Ep 241: Managing Mental Health during Pregnancy and Postpartum with Psychiatrist Dr. Stephanie Waggel

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Pregnant people who need psychiatric medication are uniquely underserved. There’s a big knowledge gap and it’s not just the general public. Med school doesn’t teach much about mental health medication and pregnancy. Fortunately, today’s guest is here to share information and dispel myths!

Dr. Stephanie Waggel is a psychiatrist certified in perinatal mental health, specifically, advanced studies in perinatal psychopharmacology (medication for pregnant people). She’s one of very few experts in her specialty so she’s working overtime to spread the word. If you need pharmaceuticals, there’s a good chance you can do so safely. Tune in and learn how to explore your options with your doctor.

In this Episode, You’ll Learn About:

  • Why Dr. Waggel uses the term “perinatal mood & anxiety disorders” (PMADs)
  • What makes prescribers err on the side of a no-medication approach
  • How common it is to suffer from PMADs
  • When it’s the baby blues and when it’s time to seek help
  • Why Dr. Stephanie encourages people to participate in medical studies
  • How therapy factors into her treatment plans
  • How medication can interact with breastfeeding
  • When it’s time to restart medication postpartum

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Transcript

Dr. Nicole (00:00): You do not want to miss this episode about perinatal mood and anxiety disorders with a psychiatrist who is certified in perinatal mental health.

(00:15): Welcome to the All about Pregnancy and birth podcast. If you're having a baby in the hospital, you are giving birth in a system that too often takes away power from women over what happens in their own bodies. I'm Dr. Nicole Calloway Rankins, a practicing board certified OBGYN, who's had the privilege of helping well over a thousand babies into this world. I've been a doctor for over 20 years, and I'm here to help you take back your power, advocate for yourself, and have the beautiful pregnancy and birth that you deserve. This podcast is for educational purposes only, and it's not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now, let's get to it. Hello there. Welcome to another episode of the podcast. This is episode number 241. Whether this is your first time listening or you've been listening before, I'm so glad you're spending some time with me today.

(01:10): So Dr. Stephanie Waggel is a mother, physician, author, motivational speaker, teacher, cancer survivor, marathon runner, and founder of Improve Medical Culture. She has a degree in psychology, biology, medicine, and she has over 17 years of experience working in the mental health field as a psychiatrist. In 2023, she decided to become certified in perinatal mental health, specifically advanced studies in perinatal psychopharmacology, which is the use of medication for pregnant people. She feels this is an area that is understudied, which is so true, and that pregnant women deserve an educated professional to provide correct diagnosis and treatment. Yes, amen to that. She really heavily advocates for expansion and integration of peds care and peds are perinatal mood and anxiety disorders. We have a really informative conversation. You're going to learn a lot. We talk about what are perinatal mood and anxiety disorders. It's more than just postpartum depression, how common they are risk factors.

(02:27): The most common conditions that she sees. This may surprise you. Spoiler alert is actually not postpartum depression. We also talk about when someone should seek help because some level of sadness, anxiety is normal when you have a baby, but when do you know to seek help? Where should you get help from? When should you consider medication? We also chat about her approach to taking care of someone who is already on depression or anxiety medication prior to pregnancy, and then they become pregnant. What should you do about continuing or not continuing to take that medication? What do you do if you decide to stop your medication during pregnancy? What are your options for managing your mental health while off medication? Also, when should you restart medication postpartum if you are breastfeeding? Tons and tons of useful information. Oh, and we end with talking about the recently approved medication for postpartum depression.

(03:28): I'm going to mess this up. Xol alone, I don't know where we come up with these medications, but this is the first FDA approved medication for postpartum depression. So we chat about how it works, how it's different than other medications. Really, really, really good information in this episode. Now you know where else you can get some really great information. My birth plan class, make a birth plan the right way. If you're having a baby, you need a birth plan. But that piece of paper, that ain't enough of a birth plan. I teach you the way to make a birth plan that is going to actually help you have the birth experience that you want. You can check out my free birth plan class. It's at dr nicole rankins.com/birth plan. It is highly, highly informative, useful people love it, and there's a little goodie at the end of the class too, so do check that out. All right, let's get into the conversation with Dr. Waggel. Thank you so much, Dr. Is it Dr. Waggel? I should have asked you this before we

Dr. Stephanie Waggel (04:33): Started. It's Dr. Waggel. Oh,

Dr. Nicole (04:34): Look at me. I got it right. Dr. Waggel. Yes.

Dr. Stephanie Waggel (04:37): Puppy dog's tail waggling. And then we got, here we go.

Dr. Nicole (04:40): Well, thank you so much for agreeing to come onto the podcast. I'm really excited to have you talk about this really important topic. Thank

Dr. Stephanie Waggel (04:47): You so much for having me. I'm super excited. Yes.

Dr. Nicole (04:50): Why don't you start off by telling us a bit about yourself and your work, and even if your family, if you like.

Dr. Stephanie Waggel (04:57): Oh, yeah, sure. So I live in Northern Virginia and I've been in the DC area for, oh my goodness, 14 years. But I keep moving further and further out into the suburbs as I grow up, I suppose. And I have two kids. I have a daughter, she's four, and a son who's 19 months old. Oh, goodness. So it does get louder out this house sometimes.

Dr. Nicole (05:24): Yes, yes.

Dr. Stephanie Waggel (05:26): And I like distance running. I just did the Marine Corps marathon.

Dr. Nicole (05:32): That is impressive.

Dr. Stephanie Waggel (05:33): Yes. Yeah. I'm not good at sprinting, but to continue to run for hours and hours, somehow I can do that. Okay, well,

Dr. Nicole (05:41): There you go.

Dr. Stephanie Waggel (05:42): Yeah. And let's see.

Dr. Nicole (05:45): And then your practice. Tell us about your practice and your work. Sure.

Dr. Stephanie Waggel (05:48): Yeah. So it's called Improve Life, PLLC, which they made me put the PLLC at the end for Professional Limited Liability Corporation, but improve life. And so we've been around for about seven years in the Northern Virginia area, and I specifically try to focus on the treatment for young women adolescents, but we also see everybody because we have other providers here. Dr. Driscoll, she specializes in the males and I specialize in A DHD. She doesn't specialize in A DHD. And then we have therapists too. And then we have Mariam Ze who we couldn't function without. She's our office manager. Yeah, so we do A DHD testing, anxiety, depression, O-C-D-P-T-S-D, just mental health in general. But I do specifically try to focus on adolescents and people of reproductive potential because I have this certification in prenatal psychopharmacology.

Dr. Nicole (07:00): Why don't you tell us what that's about? What does that mean?

Dr. Stephanie Waggel (07:03): Yeah, so as we were kind of discussing earlier is there's not really too much that goes on in medical school or residency in regard to medications to be prescribed, specifically psychiatric ones for people when they're pregnant because I think it's a bit of a sticky situation. I have on my YouTube channel, it's called The Therapeutic Orphans. It's a video about how women when they become pregnant just are told by either the pharmacist or their provider just stop taking everything because healthcare workers in general have a greater sense of responsibility if something negative happens for something that they have done or prescribed as opposed to something negative happening that they didn't prescribe. So let's say they prescribe something, there's a negative outcome, there's a lot of guilt and responsibility, but if they don't prescribe something and there's a negative outcome, that connection really isn't there. So I think a lot of prescribers err on just not prescribing anything, which actually does have detrimental effects. So I wanted to fill that gap because somebody needs to be able to go to a doctor that's going to be willing to prescribe them something while they're pregnant. And my understanding is that there's only two or three other physicians in the entire state with this certification. And the fact that a lot of prescribers aren't really super educated in this creates a lot of confusion because then people get conflicting information. So I thought, let's get some real information out there and allow for pregnant people to be able to get some medications. So

Dr. Nicole (08:57): Absolutely,

Dr. Stephanie Waggel (08:58): I got that certification about a year ago.

Dr. Nicole (09:02): And

Dr. Stephanie Waggel (09:02): So yeah, it's pretty exciting for me

Dr. Nicole (09:06): And really important. And I don't think we even said you're a psychiatrist. I don't think we even said that. Yes, yes. So you're a psychiatrist, and tell us actually what training you go through to become a psychiatrist. I'm big on making sure that people get information from reliable, trustworthy sources because there's so much out there online and social media that anybody can put up their whatever and say, so please tell us about what training you went through to become a psychiatrist.

Dr. Stephanie Waggel (09:36): So it all started long ago. So I got my undergraduate degree in psychology, and I graduated a year early. I was also pre-Med, and I had a writing minor, so I had 24 credits. It was a lot. And they were like, oh, you could graduate early. And I'm like, oh, well, what do I do before I go to medical school since I'm graduating early? So I got a master's degree in biology, and during this time I worked as a psychometrist at Allegheny General Hospital. We did Wisconsin card testing on people that had traumatic brain injuries and that sort of thing. And then I also worked at UPMC in the geriatric department for a while, and it was a lot of psychiatry, a lot of dementia and that sort of thing in the geriatric population. And then I went to medical school and I did some mental health things on top of going to medical school because a lot medical school doesn't really get into too much psychiatry, but I worked for United Planet and I worked at the United States Coast Guard, and I did a lot of mental health related things in addition to going to medical school.

(11:02): And then I did my internship, and then I did two years of psych residency, and then I opened up my own private practice because I didn't want to work for the man anymore. There

Dr. Nicole (11:15): You go. I needed to

Dr. Stephanie Waggel (11:17): Work for myself. And that actually worked out pretty well. I won't digress too much, but I was actually diagnosed with cancer when I was in residency. Oh my

Dr. Nicole (11:28): Goodness.

Dr. Stephanie Waggel (11:29): It was very challenging. And so opening up a private practice allowed me the flexibility to go to doctor's appointments and take care of myself,

Dr. Nicole (11:40): Which

Dr. Stephanie Waggel (11:40): Is really important for physicians in general, but especially in psychiatry, you need to have your own mental health taken

Dr. Nicole (11:47): Care of

Dr. Stephanie Waggel (11:48): So you can take care of other

Dr. Nicole (11:50): Well, I hope you're in remission now and everything as well. Oh, yes. Well, good. Yes,

Dr. Stephanie Waggel (11:53): Thank you. Yes. I'm getting another MRI in two months, so hopefully that looks good.

Dr. Nicole (12:00): Yes, there you go. And then how did you get interested in psychiatry? I'm just curious.

Dr. Stephanie Waggel (12:06): Well, I really like talking to people. In high school, I was voted most outgoing, and then in medical school I was social chair every year. And I just really like to listen. I like to talk to people. And some of the specialties didn't allow me enough time to really talk to my patients. I thought my ED rotation was fun, but they were like four minutes per patient, and I'm like, but I have so many things I want to ask. And so psychiatry, I get an entire hour to talk to people and really, really get into the psyche and to analyze people, and I just think it's so super interesting.

Dr. Nicole (12:47): Yeah, I love it. I love it. So let's get into perinatal mood disorders. Is it PMAD? What does that stand for? What does that encompass? Great question. Yes,

Dr. Stephanie Waggel (13:01): Great question. So it's peds, which is perinatal mood and anxiety disorders. And I like to explain. So I do talks for prescribers about prescribing, and then I do talks to the general population. So if I'm just speaking for the general population,

Dr. Nicole (13:19): Which is what my audience is, yeah,

Dr. Stephanie Waggel (13:20): That's where I'll go. Yes. I usually say postpartum depression because most people in the general audience in the general population know what postpartum depression is. But I actually prefer to use the term PA dss. And there's two reasons I think a DS is more appropriate. Again, PMA DSS is perinatal mood and anxiety disorder. PMA DS encompasses a greater period of time. So postpartum depression, postpartum is just after birth for another year. But perinatal in the PMA DS is from conception to one year after. So it encompasses a greater period of time. Additionally, number two is that postpartum depression is just depression, whereas pmms would be OCD, anxiety, PTSD, all sorts of other psychiatric issues. So pmms has a greater time period, and then it encompasses more symptoms. So I use postpartum depression because most people know, but I would prefer to use PA DS because it really takes into account more items and more people would be included into that category of

Dr. Nicole (14:35): PMA ds, which is really important because it's not just postpartum, as you mentioned, and it's not just depression, anxiety comes up, birth trauma, things like that come up. So I really appreciate that you're talking about we need to expand it in a more encompassing way. It's great that we talk about postpartum depression, but we need to add the things to that to talk about as well.

Dr. Stephanie Waggel (14:58): That's right. You don't want to leave people

Dr. Nicole (14:59): Out. Exactly. Exactly. So how common are perinatal mood and anxiety disorders?

Dr. Stephanie Waggel (15:04): Well, for postpartum depression, so there's no statistic, I think specifically on PA, but on postpartum depression, they estimate every one out of six. It's actually one out of five to seven, but I think one out of six makes more sense women. And then actually dads can get postpartum depression. And the statistics are one out of 10 dads, really, it's 10% of dads. Yeah.

Dr. Nicole (15:33): Oh, see, I did not know that. I did not know it was that common in dads. Yep.

Dr. Stephanie Waggel (15:37): Okay.

Dr. Nicole (15:37): Okay. All right. And then what are some risk factors for developing any of these conditions?

Dr. Stephanie Waggel (15:43): Right, so they're pretty, what you would imagine. So risk factors would include if you have some sort of environmental stressors, like lack of support from your family or financial concerns, or you don't have childcare or it's unexpected pregnancy that you were not preparing for, or there's abuse going on or job insecurity. So we have the environmental factors, any of those stressors, those are going to be like negative points. And then of course we have our genetic predisposition. So if you have a family history of postpartum depression or if you yourself has had some mental health challenges in the past, but sometimes it can come with no signs, no predictors, nothing. It could just be seemingly no cause. So definitely risk factors would be your social support, financial support, those sorts

Dr. Nicole (16:57): Of things. Gotcha, gotcha. Now, when you see folks that have these disorders or issues or concerns, do you mostly see depression? Do you see some anxiety? Do you see some PTSD? What do you see in your practice? Oh,

Dr. Stephanie Waggel (17:12): Well, I see it all, but I think if I had to guess, it's probably comparable with anxiety and depression. So we have this hormone ol, which sort of functions in a way to be protective, helps anxiety, and after birth, it decreases. And if you have something that's helping with anxiety and then that decreases, your anxiety is going to go up. And I really see a lot of anxiety after women give birth. It could also be that they're not sleeping and then they have this new life form and then they have to adjust their entire life. But there's hormonal factors and environmental factors. So I would say anxiety is a lot more prevalent postpartum than maybe people might think.

Dr. Nicole (17:59): Yeah, I agree too. I actually think I had, my first daughter was born premature, eight weeks premature. And looking back, I most definitely had anxiety because I was scared something was going to happen to her when she came home to a level that it was excessive. So I can see that we don't talk about anxiety enough, and the social media pressure of having everything perfect and all of those things, I'm not entirely surprised that anxiety is really prevalent. Now, some level of sadness, well, I shouldn't say sadness, but maybe some level of, especially if it's your first baby, some anxiety, some level of that, maybe normal during pregnancy and postpartum, when should someone suspect that this is a problem and that they need to seek help

Dr. Stephanie Waggel (18:51): For it? Okay, good question. Because it could be confused with the baby blues, which is in an estimated 70% of postpartum moms, and that's two weeks. So if it's longer than two weeks, it's not baby blues. Also, if it's just being a little emotional, irritable, tearful baby blues, if it's longer than two weeks, then you start thinking about depression. But if it becomes to the point where it is impeding your activities of daily living, your blues is so severe that you cannot even shower or get out of bed, that's going to be something that you want to probably get some help for. And so you want to make sure that, I think a big component is the other people in your life saying, you're not acting like yourself. You seem different because if you're going through this, you're probably not able to really recognize it as well as people on the outside. So if people are commenting to you that you just seem unusual or you've been isolating, and people were like, well, I mean if you just had a baby, it's not like you're going to go hang out or anything. But when people start commenting, that's a big clue that it's going to be more than just your typical baby blues.

Dr. Nicole (20:18): Sure. And then to follow up to that, where should people seek help? Should they go to a psychiatrist right away? Should they start with a therapist? What are things that, where should they go to look

Dr. Stephanie Waggel (20:31): For help? Excellent question. So the screening as recommended, so the American Academy of Pediatrics recommends when the baby comes in, you actually hand the parents the screening form at the first visit, and then two months, and then I think six months. I could say that that doesn't happen a lot. And then obs are supposed to provide the scale. It's either Edinburgh or if you're from Scotland, Edinburgh scale to Mons at some point throughout the pregnancy. So the obs and the pediatricians are supposed to be doing the initial screening, and then if it comes back positive or even if it's negative, but the OB or pediatrician just gets the sense that there really is something that needs to be looked into, they should refer to a psychiatrist. But then, like I was saying earlier, is that not all psychiatrists are well-versed and a lot are just like, I'm actually just not going to prescribe anything.

(21:34): I'm too afraid of what could potentially happen. So in a perfect and ideal world, you'd want to refer them to a reproductive psychiatrist, but there just aren't very many of those at all. So you could get them in presumably with a therapist much quicker. However, if it's an emergency, you would definitely want to refer to, I hate to say the er, but if they check that they're having suicidal thoughts on the scale, an emergency is an emergency and you got it, actually. So I will digress briefly to describe four levels of mental health care. So the first is your basic standard outpatient that be a therapist, psychiatrist, then an office, and then up from there if things are more severe, there's intensive outpatient, and that's where patients get three to five days for a couple hours of therapy, group therapy, they're in a program, if it's something going on like withdrawal or drug abuse or something where you need to be medically monitored and you want to have a nurse and vital signs, that would be a partial hospitalization program where you're pretty much in there all day, every day, but you do go home at night to sleep.

(22:54): And then if it's an emergency where, so let's say you're doing the screening and they say that they're having suicidal thoughts or having thoughts about harming others that they think that they might act on, or if they are so disorganized that they cannot take care of themselves, they don't remember where they live, that would be an inpatient hospitalization, and that's all day, all night. And so I just wanted to be clear that there's different levels based on that's important. Severity that's important. So if you're screening and somebody seems to have some mild depression, I would try to get them in postpartum support international. And then there's subcategories. There's different states like postpartum sport, Virginia, you can type in where you live, and there's actually a whole bunch of therapists that have the certification. And so if you are screening and it seems like there's depression, you could refer to one of them, I would make sure that you're referring to somebody that has some training because you don't want them to get conflicting information, then they'll be distrustful of healthcare providers. But if it's something serious, then you got to get to one of those other levels of care that I just spoke about.

Dr. Nicole (24:11): Gotcha. Gotcha, gotcha. Okay. So I want to back up for a minute and talk about people or not back up switch topics baby for a minute, and talk about people who are on medication before they get pregnant, either for depression or anxiety, and then become pregnant. What is your discussion or conversation about staying on medication versus coming off medication? What are your thoughts on that?

Dr. Stephanie Waggel (24:38): Yeah, this is kind of funny because I'll get calls from my colleagues, my other friends who are psychiatrists, and they'll be like, Hey, Stephanie, I have a patient on dah, dah, dah, dah. And then she just told me she's pregnant. Oh my goodness. And I'm like, well, calm down. So my general philosophy, and again, this is not medical advice because everybody's different. And so just because this is what would be applicable to most people doesn't mean that the average listener, it's going to apply exactly. But the general philosophy that I have is that if they're on a psychiatric medication that is working, I continue it except Depakote, all the other ones, which is valproic acid

Dr. Nicole (25:27): And

Dr. Stephanie Waggel (25:27): Has, I don't prescribe that to people of reproductive potential anyway. So if they're on that, it was some other doctor that

Dr. Nicole (25:33): Did that.

Dr. Stephanie Waggel (25:35): But all the other medications, if they are working, don't mess with it. One question I get a lot from other prescribers is, should I decrease X, Y, Z medication? And the answer is no. And the reason is is because if you decrease their medication, they're still going to be exposed to the medication. But now initially, they're going to potentially be exposed to uncontrolled mental illness. And I'm trying very hard not to go off on tangents, but again, briefly, I would like to point out that uncontrolled mental illness in the pregnant person, and I'm not going to get too sciencey, I swear, has epigenetic effects on the unborn child, meaning you can turn on and off DNA. So let me just put it in terms that if you are not controlling your mental health, it actually negatively affects the baby. So if you think like, oh, you know what? I'm just going to suffer through this depressive episode because I don't want my baby to be exposed to the medication, your baby is actually going to potentially have some negative outcomes from your suffering as well. But I'm going to get back on track.

Dr. Nicole (26:55): No, thank you for saying that. That is so, so important because I think people actually, and they mean, well, they think they're doing the right thing by coming off of medication because they're protecting their baby, but not realizing that so much about the baby's health is dependent on the mom's health. So it's just really important. So I'm really glad you brought that up.

Dr. Stephanie Waggel (27:18): And I could go out on the epigenetics, but I won't. But suffice it to say when I get these calls from other prescribers, my patient is on this medication, I found out they're pregnant, do I decrease it? Do I stop? And if it's Depakote, that's different, but any other med, typically I would say no, because you decrease it. They're potentially exposed to untreated mental illness and they're still being exposed to the medication.

Dr. Nicole (27:47): Gotcha. Gotcha. Yeah. So then what do you do if someone decides, and I should back up and say, obviously you'll have a discussion with your doctor about any potential risk for the baby. We're not just going to, and there are actually very few risks for psychiatric medicines that impact the baby. I don't know if you want to talk about that as well, any things to be on the lookout for, or people can just talk to their OB about that. I know with SSRIs, are there any in particular that you say maybe switch to a different one, or do you just say stay the course for what you're on?

Dr. Stephanie Waggel (28:22): Good question. I get this all the time. So in general, separate Depakote, the psychiatric medication that's working, just keep it the same. Now there's talk that Paxil, there are studies that Paxil can have negative, if this is really getting into specific case by case things. If Paxels the first thing they ever tried, then maybe you could switch to Zoloft. But it depends on how many other medications they tried. So if they are already on Zoloft and Prozac and then Paxil was the one that worked, then you can keep Paxil on. But if Paxil is the first thing, you could potentially try them on Zoloft. And then I don't just tell my patients, all right, just keep on, I have this big lengthy conversation, and I feel bad because I go into studies and they're probably like Dr. Waggel, I feel like I'm in school again, but I'll go into studies.

(29:24): I need them to make an informed decision. Absolutely. And I'll say this, okay, for example, there have been studies that have shown that the SSRIs can cause increased length and duration of crying in newborn babies. And then I have to say, is the potential that your baby's going to cry more than most babies going to be enough for you to stop it? And that sort of thing. But I'll go through the studies and I'll say, this one found this. Is this a deal breaker for you? That sort of thing. And then I also introduce them to some apps like mommy meds and things like that. And I do like to explain

Dr. Nicole (30:06): That. You said mommy meds,

Dr. Stephanie Waggel (30:07): Mommy meds. I've

Dr. Nicole (30:08): Never heard of that.

Dr. Stephanie Waggel (30:09): Yeah, it's a good one. MGH, women's Center for Mental Health has my resources. And so, okay, when I continue a pregnant woman on a medication, I go over studies, I give them resources like the apps, and these are apps created by professionals, not like social media.

(30:34): And then I give them the resources like MD H'S website. And then the fourth thing I do, which is not required, and I understand that pregnant people are just so busy and overwhelmed, they probably don't have time, but I ask them to enroll in studies because it's not ethical to put pregnant women into studies about different medications. But if you're already pregnant and taking the medication, that's how scientists are going to gather the data for future discovery. So I say, I know you're busy, and obviously you're having mental health issues, so I don't want too much on your plate, but if you want to sign up for these studies. So that's the fourth thing that I do, but that one isn't really required. Got it. But it is required that you have to listen to me

Dr. Nicole (31:26): Talk about all the information, which is important. People should make decisions from being informed, and you want them to be informed, which is great.

Dr. Stephanie Waggel (31:35): Exactly.

Dr. Nicole (31:37): So then if someone decides to stop their medication, which I'm sure some people do, obviously I

Dr. Stephanie Waggel (31:43): Don't force people to continue

Dr. Nicole (31:45): Either. Not like, yeah, exactly. Obviously you give them those resources that you talked about. And I presume maybe therapy is also another option

Dr. Stephanie Waggel (31:54): Type thing. Oh, yeah, yeah, yeah. I'm not just like, here's a pill. In most cases, especially because it's even more sensitive, even more serious of a matter when you're pregnant, I don't know. I've ever said to a pregnant person on meds, you don't need therapy because there's so many life changes coming up and you need support. So 99.999% of the time, I also recommend therapy. I just wanted to clarify that.

Dr. Nicole (32:25): Do continue. Gotcha. Thank you. Thank you. So then, if someone decides to stop, when do you recommend that they restart their medicine after they have the baby, especially, particularly if they're breastfeeding.

Dr. Stephanie Waggel (32:37): This is one of those things that I cannot generalize. You can, this is a super case by case

Dr. Nicole (32:43): Basis,

Dr. Stephanie Waggel (32:44): So especially because the concentrations of different psychiatric medications are excreted to different percentages in breast milk. And just to throw an example out there, if the mom has a DHD and she's on something like Adderall that has a higher excretion into the breast milk than something like Ritalin, which is a methylphenidate that has a lower excretion. So I would have to actually see what medication they're on. But if I have to generalize, most of the time it is because of the benefits of breastfeeding. And again, I can have a whole nother topic about breastfeeding, but it is thought that the benefits of breastfeeding outweigh the exposure to the

Dr. Nicole (33:39): Medication.

Dr. Stephanie Waggel (33:40): Now, for things like benzodiazepines, which is Xanax and Ativan, those Klonopin, those types of things, you'll probably not find a doctor that's like, yeah, you could breastfeed and take

Dr. Nicole (33:55): It.

Dr. Stephanie Waggel (33:55): Except for me, if you're checking in with me, if I've analyzed the whole situation, if your anxiety is so bad, if you're having panic attacks, then I will say, okay, you can take this benzodiazepine and breastfeed as long as you're checking in with me, but you want to make sure that you watch. There's two things, the baby, if the baby is somm and super sleepy, and then you know that the amount that is being excreted is having an effect on the baby. So you have to pay attention to the cues from the baby. The other thing is that I tell women that take benzodiazepines while breastfeeding to watch out for is falling. What if you get knocked out, benzos really make you, and you don't want to be breastfeeding, and then you take alprazolam and then you just fall asleep holding your baby. Absolutely. Yeah. So if you're going to do that, you're going to need support from your partner to really keep an eye on you to make sure that you're not just passing out in a chair, but then you also want to observe the baby. So the medication, when to start taking it in terms of breastfeeding is very medication and patient specific. So unfortunately, I don't have an all encompassing answer for you on that.

Dr. Nicole (35:21): I guess I'm thinking more like Zoloft effects or those kinds of medicines. We tend to restart those pretty

Dr. Stephanie Waggel (35:27): Quickly. Yeah, you can breastfeed on those.

Dr. Nicole (35:30): Okay. Okay. Well, speaking of medications, postpartum, let's talk about the new postpartum medicine for depression. I don't even know how you say it. Yeah, okay.

Dr. Stephanie Waggel (35:44): Whenever I talk to people in the general population, I just call it zoo because I feel like

Dr. Nicole (35:51): I don't know how they come up with the names for these

Dr. Stephanie Waggel (35:53): Medicines. I think that they just have a random letter

Dr. Nicole (35:56): Generator in life. So tell us about this medicine. How is it different than other medicines for depression or why specific for postpartum?

Dr. Stephanie Waggel (36:06): So it's year 2023, and this is the first year where there's an FDA approved medication for postpartum. All the medications that we've talked about so far, like the SSRIs, like Prozac, those are used for postpartum depression. They're used for depression in general, but they're not specifically FDA approved for postpartum depression. Now, there was another medication that was approved for postpartum depression earlier called BR samone. However, it's IV infusion over 60 hours, you have to be in the hospital and it costs 30 grand. So it's really

Dr. Nicole (36:45): Not

Dr. Stephanie Waggel (36:46): Feasible

Dr. Nicole (36:46): From that, I

Dr. Stephanie Waggel (36:48): Guess celebrities.

Dr. Nicole (36:51): So

Dr. Stephanie Waggel (36:51): That really wasn't super practical. So they were able to take that concept and put it in a pill, thankfully. And now that is what is approved. So it works. It's not an SSRI. It works similarly to a benzodiazepine, and as such, it's going to be a controlled substance. It does technically have some potential for addiction, just like the benzodiazepines like Xanax do. Well, I'll let you ask specific questions

Dr. Nicole (37:31): About it. Yeah, no, yeah, I didn't realize that it was similar to that class of medications. So who's a good candidate for it? Should this be a first line trial or who is it appropriate

Dr. Stephanie Waggel (37:43): For? So most, I would surmise the most of the people that are going to be taking it, and I actually not prescribed it yet because I'm not sure. Last I checked it was not out on the market. But once it's there, I will prescribe it to people who are not having success on your standard regular antidepressant. And you certainly can take it on top of irregular antidepressant because one of the studies was looking at the medication alone versus the medication and other antidepressants. They've already studied people on antidepressants taking it. Well, yeah, I got a lot to say about it, but No, go

Dr. Nicole (38:27): Ahead. Go ahead. Please go ahead. Tell us what else. Well,

Dr. Stephanie Waggel (38:30): I'm super excited about it, but I also don't, so okay. Don't know if I did legal disclaimers. No one's paying me to, this is just my opinions about it. I'm not like that stock in xone or anything. It's just super promising. But it is, the studies were conducted by the manufacturers. So I just say keep that in mind. Whenever you're looking at a study, you want to see what the motivation. So as excited as I am about this medication, I'm not willing to commit a hundred percent that it's going to be fantastic. People can be biased when reporting things. Now with that said, there's so many great things about this medication, allegedly we'll find out soon. You only have to take it for two weeks. So what really isn't that wild? Yes, yes. And so people get really frustrated about antidepressants. It's like it'll start working in six to eight weeks and you have to take it for a year or two. Butanol starts working in three days, and you only have to take it for two weeks, which is in a psychiatric medication. It's just mind blowing. Right? That's why I was so excited to say this, but I was like, oh, disclaimer.

(39:52): But if it works that way, that's really great. And so it kind of, let's see. I don't want to get too sciency Z, but like I said, it works on the same kind of ways that the benzos do on the gabaa receptors, but it has an additional mechanism of action that your typical benzo like Xanax, and it just has an extra way of working that those benzodiazepines don't have to.

Dr. Nicole (40:27): Okay. Well, I'm excited to see then, as it comes out and is more available, I did not know that people only had to take it for two weeks. So that could be a game changer. Seriously. Yeah. Yeah. Okay. So as we kind of get towards the end, are there any myths or things you wish people really knew about treating psychiatric illnesses in pregnancy or postpartum?

Dr. Stephanie Waggel (40:52): Yeah, there's lots of myths out there. So I think the first thing, whenever I talk about mental health treatment for pregnant persons, the first things that I start talking about is how common it is to decrease the stigma and make people feel more comfortable because, well, in my life, I'm obviously constantly talking about mental health, and then I just see people talking about getting mental health treatment. But that's not the case for all communities and all families. Some families, it's like taboo. You don't talk about it. And people think that they're the only person who's having this issue. And so I start out by saying one in every five to seven women and even one in every 10 men. And then people are like, oh, well, I feel better that I'm not the only person going through this. And so that's the first myth is that it's rare. It certainly is not rare.

(41:56): The second thing, and this is one of the most impactful and most important things that I like to emphasize, and I always make sure to bring up when I'm speaking to a group of pregnant persons, is I say, I explained, I don't like to use the word crazy. However, again, when I'm talking to the general population, I do use that term because people know. I say, you're not crazy if you're having unwanted thoughts. A lot of moms, because again, that hormone that I mentioned earlier, that decreases after pregnancy, that is protected for anxiety, it goes out the window, and then you have anxiety. And along with anxiety, you can have unwanted thoughts, and they're intrusive a lot of the times. And I will do a trigger warning for anybody right now, the unwanted thoughts are typically pretty horrific. They wouldn't be unwanted if they were thoughts about rainbows and butterflies.

(42:57): So the unwanted thoughts by definition would be like, what if I drove my car off the road or dropped the baby? And that's why I said the trigger warning. And so when moms start having these thoughts, they worry that they're going crazy. And then they're worried that if they tell anybody, they will be committed to a hospital. And I have to explain that not only are you not crazy, but this is actually very common after giving birth because you're just worried about everything. And so the differentiating factor between this being something that is anxiety versus this being something that's an emergency that you would need to go to the inpatient hospitalization is, are you okay with the thought? And I'm going to use, we're going to do just two definitions. One is ego, syn, tonic, and that is that these thoughts, I'm just going to drive my car off the road.

(44:01): They don't bother you. And if you're starting to think that it's a good idea, oh, drive my car off the road, that sounds like a good idea. I'm not bothered. That is more of a psychotic psychosis type picture, and that is an emergency. So if they wouldn't really be unwanted thoughts if you're starting to want them. And in that cases, it's typically other people that are reporting to me. My wife is starting to think that this is a good idea or the baby is a demon and she's actually believing that this is the case. So that is an emergency that's exceedingly rare, although if that is something that you're going through, there's medications for that. But it is an emergency. Now, on the other hand is the thing that I see all the time, super common is ego dystonic, meaning the thoughts are bothering mom.

(44:56): Mom would love to get rid of the thoughts. She doesn't think driving off the road is a good idea. In fact, she's terrified of it. Those are ego dystonic thoughts. Those are not an immediate emergency. However, it'd be nice if we could control those. Those are actually quite common. And those could be from anxiety or an OCD type picture. And then people were like, oh, I'm so glad I can talk about it and not fear that you're going to commit me to a hospital. And so I always say, and so many people are like, oh, man, that's such a relief.

Dr. Nicole (45:31): You were going to save a lot of people by saying that because I'm sure somebody is Hearing people were like, I thought I was crazy. And I'm like, no, definitely, yes. Thank you so much for sharing that. That's really important. So then my final questions, and I ask all of my expert guests this, what is the most frustrating part of your work?

Dr. Stephanie Waggel (45:51): That's funny. It's a toss up between, okay, I'm not blaming the pharmacists or anybody that works at the pharmacy. I'm blaming corporate because the pharmacies are so overworked. I read an article that there was a pharmacist who fills on average one prescription every minute. Oh my God. And so they're so overworked. But one of the things that really burns my biscuits is when the pharmacy loses my prescriptions,

Dr. Nicole (46:22): Yes.

Dr. Stephanie Waggel (46:23): I really get very agitated to the point I have actually started screenshotting my orders and sending them to the patients to prove I sent it in. Here's the time date, I swear I sent it. But again, if you're filling a hundred prescriptions in an hour or whatever is going on at the pharmacy, you're going to lose stuff. So I don't blame the pharmacist. They're very overworked, but then it just makes things very difficult for me when my prescriptions just disappear.

Dr. Nicole (46:55): So then the patient has to wait, and it's just like a frustrating thing. I totally get it. And then on the flip side, what's the most rewarding part of your work?

Dr. Stephanie Waggel (47:02): I love whenever a patient says, I feel that I return to my normal self. I'm back to the way I was. I'm my normal self again. I'm just like, oh,

Dr. Nicole (47:14): That's great. Yes. Yeah, absolutely. And then what is your favorite piece of advice that you would give to an expectant mother or parents?

Dr. Stephanie Waggel (47:23): It's to make sure you have a good support system and don't hesitate to take care of yourself. And if anything convinces you to take care of yourself, it would be the epigenetic factors that I talked about earlier. Basically, if you, let's say you won't take care of yourself for yourself, take care of yourself for your child, because uncontrolled mental illness or issues going on with you actually does affect the turning on and off of DNA in your baby. So if you're not going to take care of yourself for yourself, take care of yourself for your child's genetics.

Dr. Nicole (48:06): Excellent advice. Excellent advice. So where do people find you?

Dr. Stephanie Waggel (48:09): Well, I'm in Reston by, well, they call it the mc, taco Hutt because there's a Taco Bell, McDonald's and Pizza Hutt, the Wheel Reston metro stop. That's where my office is. But I do virtual, so as long as you're in Virginia, you could just find me at www.improvelifepllc.com. And oh, I would love it if people found me on YouTube because I put a lot of work into my videos.

Dr. Nicole (48:44): Well, where are you on YouTube? Tell us where you're on YouTube.

Dr. Stephanie Waggel (48:46): So it's Improve Life, PLLC on YouTube. And then on our website, there is a link to all the social media. My professional Instagram is Improve medical Culture. That one is focused on my mission to make the culture medicine not so toxic for med students and residents because they really get abused a lot. Yeah. Yeah. I have 10,000 followers on there. I'm proud of that one. Awesome. But the clinic has an Instagram too, and that's Improve life. PLLC, P as in Paul, L as in lion, L as in lion, C as in cousin.

Dr. Nicole (49:34): Awesome. Thank you so much. And we will link all of that in our show notes. Well, thank you so much for agreeing to come on to the podcast. This was really informative. I know I learned a lot, and I know that people listening learned a lot. And I know you have helped someone with this information today.

Dr. Stephanie Waggel (49:50): Oh, I hope so. Thank you, Dr. Nicole. It was super fun. I love talking about this type of stuff.

Dr. Nicole (50:01): Wasn't that a great conversation? This is so important. There just aren't that many perinatal psychiatrists out there. So I'm really glad that she was able to come on and share her experience. Now, after every episode when I have a guest on, I do something called Dr. Nicole's notes, which are my top takeaways from the conversation. Here are my Dr. Nicole's notes from my conversation with Dr. Waggel one, I do want to plug Postpartum Support International. That website has a lot of resources for you. You can put in your zip code and get connected with providers in your area who are actually interested in doing reproductive mental health. So postpartum Support international, that website is www.postpartum.net. So do check that out if you need any resources. Second thing I want to talk about is normalizing those unwanted thoughts. I thought that was such a really important thing to mention, that we all have unwanted thoughts.

(50:59): It doesn't make us bad people, it doesn't make us abnormal. It just makes us human. And it's how we manage those thoughts, how we deal with those thoughts. That is what's going to set us up for success. But it is completely normal to have unwanted thoughts. It's just a part of being human. The next thing I want to talk about is how the most important part of a healthy baby is a healthy mom. She mentioned that she actually prefers to keep patients on their medication if they were taking medication for anxiety or depression, as long as they know the risk. Because if you don't take care of yourself, then how are you going to be able to take care of a baby? So really the most important piece, and this is something that I believe we miss so much in our society, we focus so much on the baby without realizing the first step for that baby to be healthy is to have a healthy mom. So take care of yourself. Take care of the medications, take the things that you need to take in order to be the best, healthiest version of you.

(52:07): And the final thing I want to talk about is since we recorded this episode, there was an article in jama, the Journal of American Medical Association, big journal. It was like a research letter maybe or opinion letter. Anyway, it expressed some concerns about this new depression medication. And I'll say back up just a little bit. Studies in pregnant women or postpartum women, breastfeeding are really, really difficult. It can be hard to get people to enroll in studies. I mean, let's be honest, who wants to sign up to be in a study while you're pregnant? That may be concerning for you, or maybe not, maybe not. But for a lot of people, it's a natural concern. So I can see how it's challenging or you can understand how it's challenging to study any medication in pregnancy. But with this particular depression medication, when they did the studies, you couldn't breastfeed.

(53:00): You only take the medication for a short period of time. I believe it's two weeks, but you can't breastfeed during that time. They required that people were on contraception during the study. And then the final thing that was really like raising red flags about whether or not this medication is as great as it was promised to be, is that they compare the medication to doing nothing for postpartum depression, which is not the standard of care. If somebody has postpartum depression, then we're going to treat that with medication. That would be the standard of care. So what they really should have done is instead of comparing this new medicine to not doing anything, they should have compared it to not doing anything and to a group who were receiving medication for depression, like all three groups. Or if you're going to have two groups, then they should be the medication, the new medication, and then the standard of care for regular postpartum depression.

(54:01): You should not have compared it to not getting anything, because that's not a fair comparison. So just keep that in mind if that medication is ever brought up or if you've thought about pursuing or interested in that medication, just so you know. Okay. So there you have it. Please share this podcast with a friend. I so appreciate your help in reaching and serving as many pregnant folks as possible. And when you share, it helps me and it helps them. So share this podcast with a friend. Also, subscribe to the podcast, an Apple podcast or wherever you're listening to me right now, subscribing. Make sure that you never, never, ever miss an episode. And if you subscribe an Apple podcast, do leave a review there. I appreciate it. A five star review. If you like the podcast, let me know what you think about the show. Also, come let me know what you think about the show on Instagram. I'm on Instagram at @DrNicoleRankins. My dms are open. If you want to come talk to me, I'm there. Come check me out there. So that is it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.