’s after 20 weeks, I think. But either way, it’s still devastating.
Dr. Lusskin: It’s still not nothing.
Dr. Fox: Oh, no, it’s higher than people think.
Dr. Lusskin: It’s like, it ain’t over till it’s over. So you got to be in good shape to go through a pregnancy. It’s a marathon, not a sprint, I see women, and we’ve been discussing women who have an identified psychiatric problem before pregnancy, whether it’s treated or not treated, we both see a lot of patients like that. But there are also women who were just fine until they got pregnant. And then…
Dr. Fox: Right, there’s the stressor.
Dr. Lusskin: Yeah, and that is the straw that breaks the camel’s back. And that’s when they develop a psychiatric disorder, a neurobiological disorder. And so we see those and then there are women who are just fine through pregnancy and it’s postpartum where they have the very first onset of any sort of psychiatric illness. I always start out by discussing the woman who’s already treated as kind of the easy way to demonstrate what we’re looking at. But not everybody knows they had a psychiatric problem that was lurking in the background.
Dr. Fox: Right, that’s fair.
Dr. Lusskin: And it’s really shocking to people when they get pregnant and they expect to be happy, but they’re not. And one of the risks you didn’t mention about depression in pregnancy is not feeling connected to the baby otherwise known as not bonding to the baby. So bonding begins when the woman realizes she’s pregnant. That’s the start of the bonding process. Now, not everybody feels bonded right away. But have you ever seen a couple where the woman say, eight weeks pregnant and miscarries and it’s the husband who gets depressed or the partner?
Dr. Fox: Yeah, I mean, I see. Unfortunately, we see a lot of miscarriages. See a lot of pregnancy see a lot of miscarriage and I’ve unfortunately had to break the news to people because it was diagnosed by ultrasound and you see everything you see a couple or both of them literally collapse onto the floor. They’re inconsolable for two hours and they can’t be spoken to then you see one but not the other, you sometimes see anger fighting with each other. You sometimes see people like lose it. Okay, and everyone’s response is unique, right? There isn’t a good or a bad responses people respond differently. But yeah, we’ve seen, I’ve definitely have seen situations where the woman in the relationship is okay with it but she’s coping very well and her partner, husband, or whoever is just distraught and devastated.
Dr. Lusskin: And sometimes it’s that she may not have been bonded to the pregnancy or heavily invested in it, because some people don’t feel attached to the baby until they can feel the baby move, which can be, 15, 16 weeks and for some people, not until 20 weeks and they’re various… and again, I’ll let you give the more detailed talk on that one. So sometimes they didn’t feel so bonded. But the partner was intensely invested in the pregnancy right from the moment of conception. And it’s really interesting when you see that it’s not necessarily a bad thing if the woman is accepting of the early miscarriage I mean, she may just be realistic about the numbers. But it’s really interesting.
Now the problem is if you don’t feel connected to the baby during the pregnancy, it’s that much harder to feel connected to the baby when you have the baby in your arms. And that’s when we really need the mother to feel bonded. Why? Not just because it’s nice and cute. And it’s like a Hallmark card. No. If you don’t feel bonded to the baby, it’s much harder to take care of that baby.
- Fox: Sure.
Dr. Lusskin: I mean, babies are 24/7.
Dr. Fox: Right, it’s gruesome.
Dr. Lusskin: So I mean, I will tell you, after I had a baby, I was like, “Oh, I could have been an intern on an internal medicine for a whole year no problem.” That was easy, who knew?
Dr. Fox: Who knew I could not sleep for this long.
Dr. Lusskin: Yeah, and still function at some level. But it’s important to feel connected to the baby. The demands are intense, and you need to be invested in that child in a way that makes it all worthwhile that you’re gonna stay up that extra hour, that you’re gonna get out of bed and feed the baby when the baby is crying. That you’re going to console the baby and take care of it. And in extreme cases, you can…you know, women who were very depressed can neglect the baby.
Dr. Fox: Yeah. And it’s sad.
Dr. Lusskin: And it’s cyclomatic. And there’s also I mean, like, you said everybody’s individual and how they respond to good news, to bad news. In the same way, you can also have somebody who’s severely depressed, who takes exquisite care of the baby, but feels no emotional connection to the baby, but they feel compelled to perform, in spite of how they feel inside. And obviously that’s better than the person who neglects the baby completely. But not having that emotional bond with the baby can have an impact on the child’s development.
Dr. Fox: Sure.
Dr. Lusskin: Because when a child develops their emotional brain, it requires a dynamic interaction between the mother or the primary caregiver and that baby.
Dr. Fox: And it’s interesting because also a lot of the data on nursing is that the benefits are probably more related to the actual bonding holding caressing then to the actual breast milk just fascinating. Again, there’s probably benefits to both, but it seems like the bulk of it based on the research is not bottled versus breast, it’s holding the baby on a regular interval, and having that touch, that skin-to-skin touch versus not. And it’s for the baby’s health we’re talking about, it’s good for the mother too, but we’re talking about with the baby.
Dr. Lusskin: And I find that if I have a mom who’s very anxious who’s very uncomfortable with nursing, because the baby latches but it hurts her nipples or she’s got mastitis or that the schedule disruptions or and the sleep deprivation just make her craze. In that case, bottle feeding is better, it’s less stressful for mother, she can hold the baby, caress the baby, rock the baby, feed the baby without having to deal with the complications that she has with breastfeeding. You know, we kind of have hinted at it without saying it specifically but there’s such a stigma against psychiatric illness in our society. Even though it’s better than when I started doing this work…
Dr. Fox: Right, it’s less of a stigma. But it’s a stigma…
Dr. Lusskin: It’s less, but it’s still pretty stigmatized. There’s still tremendous pressure for women to breastfeed that they’re bad moms if they don’t and not everybody can breastfeed. It’s a whole host of reasons.
Dr. Fox: Yeah, I can go hours and hours on this. It’s a problem that we’re still stigmatizing women and men anyone who has these challenges, these illnesses, whatever it is, and if I could speak to anyone who’s not yet pregnant or thinking of getting pregnant, address this before you get pregnant, meet with your psychiatrist and say, “Hey, what’s gonna be my plan if and when I get pregnant?” And you don’t have to have a date of when I’m… but just I’m curious, what would be your plan and if the psychiatrist says, “Oh, we’re gonna do this, we’re gonna do this.” And it sounds really reasonable and great. You have a plan me with an obstetrician meet with the maternal fetal medicine doctor whoever and say, “What would you recommend?” And if you’re getting answers that sound really off to you, get another opinion, meet with a reproductive psychiatrists, I mean, not everyone needs to meet with a reproductive psychiatrist if everyone’s doing the right thing, but many do, and get as much information as you can on the front end so that when you are pregnant, you have a plan in place. And it’s the right plan for you.
And I think that what happens, in a lot of people just sort of…they just wing it. And then they’re trying to work this all out in the first trimester, when they’re nauseous, and they’re tired, and they may be bleeding, they’re going to visits and it’s really stressful, and then it compounds the problem. And so balance planning is great. And you don’t have to have a date of conception in mind. It could be 10 years down the road, just to make sure it’s sort of, you know, it’s gonna be addressed.
Dr. Lusskin: You asked me before, what do I want people to know? And I didn’t really answer that other than happy mommy makes happy babies.
Dr. Fox: That’s enough.
Dr. Lusskin: As to which is the kick. But if you can plan beforehand, that’s great. I tell psychiatrists that they should be planning in advance whenever they’re treating a female patient with a functioning uterus. So if you’re a child psychiatrist, treating a 10-year-old and you’re putting that 10-year-old let’s say on a serotonin re-uptake inhibitor, i.e., SSRI for panic disorder. You got to be thinking what’s gonna happen when that girl gets pregnant 50% of 14-year-olds in the United States have had…
Dr. Fox: Oh, don’t finish this sentence because my daughter turned 14 yesterday. Because you’re not gonna say 50% get pregnant are you? Oh, no.
Dr. Lusskin: No, I’m gonna say 15% have had sex.
Dr. Fox: All right, whatever.
Dr. Lusskin: Sex mix.
Dr. Fox: We’ll talk about that later, but…
Dr. Lusskin: Yeah, no glove no love.
Dr. Fox: Yeah, oh, my God yeah, I was thinking you’re gonna say only 50% of 14-year-olds get pregnant. I’m not ready for that.
Dr. Lusskin: No, but we do have one of the highest rates of teen pregnancies in the developed world. A few years ago we were second only to Belarus.
Dr. Fox: What’s going on in Belarus? All right.
Dr. Lusskin: Well, you know, Belarus is another one of those countries that doesn’t have Coronavirus. So I tell psychiatrists, you should be making your medication change choices in anticipation that this patient will get pregnant. As a psychiatrist, you should be tracking when does she get her period? What form of contraception is she using? So that you can act early if the patient does get pregnant? If you’re a psychiatrist treating a female patient, don’t put her on valproic acid, because she will get pregnant. That’s what I tell the doctors for the patients. Yes, just what you said, ask the questions early and often, like voting in Chicago.
Dr. Fox: It’s fun. Yeah, it’s how we vote.
Dr. Lusskin: Early and often ask those questions early. Arm yourself with knowledge when you can. And the next part of that is, don’t ask don’t tell doesn’t work. If you don’t feel good you should tell somebody. Tell your OB tell your primary care provider. Certainly if you already have a psychiatrist, or a health care mental health provider that you’re working with, tell them and don’t take no for an answer. If somebody says, “Well, we can’t do anything about that toughed it out.” That’s not the case. And there’s information available. Another organization women should know about is called Postpartum Support International. And that’s a very good peer support organization that provides some educational materials for patients and their partners. So that’s a good source of information. You presented a case where a patient said, “Should I take this medicine or not?” And you said, “Well, let me call your psychiatrist.” We’ll encourage that your psychiatrist call your OB.
Dr. Fox: Yeah.
Dr. Lusskin: And the same goes for somebody working with a reproductive endocrinologist, get the doctors to talk to each other.
Dr. Fox: Absolutely.
Dr. Lusskin: I like to say to my patients, the answer to all questions is “Call Dr. Lusskin.” I was like, “Let’s keep it simple.” If they ask you a question about your medications just tell them to call me. I will have a doctor to doctor discussion about it and doctor to health care provider discussion about it. And then you can participate in collaborative decision making.” And what collaborative decision making means is, the patient participates in the discussion about the disease and about the treatment options. One day in my lifetime, I hope we will have the ability to practice personalized medicine, which you had hinted at before, where we can kind of drill down on an individual level to see what’s wrong with you, and figure out what treatment option is going to be the most effective, and the safest for you. So I’d like to finish my thought on this as if you’re on the wrong medicine for the wrong condition at the wrong dose. It really doesn’t matter what the reproductive safety data is. Those three things have to be in place first before we worry about whether you should stay on your medicine in pregnancy.
Dr. Fox: Shari, thank you so much for coming here today and for talking to our listeners about this. This is such an important topic. I am so glad that you’re around you are so helpful to us to our patients, obviously to everybody with what you do, and just for our listeners. Dr. Lusskin has a website. It’s www.sharilusskinmd, that’s sharilusskinmd.com. We mentioned reprotox.org, which is a little more clinical, but mothertobaby.org. Obviously, there’s gonna be links on my website as well for healthfulwoman.com, and we’re certainly gonna have you on again to discuss maybe specific conditions like, depression, or anxiety, or bipolar, schizophrenia, whatever it is, because each of these deserve their own discussion or a specific medication. But again, thank you for coming on. This is a great start to this discussion. And I’m gonna continue to convince you to come back and come on.
Dr. Lusskin: It’s a pleasure to be on it, and congratulations on the podcast. I think you’re going to reach a lot of women and their families through this which is a great way to take complicated information and spread the wealth.
Dr. Fox: Thank you so much. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcasts, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topics you would like us to address, please feel free to email us at hwhealthfulwoman.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.