By MGH Center for Women's Mental Health | May 19th, 2021
"This is a question we often hear. One of the challenges in answering this question is the interpretation of the word “best”. On one hand, the best antidepressant is the one that is the most likely to be effective. On the other hand, the best antidepressant is the one that carries the least risk when used during pregnancy. What this means is that there is no single answer. Each situation is different, and our recommendations are based on a careful assessment of the patient’s course of illness, treatment history, past medication trials, and the most up-to-date information on reproductive safety. Added to this calculation is the understanding that untreated depression also carries some risk in terms of maternal well-being and has been associated with worse pregnancy outcomes.
Stay with the Same Treatment or Switch?
We often meet with women who have switched to a different antidepressant medication in preparation for pregnancy. Other women make a switch when they discover they are pregnant. These switches are motivated by the belief that there is a “safer” medication to be used during pregnancy. The reality is that most of the antidepressants taken by women today are relatively safe and carry a very low risk to the developing fetus. What separates one antidepressant from another is that some medications have more data to support their reproductive safety than others. But even this distinction is disappearing; we have data to support the use of most SSRIs (with less data on fluvoxamine or Luvox), the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor), and bupropion (Wellbutrin). Tricyclic antidepressants, although not commonly used today, also have data to support their reproductive safety.
We have very little data on the reproductive safety of the MAO inhibitors. In addition, MAO inhibitors may have serious interactions with other medications frequency used during pregnancy and labor and delivery, specifically medications used to manage pain, such as nalbuphine (Nubain) and meperidine (Demerol). In women taking these medications, we are likely to suggest switching to another antidepressant with a better reproductive safety profile.
At this point, we have less data on the use of the newer antidepressants. There is some data on mirtazapine, with the most recent study including 334 cases of neonates with prenatal exposure to mirtazapine. While these data are reassuring and there is no indication that mirtazapine carries significant teratogenic risk, the number of mirtazapine exposures remains small. Ideally we would like to have data from 600-700 exposures to get a better estimate of risk. Making decisions regarding safety on studies with small sample sizes can lead to miscalculations of risk in either direction.
The data is even more limited with regard to the use of vortioxetine (Trintellix), vilazodone (Viibryd), levomilnacipran (Fetzima). If there are effective alternatives, we typically recommend switching to another antidepressant.
In settings where we have limited data regarding the reproductive safety of a particular antidepressant, we may consider switching to an antidepressant with a better characterized reproductive safety profile. It is important, however, to carefully consider the benefits and risks of making this switch. With any switch, there is the risk of relapse when making a change in the maintenance treatment. Thus, there are situations where we recommend continuing an antidepressant with limited reproductive safety information because there are no effective alternatives and the risk of relapse is significant.
What About Zoloft? Isn’t Zoloft the Safest?
At some point in the early 2000s, there emerged the belief that sertraline (Zoloft) was the safest antidepressant to use during pregnancy, and many women taking other antidepressants were encouraged to switch to sertraline during pregnancy. It is somewhat unclear where this opinion came from — maybe one paper suggesting lower placental passage of sertraline compared to other antidepressants; however, there is and never was any solid data to support the assertion that sertraline is safer or the safest antidepressant. Reflexively switching women to sertraline puts women at risk for recurrent illness.
While sertraline is effective for the treatment of depression and anxiety and is a reasonable choice for many women, one problem with sertraline is that it tends to be under-dosed. The typical starting dose is 50 mg; however, many individuals will need 150 mg to 200 mg to effectively manage their symptoms. Especially when sertraline treatment is initiated in the primary care setting, we often see women whose dose is too low to effectively manage their symptoms.
What About Paxil? Doesn’t It Cause Heart Defects?
The most current data regarding the use of paroxetine (Paxil) during pregnancy does not indicate an association between the use of paroxetine during pregnancy and risk for cardiovascular malformations. However, in 2006, GlaxoSmithKline (GSK) elected to change product label warnings for the antidepressant paroxetine (Paxil), advising against the use of this drug by women who are pregnant. This decision was based on two preliminary studies which suggested a small increase in the risk of cardiovascular malformations among infants exposed to paroxetine in utero. For many years, this concern regarding risk of heart defects resulted in recommendations that women taking paroxetine should either stop paroxetine or to switch to a different antidepressant during pregnancy.
However, in 2008, a study from the Motherisk Program in Toronto reported on the outcomes of over 3000 paroxetine-exposed infants and found no association between the use of paroxetine during pregnancy and increased risk of cardiovascular malformations. Nonetheless, some women and their treaters continue to feel uncomfortable with the use of paroxetine during pregnancy. Furthermore, many websites (including reputable sites like the Mayo Clinic) continue to urge women to avoid paroxetine during pregnancy because of the risk of malformations.
At this point, we typically do not recommend switching from paroxetine to another antidepressant for pregnancy. Although paroxetine is an SSRI, there are definitely situations where an individual may respond better to paroxetine than to other SSRIs. Thus, switching to a different antidepressant may increase risk for relapse.
What About Lexapro? And Pristiq?
There are some newer antidepressants that are derived from older parent antidepressants. For example, citalopram (Celexa) is a racemic mixture, composed of R- and S-enantiomers (or mirror images) of citalopram. While the S-enantiomer is clinically active, the R-enantiomer is not. Escitalopram or Lexapro contains only the active S-enantiomer. Because the S-enantiomer is contained in the original citalopram formulation, we can infer that the reproductive safety of escitalopram (Lexapro) is the same as that of citalopram (Celexa).
Another example is desvenlafaxine or Pristiq. For venlafaxine to be effective as an antidepressant, it must first be metabolized by the body to desvenlafaxine. Pristiq contains only the active metabolite desvenlafaxine. Because desvenlafaxine is a metabolic byproduct of the original venlafaxine formulation, we can infer that the reproductive safety of desvenlafaxine (Pristiq) is the same as that of venlafaxine (Effexor).
The Bottom Line
No two situations are identical; thus, we must carefully consider each woman’s clinical history and preferences in order to select a treatment plan that makes sense. Ideally this discussion should occur long before a woman is pregnant, so that there is ample time to consider the various options and to make changes, if necessary.
When we meet with women to discuss the use of antidepressant medications during pregnancy, we typically consider a number of issues:
The perinatal psychiatry consultation should be viewed as a collaborative venture, where provider and patient decide together what is the best option for treatment during pregnancy."
-Ruta Nonacs, MD PhD
By: Bethany Braun-Silva
"Expecting parents have multiple checklists of everything they need to get ready for their baby’s arrival. Cribs, bottles, car seats, and strollers are just a few of the essentials you need to consider before welcoming a new baby. But even before any of that, there’s the hospital bag checklist. A robe, a nightgown, slippers, and a few blankets are sure to make the list, but oftentimes, a postpartum recovery kit gets overlooked.
A postpartum recovery kit has what moms need to help with bleeding, soreness, and overall discomfort. You can create your own kit by buying things like disposable underwear, ice packs, and perineal spray separately, but there are also ready-made kits for moms that include all these things and more.
Many moms agree that postpartum recovery kits are a great choice. The Frida Mom Hospital Packing Kit for Labor, Delivery, Postpartum, for example, has over 1,000 five-star reviews on Amazon and a near-perfect 4.8-star rating. “I would 100% say that every postpartum experience needs this kit,” writes one customer. “I think it’s well worth the price for the comfort you’re getting.”
The Miloo Mom Hospital Labor and Delivery Gift Packing Kit for Delivery, Postpartum is also a great choice available on Amazon. One reviewer writes, “I was very impressed with my kit, and I used all of it when I was in the hospital.”
Convenience is so important when you have a new baby, especially when it comes to your healing. The first six weeks after giving birth are a critical time in the healing process, and having the right tools handy can make all the difference in your physical (and mental) health. If you’re pregnant or know someone who is, check out the postpartum recovery kits below."
"Lifestyle changes to improve and prevent symptoms of depression and anxiety."
I knew he’d run the other way if I jumped too quickly into a medical referral or diagnosis, so we started with the most human approaches — connecting about what was really going on for him, and exploring readily available lifestyle changes that aligned with his interest, motivation, and values. Within weeks, his spark started to come back, and within months he felt he had a new lease on life. He wasn’t suddenly happy all the time. But he felt a new sense of his capacity to take charge of his mental health.
Will everyone have an outcome like Roy from lifestyle changes? Definitely not — anxiety and depression are complex conditions with tremendous individual variation, varied underlying causes, and varied levels of severity. But can everyone benefit from learning the foundation for how to care for their mind either separately or as an adjunct to professional treatment? I believe so.
The following seven health behaviors are key ones linked to prevention or symptom improvement of anxiety and depression.
While everything on this list is simple, it’s far from easy. Change is hard. And if you currently have depression or anxiety, it can be especially challenging. That’s why one of the key behaviors is being kind to yourself.
If moved to do so, choose one area to work on at a time, perhaps an area you feel especially motivated or confident to address, or an area that feels aligned with your most important values. Then take it one step at a time. The funny thing about change is we often don’t know it’s happening, we just keep rowing in the right direction, and usually after a few, or a few thousand, twists and turns, we look back in awe at how far we’ve come.
While 10-18% of adults in the U.S. experience chronic sleep issues, this number jumps to 65-90% of those with depression, and over 50% of those with generalized anxiety disorder. Of those with depression, 65% had sleep issues first. Addressing sleep issues can alleviate symptoms of mental health conditions, and given sleep problems are a risk factor for mental health conditions, can also help protect your mental health.
There are many resources to help improve your sleep, such as this free app.
A disposition that tends towards self-critical, or perfectionistic, can be a risk factor for anxiety and depression. This can include feeling like you must be perfect to be accepted, an inability to accept flaws within yourself, intense self-scrutiny, or an unrealistic sense of others’ expectations and your capacity to meet them.
Despite the fear of many who have this characteristic, the antidote to perfectionism isn’t letting it all go, or saying goodbye to standards – it’s self-compassion. According to researcher Kristen Neff, self-compassion has three components: self-kindness vs. self-judgment, common humanity vs. isolation, mindfulness vs. overidentification. How we treat ourselves through the ups and downs of life can have a tremendous impact on health and mental health.
3. Social Connection
From the time we are born, we need social connection in order to thrive.
A recent study lead by researchers at Harvard sought to understand what could most protect us from depression that is within our control. After analyzing over 100 potential factors, they found that social connection was by far the most important protective factor.
It’s been a lonely year for many. And many are anxious at the prospect of going back to normal. But connection doesn’t mean a big party or bustling office. It can be confiding in one trusted person about how you’re really doing, listening to how someone else is really doing, giving a meaningful thank you, or having a (safe) visit with any family member or friend. If this feels out of reach, try making a short list of people who at any point have given you a sense of belonging. Other studies have shown that just calling positive relationships to mind can have a positive impact on our capacity to tolerate stress."
"Registered Dietitian Tracy Lockwood Beckerman gives tips on the most nutritious foods to eat to support your baby in each trimester of your pregnancy."
No, lying flat after sex won't increase your chances of conception.
By Jen Gunter, MD| April 15, 2020
Photo: Armando Veve
"As an ob-gyn, I’ve personally encountered many fertility myths in my office or online — some of them even during my training. Why do they persist? Sex education, particularly about the physiology of reproduction, is typically incomplete and subpar. And when we do talk about fertility and reproduction, we don’t talk about it directly — euphemisms for the uterus, menstruation, the vagina and the vulva are still common, and when you can’t use a word, the implication is that the body part is shameful. And, of course, many myths persist simply because they’re alluringly fantastical, and we’re inclined to believe these tall tales over the stodgy facts. Here are seven fertility myths that need to be forgotten.
1. Phases of the moon affect menstruation
This is not an uncommon belief-some women even refer to menstruation as their "moon time." The confusion is understandable: The 29.5-day lunar cycle (from new moon to new moon) is very close to the average 28-day menstrual cycle. But studies show no connection between the moon and menses. Moreover, it is hard to envision how a moon-menstruation would be biologically beneficial to human reproduction.
2. Reproductive hormones need to be ‘in balance’
This is a common modern myth in gynecology exam rooms all across North America-and it results in a lot of unnecessary testing of hormone levels. The truth is that, for women of reproductive age, the hormone levels for FSH, LH, estrogen and progesterone change not only day to day, but also often hour to hour. When a women has certain symptoms-for example, an irregular menstrual cycle or infertility-hormone testing may be recommended to make a diagnosis. But in these situations, doctors will look at individual levels in conjunction with symptoms, rather than comparing levels with some mythical "balance." Being "in balance" may sound natural, like a person who is "in tune" with her body. But it is simply not a factual statement, or even a good analogy, for what happens biologically."
How women find the strength to endure multiple pregnancy losses
February 9, 2020| By Meghan Holohan
"Soon after getting married, Jenn and Phil Tompkins learned they were expecting a baby. Tompkins had always dreamed of being a mother and wanted to start her family as soon as possible. At six weeks pregnant, she excitedly announced it on Facebook.
"It's not a fantastic thing to do on multiple levels because once you announce it, not everyone gets the un-announcement," Tompkins, 43, of Freeport, Pennsylvania, told TODAY Parents.
When Tompkins went to her eight week ultrasound, she worried when the technician kept asking her questions.
"She asked if we were sure on our date, which I thought was a weird question, and she turned the screen away and said she had to come back," Tompkins explained.
The tech returned with the doctor and they shared the news.
"The baby stopped developing and did not have a heartbeat," Tompkins said. "That day our world changed."
The doctor advised the couple wait for Tompkins body to heal before trying again. Soon after, Tompkins got pregnant again and miscarried. A third time, Tompkins became pregnant and lost the baby. After her third miscarriage, her doctor recommended she visit a maternal-fetal specialist who could test the couple to try to understand why the miscarriage kept happening. Before they even tried any treatments, Tompkins became pregnanct again."
By Guy Winch
"At some point in our lives, almost every one of us will have our heart broken. Imagine how different things would be if we paid more attention to this unique emotional pain. Psychologist Guy Winch reveals how recovering from heartbreak starts with a determination to fight our instincts to idealize and search for answers that aren't there -- and offers a toolkit on how to, eventually, move on. Our hearts might sometimes be broken, but we don't have to break with them."
By Guy Winch, Ted Talk
"We'll go to the doctor when we feel flu-ish or a nagging pain. So why don't we see a health professional when we feel emotional pain: guilt, loss, loneliness? Too many of us deal with common psychological-health issues on our own, says Guy Winch. But we don't have to. He makes a compelling case to practice emotional hygiene — taking care of our emotions, our minds, with the same diligence we take care of our bodies."
By: Dr. Wendy Suzuki, Ted Talk
Wendy Suzuki is researching the science behind the extraordinary, life-changing effects that physical activity can have on the most important organ in your body: your brain.
"What's the most transformative thing that you can do for your brain today? Exercise! says neuroscientist Wendy Suzuki. Get inspired to go to the gym as Suzuki discusses the science of how working out boosts your mood and memory -- and protects your brain against neurodegenerative diseases like Alzheimer's."
By: Katty Kay and Claire Shipman
“Evidence shows that women are less self-assured than men-and that to succeed, confidence matters as much as competence. Here’s why and what to do about it.”
Confidence in Women
Although women have worked hard and have made great strides including the following:
**Men still get promoted faster and paid more. Women still struggle to make it to top positions. The number of women in top positions is very small and barely increasing.
Women are lacking in confidence, including women who are highly successful in the professional world. There is a vast confidence gap that separates women and men. Compared with men:
*Women don’t consider themselves as ready for promotions.
*Women predict they’ll do worse on tests.
*Women end up going into less competitive fields like human resources or marketing.
*Women generally underestimate their abilities.
*Women feel confident only when they are perfect…or practically perfect.
"The confidence gap is important because success correlates with confidence just as much as it correlates with competence. Having talent isn’t merely about being competent; confidence is a part of that talent, you have to have it to excel."
“Confidence is the stuff that turns thoughts into action. It is the factor that turns thoughts into judgements about what we are capable of, and that then transforms those judgements into action.” –Richard Petty (Psychology professor at Ohio State University who has spent decades studying confidence.)
"Women also suffer from the perfectionism mentality. Women strive to be perfect in all that they do. Women have fixating thoughts on their performance at home, at school, at work, at the gym, and even on vacation. Women have obsessive thoughts about every role in their lives because we want to do them all perfectly, but perfectionism is another confidence killer. Striving to be perfect actually keeps women from getting too much of anything done.
Is this to say that men don’t suffer from thoughts of doubt?
No, men do suffer the occasional thought of doubt, but not with such exacting and repetitive zeal, and they don’t let their doubts stop them. Women often times let their doubt or lack of confidence get in the way of trying. Women can do just as well as men when taking tests or performing in top positions, but they choose not to try because they don’t feel confident in their ability to perform. This is what holds women back. Women avoid taking risks because they fear making mistakes and strive to be perfect. When we hesitate because we aren’t sure (low confidence), we hold ourselves back.
The good news is that we are capable of performing just as well as men do! The evidence is implicit, to become more confident, women need to stop over thinking and just act! The more that we do this, the more confidence we will build. By shifting our thought patterns and behavior, by keeping at it, channeling our talent for hard work, we can make our brains more confident prone."
“What neuroscientists call plasticity, we call hope.”