Dr. Adam Murado is a Harvard-trained, board-certified OBGYN who specializes in maternal fetal medicine. His focus is on the increase of the prescription of SSRIs, also known as antidepressants, during pregnancy, and the effect that that has on women after they are born.
00:04:02.320And what have you seen change in the world of obstetrics in that almost 30-year period, maybe for better and for worse?
00:04:11.160I feel like we're seeing more intervention now progressively over time just in terms of the medicalization of pregnancy.
00:04:20.640And pregnancy and childbirth is something, obviously, that's been worked out in mammals for millions and millions of years.
00:04:27.520And so there's a lot to be said for trying to allow the natural process to proceed without a large number of interventions.
00:04:36.820And I've seen over time progressively that we're doing more and more, whether it's ultrasound or whether it's medications, which is the area that I focus on now, medication exposure in pregnancy, or C-sections for delivery, et cetera.
00:04:50.660Sort of over-intervention and sometimes causing more harm than good.
00:06:06.720End of pregnancy care is challenging for moms and babies and the family and also for the OB providers, doctors, nurses, midwives, et cetera.
00:06:17.720And I think that they and all parties there, I think, mean well.
00:06:22.240I take care of a lot of home birth patients now, patients that plan a home birth that want a minimum of intervention or they might have had a bad experience previously.
00:06:29.160And I'm sympathetic to what they're saying about feeling maybe forced into certain things.
00:06:33.340But I think my colleagues, my fellow doctors and midwives, et cetera, they want the best for the patients.
00:06:39.580But it's hard at the end of pregnancy trying to balance things.
00:06:42.920We tend to, as providers, want to avoid disaster, want to avoid the worst outcomes.
00:06:49.480So with end of pregnancy care, there's a lot of things that can go wrong at the very end of pregnancy, things like preeclampsia, hypertension, stillbirth is the one everyone worries about.
00:07:01.180Stillbirth, which can – it's not common, but it's not terribly rare either.
00:07:07.540So as we get towards the end of pregnancy, as we get to the due date, that's always kind of weighing on the OB provider's mind.
00:07:14.960And so there's an argument to be made, and some people are making this argument for delivery – excuse me, for delivery at 39 weeks because that prevents any complications from happening beyond that.
00:07:25.780The problem with that approach, though, is that while it does avoid disaster by getting the babies out at 39, it really ends up being, in most cases, in the overwhelming majority of cases, over-intervention.
00:07:39.160Most women don't need to be delivered at 39 weeks, and the labor and birth experience will be much better if we just wait and let the woman go into her own natural labor.
00:07:49.020So if you stay – if you just keep your hands off and follow the mom, follow her closely, and, say, let her get to her due date and she goes into labor, she may be able to come into the hospital and have a labor and delivery that lasts on the order of 8, 10 hours or something like that.
00:08:04.320If you do the induction at 39 weeks, you may be looking at a 1, 2, 3, 4-day induction.
00:08:10.620And so that's a much more difficult birth experience for the mom.
00:08:13.620And so for an OB provider, it's trying to balance those things.
00:08:18.420In terms of cesarean, the cesarean delivery, our rates are way too high in the United States where it's about 1 in 3 now.
00:08:31.100Part of that problem is also the same dynamic, though, where if you're watching a woman in labor and you're watching the heart rate tracing and there's any question, any concern about it, the fault will always be failure to do a C-section.
00:08:46.520That's what gets the doctor in trouble.
00:08:48.880There's almost never or very rarely examples where doing the C-section early leads to litigation, for example.
00:08:57.120And not that doctors are just focused on litigation, but they're also focused on good care of the patient and avoiding the very bad outcome.
00:09:04.200And so I think that's probably what's pushing it, both early inductions and the move towards cesarean, is the desire to avoid the catastrophic or the very bad outcome for the patient.
00:09:16.240Why do you think that has increased, the interventions have increased over the past 28 years, though?
00:09:23.920Is it just because there's more fear for some reason?
00:09:27.120Is there a justification behind the higher rates of intervention?
00:09:30.860Is it because patients are more litigious than they used to be?
00:09:35.120Like, why do doctors now feel more so than they used to that they've got to do something and induce?
00:09:42.280So as far as the area that I'm interested in particular now, which is medications, I think that the increasing use of medications in pregnancy is just a reflection of the broader society.
00:09:53.100I heard a statistic the other day, I think this is accurate, that the United States population makes up about 2%, about 4.2% of the world, but we use about 70% of the pharmaceuticals or 50 to 70%.
00:10:05.840So we're using a large number of medications anyway, background in society, and then that spills over into pregnancy.
00:10:13.300And so we're seeing more interventions, more medication use.
00:10:16.700And I think that's just a reflection of the broader society.
00:10:19.620In terms of things like induction of labor, we're seeing, I think, less tolerance for watching those pregnancies late.
00:10:29.160And there's also been studies, a study came out called the ARRIVE trial.
00:10:33.640ARRIVE is an acronym that made people feel that it was a safer route to take, the 39-week induction, to prevent problems later.
00:10:43.140The group that got induced in that study had lower rates of hypertension, lower rates of complications, and naturally they're going to have lower rates, if you do it in a widespread population basis, lower rates of stillbirth, etc.
00:10:55.860Because you can't have a 40 or 41-week stillbirth if you've been delivered at 39.
00:11:00.780So when that trial came out, it pushed people in that direction towards more intervention.
00:11:06.920It can be difficult for women to find doctors that are striking that balance because I can sympathize with how difficult it is.
00:11:14.840Obviously, you want to care for the patient.
00:11:16.720You want to care for the little patient inside her womb.
00:11:19.500And the worst case scenario is that someone dies or someone is catastrophically injured.
00:11:25.600For example, in like a VBAC, you know, vaginal birth after cesarean, for those out there who don't know, there's a risk of uterine rupture, which I guess there's a risk of uterine rupture at, you know, for any pregnancy.
00:11:37.380But it's increased when you have that scar in your uterus.
00:11:40.140And I actually had a VBAC after two C-sections.
00:12:32.080But I just say that to say that it was very difficult to find a team that would balance that, that obviously didn't want anything catastrophic to happen, but also, you know, trusted that childbirth is a natural process and that the risk of uterine rupture is very low.
00:13:02.800Yeah, I think that with my patients, the main thing for me is to just inform them, inform them accurately, and then support them in the decisions that they make.
00:13:12.800But the big part of that, of informed consent, is making sure that the patients actually have the accurate information, which in particular in the area that I focus on with medication exposure is a big one.
00:13:24.400We've been trying to make sure that women have accurate information so that they can make the decision that's right for them and then to try to support them in that process.
00:13:33.040It sounds like you got that information.
00:13:34.740You made the decision that you wanted to and had a successful outcome.
00:15:46.940We've kind of turned that on their head and felt like, well, they're probably okay unless we can prove that they're harmful.
00:15:52.200And so I think we've moved away from that over time.
00:15:54.200Before I get into that, I just want to say that it's important that I talk about safety of medications in pregnancy all the time.
00:16:31.160Compassionate care is what you want to provide, compassionate, loving care, but a big part of that compassionate care is giving patients the correct information, telling them the truth about what they're taking.
00:16:42.840And so that has become, over my career, more and more of a focus for me, especially as I've seen more and more use over time.
00:16:52.420And these are medications just in general, whether it's for nausea and vomiting early or whether it's for conditions late.
00:17:00.020The main one I'm focusing on currently is the use of antidepressants during pregnancy because we're seeing so much of that in the general population, but in particular in pregnancy as well.
00:17:10.500And I think the big thing I feel about it is the patients that I'm seeing just aren't getting the accurate information about what the actual impact of antidepressants, or in particular the SSRI antidepressants are, on the pregnancy, on the developing baby.
00:17:25.480Okay. I have so many questions about that, but you mentioned all medications, that you're not only talking about SSRIs.
00:17:46.840I have never taken a medicine that worked that quickly.
00:17:50.000Before we get into the SSRIs, because that'll be the longer conversation, like what is your thought about prescribing the anti-nausea medication in the first trimester?
00:17:58.960Well, I'm glad you got relief from your episode there.
00:18:01.200I think that it's always, for patients in these scenarios, it's always a balance of risks and benefits and alternatives, and just making sure that the patient's informed.
00:18:12.700So most nausea and vomiting of pregnancy is well tolerated by the mom.
00:18:16.620It may have some physiologic reason for being there in terms of avoiding exposures, avoiding toxins early while the embryo is developing.
00:18:24.820But some moms will get very severe forms of it, where they'll move into something called severe hyperemesis gravidarum.
00:18:47.460It really depends on the mom and, again, on the counseling.
00:18:51.760Any medication that a mom takes, virtually any medication that a mom takes, is going to cross over, go into the mom and cross over to the baby.
00:18:59.760And I tell my patients that medications are chemicals.
00:19:05.220They're not naturally occurring substances.
00:19:07.660They're not like oranges growing on an orange tree.
00:19:10.860They're like they're synthesized in a chemical manufacturing facility.
00:19:14.740So if you think about it, if you like look up how chemicals are synthesized, you'll see it's by a lot of steel tubes and workers wearing goggles and they're wearing masks because they're working with chemicals.
00:19:29.580So those come out of the chemical plants and then they get packaged in a little amber bottle and then they get ingested by the women.
00:19:38.780So those medications are going to cross over from the mom into the baby.
00:19:43.120A drug like Zofran has an impact on the serotonin receptors.
00:19:48.600Serotonin is a crucial cell signaling molecule.
00:19:53.780Serotonin is crucial for fetal development.
00:19:56.620So this discussion now also applies to the SSRIs.
00:19:59.840Serotonin is absolutely crucial for formation of the baby.
00:20:04.100And these drugs, Zofran and then in particular the SSRIs, they really impact the serotonin system.
00:20:10.360So if you just put A and B together, what I just said, the two things I just said, if serotonin is crucial for fetal development, which it is, and there's no scientific controversy about that.
00:20:41.200It's a neurotransmitter and it's a cell signaling molecule that goes way back in evolution.
00:20:47.800This is a basic chemical compound that helps to, for all of us, regulate our mood, regulate our behavior, regulate our sexual functioning.
00:20:59.440It plays a significant role for adults, for children, etc.
00:21:02.820At the fetal level, it plays a crucial role in cell signaling and in actually the formation of the fetus and in particular the fetal brain.
00:21:12.100I compare it to like a molecule that's acting as a director, an engineer, a supervisor in the building of a building or a town giving directions to the neurons which way to go.
00:21:26.220The fetal brain has to go basically from zero to like 100 billion neurons with 100 trillion connections.
00:21:35.220And so what's orchestrating that serotonin and other cell signaling molecules telling the nerves how to grow, where to branch, how to develop.
00:21:45.580So it's this incredibly intricate, well-developed, well-preserved system that we find through mammals.
00:21:53.260We find it across the board that's absolutely vital to the formation of a human baby.
00:22:02.660And so if you've got this delicate system, intricate system that relies on serotonin and other neurotransmitters like norepinephrine, dopamine, that relies on those things.
00:22:11.960If you have that and you then disrupt it with chemicals like Zofran or like the SSRI antidepressants or other antidepressants, it's going to have an impact.
00:26:36.120But that's not, in fact, what's going on.
00:26:38.820Diabetes, you can address that with insulin.
00:26:42.360Depending on the type of diabetes, there can be a mismatch between how much insulin.
00:26:46.600There's not enough insulin, and so that can address it.
00:26:48.740But with the SSRIs, there is no proven, and Joanna Moncrief addressed this in her paper a couple of years ago in her current book that she has on this.
00:26:58.340There is no evidence for a chemical imbalance that you're then addressing or correcting.
00:27:04.140What you're doing essentially is creating an altered mental state for people by virtue of taking the drug.
00:27:11.080And this is even more so for the developing baby, because the developing baby has no issue going on.
00:27:18.340And now, at the point where the developing baby needs to have the serotonin system functioning optimally to form the brain, to form the organs, to wire the brain,
00:27:28.700it's got this chemical, this synthetic chemical compound coming out of a chemical factory and going into its brain and essentially disrupting that development.
00:29:05.020I'm wondering why more doctors don't have the concerns that you are raising.
00:29:12.200You've mentioned that there are more interventions than there were before, and yet we seem to know more about what these SSRIs are actually doing, how they can affect fetal development.
00:29:26.620Why are we seeing more prevalence of the usage of these drugs on pregnant women?
00:29:32.760Yeah, I think there's two things pushing this, basically.
00:29:35.520I think that the pharmaceutical industry is like the 800-pound gorilla in our lives in terms of how we provide medical care.
00:29:45.280And they're able to kind of shape the debate and shape the thinking around these topics.
00:29:49.940And so they're able to throw their weight around through finances and through sponsorship.
00:29:56.900And I can discuss more of that, how they influence medicine.
00:30:00.400Sorry to interrupt, but does the chemical imbalance message that you just debunked, does that come straight from the pharmaceutical companies?
00:30:08.460Is that basically just a marketing slogan?
00:30:10.300I think of that as a marketing slogan, whether how it was introduced or how it was brought about in widespread fashion, probably through some combination of pharma and what I would call the medical establishment, where that message then took hold.
00:30:29.340And the messages that the public hears, and this is an important lesson for people to understand, is that the messages you're going to get or hear sort of in mainstream media or through a lot of medical establishment sources are going to be messages that are pro-pharma, that are pro-drug because of the disproportionately high influence that the pharmaceutical industry has.
00:30:57.180And this is across the board with what I would call the medical establishment.
00:31:01.840So the information, we have a real problem with information and regulation of pharmaceuticals, of drugs in our society.
00:31:10.440And a big part of that is because of how strong the pharmaceutical industry is.
00:31:15.140So the way the system should work is you've got a bunch of patients here who are trying to take care of their health, who need good information.
00:31:21.600You've got the pharmaceutical industry over here who wants to sell them products.
00:31:27.380But between the pharmaceutical industry and the patients, you should have this great medical establishment that are working on behalf of the public, trying to protect them, trying to inform them.
00:31:40.580And that would be places like regulatory agencies like the FDA, like the CDC, as well as institutions like our institutions of higher learning, all of the universities.
00:31:55.000Also in that middle area between patients and pharma would be experts, the experts in a given area, researchers.
00:32:03.880And then another aspect of that medical establishment would be the media, trying to inform patients correctly, get out proper information on these things.
00:32:12.660So the model is you've got pharma here, you've got patients here, and between them what we should have is a real protective layer.
00:32:20.500But that's not what we have in our society.
00:32:25.040For years, the FDA, the CDC, the leading academic centers, even the media were all funded by pharma.
00:32:34.900So instead of playing that protective role, they're essentially playing a role of salesmen.
00:32:40.880They're basically working for pharma to get the public to take the medications.
00:32:46.020And we see this again and again with various models, with the serotonin hypothesis, et cetera.
00:32:51.340And so that's one part of your answer, why we're seeing more and more women using these.
00:32:57.060It's just the pure power of pharma and money that has allowed them to shape the message through pharma itself, but also through these other what should be trusted sources who are basically, in a lot of ways, funded by pharma and then parroting that message.
00:33:15.920The second reason, though, I think, gets to this notion of toxic empathy that you talk about in your book, which is that we all want to help the pregnant woman who's struggling.
00:33:31.220And a woman in distress who's pregnant, it's very sad, and we want to help that woman.
00:33:37.000And so there's a human desire to tell that woman a story that's going to be shaped like what pharma is actually trying to say, which is that the medication is okay, it's going to make you feel better, and by making you feel better, you're going to end up with better pregnancy outcomes for the baby, better development of the baby.
00:33:58.100But I would also call that toxic empathy, that that's not what we need to be saying.
00:34:04.280We need to be telling the truth, as you very well point out.
00:34:07.100You need to tell the truth, which is telling a patient in that scenario that this is what the medication's risks are, and you can also review benefits, for example, not going into withdrawal during pregnancy, which is part of the counseling, and then allowing that woman to make the best decision for herself and support her.
00:34:23.920But that second reason, I think, is how a lot of people in society, even if they don't want to be parroting pharma's propaganda, how they'll still end up doing that because they're trying to give a message to depressed pregnant women or depressed women of childbearing age that will be friendly to what they're doing currently.
00:34:44.840Can you tell me more about what SSRIs can affect when it comes to fetal development?
00:34:53.920Sure. That's really the nuts and bolts of it. That's a great question.
00:34:56.820So early along in pregnancy, I will say, when we look at animal data, the animal data is very clear.
00:35:05.720When we look at animal data, we see pregnancy complications.
00:35:09.440If you take a group of mice or rats or rabbits and you expose one group to SSRIs and the other group to a placebo, you see poor pregnancy outcomes in the SSRI exposed group.
00:35:20.840That's clear. When you do it in humans, it gets a little harder to study because you get into things like, are you going to look at how are you going to tell that they were exposed?
00:35:32.340Are you going to look at prescriptions? If you look at prescriptions, maybe they didn't fill the prescription.
00:35:37.520Now you're calling them exposed, but they're actually not exposed.
00:35:40.540So the study in humans gets more difficult and there's some mixed data.
00:35:45.040But overall, my take on the science is that we're seeing, just like we do with animal data, we're seeing increased rates of miscarriage.
00:35:53.180So the woman losing her pregnancy early, we're seeing increased rates of birth defects.
00:35:58.340It's been clearly shown with some of the drugs, things like heart defects.
00:36:03.320People usually know about Paxil or paroxetine and heart defects, but other SSRIs and other SNRIs as well have been associated with birth defects.
00:36:12.660Then moving through the pregnancy, we see increased rates in preterm birth.
00:36:16.840We see increased rates in PPROM, breaking your water early, having the rupture of the membranes.
00:36:23.080We see increased rates of low birth weight babies, small for size.
00:36:28.080They didn't grow well, likely because of the impact of the drugs on the placenta.
00:36:33.060Late in pregnancy, we see an increase in a disease called preeclampsia, which causes high blood pressure in women and proteinuria, protein in their urine.
00:36:42.680We see higher rates of that in the women on the SSRIs.
00:36:46.500At the time of delivery, for sure, we see higher rates of postpartum hemorrhage.
00:36:50.800There's higher rates of women bleeding who are on SSRIs in pregnancy.
00:36:54.280Because of the platelet thing you talked about with serotonin.
00:38:20.020When the studies have looked at this, the studies quote rates as high as one textbook or one online textbook cites a rate as high as 85%
00:38:29.960for seeing some impact of the exposure to SSRIs during the pregnancy.
00:38:35.180So we see high rates of this, more likely to end up going into the NICU, more likely to have what's called a low APGAR score.
00:38:44.700The APGAR score is a way of assessing how the newborn's doing after birth.
00:38:49.480And babies that have been exposed to SSRIs in utero are more likely to have an APGAR at five minutes less than seven, which has been predictive of future problems.
00:39:15.380But it looks like the offspring who are exposed to SSRIs prenatally have higher rates of depression, higher rates of anxiety.
00:39:28.400They have higher rates of neurobehavioral abnormalities, difficulties with motor skills.
00:39:33.940It depends on the study that's looked at it, but they've found difficulties in speech, delays.
00:39:39.920And autism is the one everyone asks about.
00:39:42.380Several animal studies, numerous animal studies of exposure in utero or exposure during development show that the mice and the rats have what they call autistic-like behaviors.
00:39:55.220We see this in terms of they're not socializing in the same way.
00:39:59.620And so people have said, well, this could certainly be contributing.
00:40:02.980When you start talking autism, though, it gets very controversial and very murky because how that diagnosis is made, whether you're talking about just a personality difference versus profound autism, which is an IQ less than 50, lack of verbal skills, etc.
00:40:21.800It's, you're talking about complexity in the diagnosis, but it looks like without a doubt from the reading of this literature, it looks like there's an impact for sure on the baby's developing brain that then shows up as they grow up.
00:40:35.740A study just came out, actually, in fact, last week, Zani is the lead author, that looked at mice who were exposed during development and then how they responded, what their fear response was.
00:40:54.100So they had those mice exposed during development and then as they grew up, they did a study where they exposed them to the stimuluses, mountain lion urine, I think is what they use, because the scent of the mountain lion is their predator.
00:41:07.700And they can see that the ones that were exposed to SSRIs during pregnancy have a different fear response as they grow up.
00:41:16.400The same study was then done in humans, where they looked at humans who had been exposed to SSRIs during pregnancy, and then at age 11 to 13.
00:41:25.960So we're not talking newborn period, we're talking 11 to 13.
00:41:29.440They did MRIs on them, functional MRI, while showing them pictures to induce fear.
00:41:35.360Sounds like a terrible study. It's really sad.
00:41:39.240We shouldn't be scaring 11 to 13 year olds that way, right?
00:41:42.280But they find a difference in the children or in the adolescents at that point who have been exposed to the SSRIs in Europe.
00:41:49.220Like less of a fear response? It's a suppressed fear response?
00:41:59.360This just came out from Columbia University Medical Center and it's just out now.
00:42:04.560But this is not the first study showing this kind of thing.
00:42:08.200I've been following this literature now, the scientific literature, for 20 plus years.
00:42:13.500And it's study after study is showing this, these effects on the developing fetus, in particular the developing fetal brain, of being exposed to SSRI antidepressants during pregnancy.
00:42:27.080The one I get asked about all the time is, could there be an impact on sexual functioning?
00:42:32.340And this has absolutely been shown in the animal studies.
00:42:36.900So if you expose a mouse in development during the period that corresponds to third trimester human development, if you expose a mouse to an SSRI, a male mouse or male rat, and then you study their sexual behavior in adulthood, their sexual function in adulthood is significantly different than the mice or rats who weren't exposed to the SSRI during development.
00:43:03.900They do these studies where they will look at the, they'll expose them during development at an early time and then look at them in adulthood.
00:43:13.520They present them to a female, mouse or rat, and then they look for activity.
00:43:40.540That's what I was trying to understand.
00:43:41.840So it could be that these SSRIs are affecting the sexual function or desire of, you know, the future adults.
00:43:53.000Like once they become adults, if they were exposed to SSRIs in utero, it is possible that that will affect their sexual desire and function later on.
00:44:47.220I think it's coming more to the fore because there are these questions in our own society of sex and sexuality and gender issues and whatnot.
00:44:55.860And could, the question I often get asked is, could the exposure in utero be affecting things like sexual identity or sexual behavior in the future?
00:45:08.680And I would say absolutely yes, because those tracks get laid down during development of the brain.
00:45:15.600And so could it possibly have an impact?
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00:46:26.920So what I'm trying and maybe this is a redundant question, but you mentioned that a lot of doctors are simply trying to avoid catastrophe at all costs.
00:46:41.540And so they will make decisions that they feel are more under their control, like maybe having a C-section or inducing labor earlier on to try to mitigate some risk that could happen later in pregnancy.
00:46:52.060But what you're saying is that these SSRIs that are given to women actually increase the risk of catastrophic events happening to the baby or mother at the end of pregnancy.
00:47:01.860And so how does that disconnect exist?
00:47:07.120And it should certainly be more in the fore, I think, of the OB providers' minds that this is not necessarily the safe route because of this increase, this disruption of fetal development, the impact on bleeding, the problems after birth.
00:47:23.820All of those things need to come to the fore.
00:47:25.740But I think what many OB providers are concerned about is another catastrophe, which is a mom's mental health spiraling downwards and suicide and that being the catastrophe that they're concerned about.
00:47:42.200And I would say here also that really this message, what I'm discussing, these risks that I'm discussing, really need to be risks that are understood in women of childbearing age.
00:47:54.540And it's too late if you're having this conversation at 12 weeks when I often see patients or at six or eight weeks.
00:48:02.920It's too late for a couple of reasons.
00:48:04.920One, the woman's already been exposed now for weeks during embryonic development.
00:48:12.200But it's also too late because it's a challenge coming off these medications.
00:48:17.080One thing that's become clear over time is that there's a real withdrawal syndrome that can occur.
00:48:23.200And patients have an awful time coming off of these.
00:48:26.340So that gets thrown into the counseling, which is that the mom has to then weigh that as a risk to coming off of her medication during pregnancy.
00:48:35.200So this is a message, what I'm saying here today, and in general about the SSRIs and pregnancy that really needs to get out to women of childbearing age and also providers and primary care providers.
00:48:46.960I see so many patients in my office every day.
00:48:57.520And I see this all the time where they'll come into my office and they'll say, I was started on this during college, after a breakup or after some setback in my life.
00:49:08.720And then they were maintained on this.
00:49:11.100And at the time they were started on it, I'm guessing pregnancy wasn't on their radar or wasn't on their provider's radar.
00:49:18.240But now you get down the road five, eight, ten years that they've been on it for, and those patients can have a very difficult time getting off the medication.
00:49:28.360And so this becomes a real challenge, which, again, is why it really needs to be a broader message that gets out to the public about the concerns with the use of these drugs in pregnancy.
00:49:37.120Okay, so if there is a pregnant woman, she's not on SSRIs, but for whatever reason she feels that she is depressed to a debilitating degree or she has crippling anxiety, what is the healthy suggestion for that woman?
00:49:53.260Yeah, I think the important thing is that it's a case-by-case issue.
00:49:56.860The first thing is you treat her with love and compassion as her family or as the provider, the OB provider.
00:50:03.840You want to take really good care of her.
00:50:29.000There's other methods of treatment in terms of family support, psychotherapy, exercise, meditation.
00:50:36.620There's other methods that don't involve ignoring the pregnant woman.
00:50:40.600A lot of times people will present this as a choice between either staying on Zoloft or just ignoring the pregnant woman and making her feel guilty about medication and telling her to suck it up.
00:50:52.020Like, that's not really what we should be doing.
00:50:55.120The other alternative for that patient you just presented is explaining what resources are available to her out there, what other options are out there.
00:51:02.620And that can include a discussion of medication as well, going again into risks and benefits and alternatives with her, and then allowing her to make the best choice and supporting her in that choice.
00:51:14.560Because, again, from my perspective, I'm going to be seeing her multiple more times during the pregnancy, and I want her to know that, like, I'm in her corner, I'm on her dream, I'm treating her compassionately.
00:51:25.360And then I'm going to see her after her deliveries either in her next pregnancy.
00:51:29.440I've been doing this in my community for 20 years, so I'm going to see her in her next pregnancy, or I'm going to see her at the coffee shop.
00:51:35.680And I want her to know that I took good care of her, that I presented her correctly with the options, and then supported her in the choices she made.
00:51:42.780Yeah. What about SSRIs that are prescribed to women postpartum?
00:51:48.840I feel like that would be a pretty common thing, because postpartum can be difficult, and so many hormones, so many things going on.
00:51:57.620I remember after my first pregnancy, it was like two weeks maybe after I got home, and I saw the cup that I brought home from the hospital, and I burst into tears.
00:52:09.660And so there's just a lot going on, and I look back, and I think, wow, that was a very paranoid and anxious time for me.
00:52:17.500I didn't go on SSRIs or anything like that, but I can imagine what a woman would feel like if she was told this SSRI is going to make postpartum easier for you, it's going to make you happier, it might even help your strained relationship with your husband, whatever.
00:52:33.400I think women are basically made to feel in a lot of cases that if you feel bad at all postpartum, something is wrong, you need to get on medication.
00:52:42.320How much do you see that happening, obviously not in your practice, but just across the board, and is that different?
00:52:49.040Like, is the calculation different after she's already had the baby?
00:52:51.840Yeah, I think at that point, the postpartum time can be a challenging time, certainly, with the hormones changing, and a major thing that goes on at that time is sleep.
00:53:03.220Sleep is so crucial for humans for regulating our mood, regulating so much about how our bodies function, and that's a disrupted time, a disrupted sleep time.
00:53:14.400And so we see that along with the hormonal changes, as well as changes in the family during that time, a lot, a lot changes, obviously, during the postpartum period.
00:53:22.980In terms of what that counseling of the patient looks like, there's not exposure at that point to a developing fetus, but there can be exposure to a breastfeeding baby at that point.
00:53:34.420And so we look at impact of the SSRIs or other chemicals or medications on breastfeeding, and it looks like it does get into breast milk.
00:53:45.260The medications do get into breast milk.
00:53:47.180The medications do go across into the baby.
00:53:49.720Many of the studies have shown low levels, but the truth is, is we really don't know what even the impact of low levels are on the developing neonatal brain at that point, because the brain is still undergoing development.
00:54:01.660So it may look like a low level, for example, to, to an adult or checking a blood level.
00:54:07.500But in terms of like receptor occupancy in the baby's brain, like how many of the receptors have become occupied by the medication, it may be substantial still.
00:54:39.920So you've got these effects that need to be reviewed with the mom.
00:54:43.440And then you're getting into a question about whether there's benefit.
00:54:46.960And the studies that have been done looking at the benefits of antidepressants versus placebo do not show a really significant or dramatic benefit in that, in the use category.
00:55:11.060But when we look at the studies, when we do the studies, it looks like the evidence for benefit is very, very minimal.
00:55:18.680And so the question in that scenario would be, are there other ways to address what the mom is going through first that are non-chemically based, that aren't going to expose her to a chemical and going to expose the baby to a chemical?
00:55:33.380Things like family support, things like better sleep, are there other ways of addressing that so that there's not chemical exposure?
00:55:41.800And then the other question is, is that does the serotonin system in the mom impact the way she bonds with her baby?
00:55:53.400Like the way that serotonin system has been worked out for millions and hundreds of millions of years in mammals, does that affect that bonding?
00:56:03.560Do you want to disrupt that with a chemical effect?
00:56:06.920And so I think all of that would be part of the counseling.
00:56:10.220But as I've said, at the end of the day, if my patients decide when presented with their options, if they decide, no, I want to be on this medication or that medication, then they started on it.
00:56:21.120You support them and you follow them up closely.
00:56:23.420Yeah, a lot of the symptoms, the outcomes that you listed earlier that you see in the newborn in particular, when the child has been exposed in utero to SSRIs, child agitation, difficulty feeding, and then postpartum difficulty with milk production.
00:56:41.180All of those things in just a mom who is not dealing with any kind of depression can cause anxiety and can make you sad.
00:56:50.240If you feel like your child isn't bonding with you, if they're agitated, if there are things going wrong with them after they're born, if you're not supplying enough milk, like that already contributes to anxiety.
00:57:01.860So it actually seems like the SSRIs could potentially make things a lot worse and make women a lot more anxious and a lot sadder than they would have been otherwise.
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00:58:47.560And I think the current labeling is just inadequate.
00:58:50.700And I think the time has come, or probably we're past the time, where there's enough evidence that's accumulated showing that there's developmental harm, that's showing that it impacts development,
00:59:01.480that the FDA needs to look at this and really change the labeling and put a warning on there that's not presently on there.
00:59:49.200Yeah, they affect, they have impact on the baby.
00:59:51.980They have impact on fetal development.
00:59:53.480So I'm working with a group right now to try to pull together a petition to the FDA, to petition to the FDA, to change the labeling so that there is a clearer warning about the impacts of the SSRI antidepressants on the developing fetus and to try to make that clear.
01:00:11.120And then hopefully with that warning and with more public information about this, like coming on your show and talking to more people about this, hopefully with this, the word will get out.
01:00:22.740The word will spread so that young women of childbearing age, their PCPs, their psychiatrists and whatnot will understand that being on these drugs, what challenges that have.
01:00:33.900If they can't get off of them and if they stay on them through the pregnancy, that that will alter fetal development, that will disrupt fetal development with unknown or uncertain long-term impacts.
01:00:45.580Yeah, we've had Dr. Marty McCary on the show and it seems to me like he would be sympathetic, certainly, to your argument, if not in complete agreement.
01:00:54.440Speaking of the FDA, I just want to quickly talk about this kind of scandal or when you critiqued the FDA's handling of McKenna.
01:01:04.540Is that how you pronounce the drug or McKenna?
01:01:18.360Yeah, I try to tell people, I focus a lot nowadays on antidepressants, but my broader focus is on just medication exposure across the board in pregnancy.
01:01:30.600So McKenna was a drug hormone, a synthetic hormone, 17-hydroxyprogesterone that we injected into pregnant women for 20 years.
01:01:41.760Basically from 2003 until 2023, we injected it into pregnant women with the idea that it could prevent a recurrent preterm birth.
01:01:51.200From very early along though in the process from the first study that came out in 2003, I thought that study doesn't look right.
01:02:00.020It had a lot of flaws in it and I was opposed to the widespread use, widespread injecting synthetic hormones into pregnant women that might not work.
01:02:10.300But it was used for years and it had very high sales for a while.
01:02:16.440Those sales were then, again, getting back to my point about how the pharmaceutical industry can control the message and the information the public gets.
01:02:24.640The money from the sales of McKenna was used to sponsor, for example, the professional medical societies like the American College of OBGYN, the American Society for Maternal Fetal Medicine, who then recommended and promoted its use, the March of Dimes, etc.
01:02:38.500So you end up with this system where the more use, the more money gets raised, the more money gets raised, the more they can pay experts and professional societies to recommend it and the cycle continues.
01:02:53.140In 2019, the follow-up study to the original one showed that it actually didn't work.
01:02:58.720And that was after several other observational studies were suggesting that it didn't work.
01:03:03.020So I had been making noise about this for years and then finally, fortunately, it was pulled off the market in 2023.
01:03:09.560But one of the arguments that was being made at the time was that we needed to keep this drug on the market because black women have a higher risk of preterm birth.
01:03:21.360This is the company making this argument.
01:03:23.480The company was making the argument that because black women have a higher risk of preterm birth, it's important from a racial equity standpoint to keep this drug on the market, which just boggles the mind, essentially boggles the mind.
01:03:37.540But it's this whole idea of toxic empathy, of trying to get the pharmaceutical industry, trying to craft a message, an empathetic message that will get people supporting their product, really not for any reason other than to increase profits.
01:03:56.060To try to keep the drug on the market for that reason.
01:04:00.780I wrote an editorial against that in Stat News, one of the online medical sources, and basically completely arguing against that.
01:04:10.460I think that it got to the point where I think the NAACP actually wrote a letter in support of the drug.
01:04:18.000This is saying that in order to have racial equity, we need to keep this drug on the market.
01:04:23.980The argument I was making, I still, I'm smiling, but I'm laughing.
01:04:28.320It's like, how does injecting black women with an ineffective synthetic hormone, how is that going to help the black community?
01:04:38.320How is that going to provide racial equity?
01:04:40.080All you're doing is you're targeting a group that has a higher risk of preterm birth with an ineffective drug that's not going to work and lead to possible increased risks of harm to moms and babies.
01:05:01.800Whenever we hear the defense of any drug that sounds a lot like marketing, we should at least ask ourselves, but is that true?
01:05:10.040And dig into who is actually saying it and why they're actually saying it.
01:05:14.100Also, a lesson that I was reminded of the whole time that you're talking is so often if a patient raises a concern, especially a mom, the doctor or a professional will say, there's no evidence to prove your point.
01:05:26.420But just because there's no data to prove something doesn't mean there's data to prove otherwise either.
01:05:33.780And very often that's used as kind of a mode of manipulation to make a patient kind of sit down and shut up and make them feel like they're stupid.
01:05:42.240But you've also proven that there is a lot of data when it comes to SSRIs and how they're affecting moms and babies.
01:06:15.320Just talking, people talking to each other, watching your show, communicating.
01:06:19.220The other big thing I just wanted to point out about McKenna is that I was basically arguing against the conventional wisdom at the time.
01:06:27.280And I was making an argument that was, as you were just describing, sometimes patients do in the office.
01:06:32.780But it's so important that we support dissent in our society because often that's where the truth lies.
01:06:40.780And this whole move that we're seeing now towards censorship and towards cracking down on misinformation, that's really harmful to our society.
01:06:50.780And it's really harmful towards coming up with the truth and the right answers because what it really does is it's meant to silence dissent.
01:06:59.600Whether it's in the doctor's office when the doctor silences dissent by saying you don't have the information or whether it was with me.
01:07:07.540I wasn't over McKenna, but I was saying things that were against the conventional wisdom at the time.
01:07:13.820So it's very important for your listeners and viewers to support the free flow of information and support dissenting voices.
01:07:22.580This movement that we're having, I feel like, in our society towards censorship and cracking down on misinformation or whatnot is really, it's really errant and really going to lead us down a bad path as a society.
01:07:35.680Well, thank you for being one of those dissenting voices and for speaking up when it would be a lot easier to just go with the flow.