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Prescriber’s Corner: Shared Insights from Flourish’s prescribers, Amy Wasserman & Cynthia Jacinthe

Disordered Eating During Pregnancy and Postpartum

Dr. Cynthia Jacinthe, DNP, APN, PMHNP-BC, CNM-FPA, PMH-C
Disordered Eating During Pregnancy and Postpartum

Pregnancy comes with changing emotions as well as a constantly changing body. Pregnancy is 40 weeks long, and each week will look different. One of the first things most people think about when they become pregnant is, “How much should I eat?”, “How much weight can I gain?”, “What happens if I gain too much or not enough weight?”. All these questions are important to talk with your midwife or OB provider about.

What is not often talked about is disordered eating in the pregnancy and postpartum period.

What is Disordered Eating?

Disordered eating is defined as a range of irregular eating behaviors that may not warrant a diagnosis of a specific eating disorder, such as anorexia nervosa, bulimia nervosa, or binge eating disorder, but still negatively impact physical and mental health. These behaviors can include:

  • Obsessive calorie counting or food restriction
  • Binge eating followed by guilt or shame
  • Purging through vomiting, excessive exercise, or laxative use
  • An unhealthy preoccupation with body image or weight

During pregnancy, these behaviors can be triggered or exacerbated by the physical and emotional changes that occur, including weight gain, body shape changes, and hormonal fluctuations.

How Disordered Eating Affects Mom and Baby

Disordered eating during pregnancy can have significant consequences for both the mother and the growing fetus. Research shows that it can lead to:

  • Miscarriage: Due to nutritional deficiencies and stress on the body.
  • Low birth weight: Resulting from inadequate nutrition reaching the fetus.
  • Prematurity: Babies may be born too early due to poor maternal health.
  • Developmental delays and complications: Linked to nutrient deficiencies and poor fetal growth.

The impact extends beyond pregnancy. In the postpartum period, disordered eating can:

  • Delay recovery: Poor nutrition can slow the healing process after childbirth.
  • Affect breastfeeding: Insufficient calorie intake or nutrient deficiencies can impact milk production and quality.
  • Increase the risk of postpartum depression and anxiety: Disordered eating is strongly associated with mood disturbances, which can affect maternal-infant bonding and overall mental health.

Seeking Help: You’re Not Alone

If you’re struggling with disordered eating during pregnancy or postpartum, it’s important to reach out for support. Start by talking to your healthcare provider, such as a midwife, OB-GYN, or mental health professional. They can connect you with resources like:

  • Registered dietitians specializing in perinatal nutrition
  • Therapists trained in cognitive-behavioral therapy (CBT) or other evidence-based approaches for eating disorders
  • Support groups where you can connect with others experiencing similar challenges

Breaking the Silence

It’s crucial to recognize that disordered eating is not uncommon during the pregnancy and postpartum periods. Yet, because of societal expectations and stigma, many people suffer in silence. By talking about it openly and seeking help, you can prioritize your well-being and the health of your baby.

If you or someone you know is struggling, don’t hesitate to reach out. Remember, asking for help is a sign of strength, not weakness.

References

  • Mantel, Ä., Hirschberg, A. L., & Stephansson, O. (2020). Association of Maternal Eating Disorders With Pregnancy and Neonatal Outcomes. JAMA Psychiatry, 77(3), 285-293. https://doi.org/10.1001/jamapsychiatry.2019.3664
  • Pettersson, C., Zandian, M., & Clinton, D. (2016). Eating disorder symptoms pre- and postpartum. Archives of Women’s Mental Health, 19. https://doi.org/10.1007/s00737-016-0619-3
  • Raykos, B., & Watson, H. (2021). Treating eating disorders in pregnancy and the postpartum period. In C. C. Tortolani, A. B. Goldschmidt, & D. Le Grange (Eds.), Adapting evidence-based eating disorder treatments for novel populations and settings: A practical guide (pp. 238-267). Routledge/Taylor & Francis Group.

 

January 2025

Navigating ADHD Medication Use During Pregnancy and Lactation: What Does the Evidence Say?

Written by: Amy Wasserman, MPH, MSN, APRN, PMHNP-BC, CNM-FPA, PMH-C
Psychiatric Mental Health Nurse Practitioner

For those who are pregnant or trying to conceive, managing Attention Deficit Hyperactivity Disorder (ADHD) can feel particularly challenging. The prospect of medications that help manage ADHD symptoms can be daunting when considering their potential impact on both the individual and the developing baby. It’s essential to approach this subject with a blend of understanding, evidence-based information, and support.

Understanding ADHD and Its Treatment

ADHD affects many individuals, and symptoms can include inattention, hyperactivity, and impulsiveness. For many, managing these symptoms often provides for the use of medication, particularly stimulants like methylphenidate and amphetamines and/or non-stimulants like atomoxetine or bupropion. However, the safety of these medications during pregnancy and lactation is a common concern and the decision whether to continue on medication or discontinue is complex.  A recent study showed almost 60% of women discontinued their ADHD medication and only 17% re-initiated medication in the postpartum period.

Stimulant Medications

Research indicates that stimulant medications generally pose a low risk of serious complications during pregnancy. A comprehensive review found no substantial evidence linking the use of these medications with severe birth defects and a population based study demonstrated no increased risk of any developmental disorders in newborns exposed in utero to ADHD medications compared to those unexposed. However, some studies suggest a very small increased risk of cardiac malformation in methylphenidate-exposed infants. In women with histories of hypertensive disorders, panic disorder or who are at increased risk of hypertensive disorders in pregnancy, studies suggest gestational hypertension was significantly associated with stimulant use. For women currently taking stimulants, a carefully monitored continuation of medication may be advisable, especially for those whose ADHD symptoms significantly affect their ability to function optimally.

Non-Stimulant Medications

Non-stimulant options, such as atomoxetine, also present a mixed picture. Current data suggests that atomoxetine may be safer than its stimulant counterparts, with limited evidence of adverse pregnancy outcomes and bupropion data is reassuring but demonstrates a very small absolute increased risk of cardiac malformation. However, rigorous studies are still ongoing, and individual responses can vary. Maintaining an open line of communication with your healthcare provider is crucial to tailor a plan that feels right for you.

Lactation Considerations

For new parents choosing to provide breastmilk, continuing ADHD medication is yet another layer to consider.  Studies on the use of stimulants during lactation are limited and therefore the impacts on exposed infants and effects on milk supply are unclear but appear to be reassuring. There are many factors that contribute to the potential effects including the age of the baby, whether or not the baby is exclusively receiving breastmilk, the dose of medication, and the formulation (immediate vs sustained or extended-release). In lactation, using an immediate-release formulation could provide more flexibility and predictability related to peak blood levels. However, it’s essential to proceed with caution and consult your healthcare provider to ensure that you’re making informed decisions that prioritize your health and your baby’s.

Making Informed Choices

The decision to use ADHD medication during pregnancy and lactation should be approached thoughtfully. Each individual’s circumstances are unique, and many factors – including the severity of ADHD symptoms, the potential risks of untreated ADHD, and the overall health of both the individual and child – must be considered.

It’s vital to have open dialogues with healthcare professionals who can provide personalized advice and up-to-date information based on the latest research. If you’re considering stopping your medication, discuss alternative strategies for managing symptoms during this crucial time as studies have shown that discontinuing medication can increase depressive symptoms in pregnancy and postpartum. Behavioral therapies or support groups can provide significant assistance and can be especially helpful for those who may not feel entirely comfortable with medication use while pregnant.  ADDitude is a trusted online resource sharing the latest evidence and providing guidance and support for living better with ADHD.

Closing Thoughts

If you’re pregnant or trying to conceive and manage ADHD, it is essential to recognize your needs, seek support, and advocate for your health and well-being. Remember, informed choices can empower you to make the best decision, whether that involves medication or alternative approaches. Your mental health is important, we are here to assist you in managing your ADHD with care and understanding as it is a vital part of your journey throughout parenthood.

References

Andersson A, Garcia-Argibay M, Viktorin A, Ghirardi L, Butwicka A, Skoglund C, Madsen KB, D’onofrio BM, Lichtenstein P, Tuvblad C, Larsson H.  Depression and anxiety disorders during the postpartum period in women diagnosed with attention deficit hyperactivity disorder.  J Affect Disord. 2023 Jan 18: S0165-0327(23)00085-X.

Baker AS, Wales R, Noe O, Gaccione P, Freeman MP, Cohen LS. The Course of ADHD during Pregnancy. J Atten Disord. 2022 Jan;26(2):143-148.

Bang Madsen K, Bliddal M, Skoglund CB, Larsson H, Munk-Olsen T, Madsen MG, Hove Thomsen P, Bergink V, Srinivas C, Cohen JM, Brikell I, Liu X. Attention-Deficit Hyperactivity Disorder (ADHD) Medication Use Trajectories Among Women in the Perinatal Period. CNS Drugs. 2024 Apr;38(4):303-314.

Bang Madsen K, Robakis TK, Liu X, Momen N, Larsson H, Dreier JW, Kildegaard H, Groth JB, Newcorn JH, Hove Thomsen P, Munk-Olsen T, Bergink V.  In utero exposure to ADHD medication and long-term offspring outcomes.  Mol Psychiatry. 2023 Feb 9.

Newport DJ, Hostetter AL, Juul SH, Porterfield SM, Knight BT, Stowe ZN.  Prenatal Psychostimulant and Antidepressant Exposure and Risk of Hypertensive Disorders of Pregnancy.  J Clin Psychiatry. 2016 Nov;77(11):1538-1545.

Suarez EA, Bateman BT, Hernandez-Diaz S, Straub L, McDougle CJ, Wisner KL, Gray KJ, Pennell PB, Lester B, Zhu Y, Mogun H, Huybrechts KF. Prescription Stimulant Use During Pregnancy and Risk of Neurodevelopmental Disorders in Children. JAMA Psychiatry. 2024 Jan 24:e235073.

 

October 2024

Midlife Mental Health

Written By- Amy Wasserman, MPH, MSN, APN, PMHNP-BC, CNM-FPA, PMH-C

On the heels of World Menopause Day October 18th, I want to acknowledge this pivotal transition during the reproductive life cycle and the significant impact it can have on an individual’s mental health. The journey to menopause and how one experiences it can greatly vary and is often influenced by a complex interplay of biological, psychological and social factors. This is similar to other significant transitions in the reproductive life cycle including the onset of puberty and the perinatal period. However, menopause is often stigmatized, associated with aging and individuals may feel ashamed and isolated by their symptoms or situation.  In the past this period was referred to as a “midlife crisis”.  Navigating through the many uncertainties that come with midlife can often feel very daunting and without the proper support it certainly feels like a crisis.

This is especially true for those individuals who experience an array of symptoms associated with the transition leading up to menopause aka (peri)menopause – back to those symptoms in a minute. Menopause, is marked by the day of the final menstrual period which is often determined retrospectively after an entire 12 months passes in absence of menstrual bleeding. On average, an individual will approach menopause by age 52 but it may happen as early as in your 30’s or as late as in your 60’s, occurring either naturally or as a result of medical or surgical reasons.

Regardless of the cause, you may notice a syndrome of symptoms including hot flashes, night sweats, inflammation, joint pain, weight gain, muscle wasting, sexual dysfunction, pelvic floor weakness, genitourinary symptoms, cognitive changes, sleep disturbances, loss of skin elasticity and dryness, hair thinning on the scalp and excessive hair growth on the face, acne, increased headaches, elevated blood pressure, mood changes and more. Many of these symptoms contribute to lost wages, missed work days and employee resignations costing employers $1.8 billion annually.

Mood changes can look like anxiety, depression or a mixture of both. Many of these symptoms can be a result of hormonal changes, significant life events, relationship issues, caretaker fatigue, financial stress and limitations in physical health. While not a lot of research has been conducted on this important topic, two pivotal studies offer some insight on how to support individuals during this time. The Women’s Health Initiative (WHI) and the  Study of Women’s Health Across the Nation (SWAN) both have provided important findings to help frame evidence-based approaches throughout midlife and menopause to improve an individual’s physical, social, psychological and mental well-being.

In the SWAN, depending on ethnicity, 20 to 70 percent of participants reported using some form of complementary and alternative therapy (CAM) during the menopausal transition phase to manage symptoms.  Adopting healthy lifestyle behaviors focused on eating a healthy diet, regular exercise, quality sleep, mindfulness practices and socializing with friends can help to reduce stress and depressive symptoms.  Reduce the use of substances that may also impact your sleep, stress levels and overall health. Evidence suggests hormone replacement therapy can help to manage some of the myriad of symptoms including balancing mood but it may not be safe or appropriate for everyone. Psychiatric medications may also help to reduce anxiety and depressive symptoms, reduce hot flashes and improve sleep quality.

Finding a provider who can help navigate the constellation of symptoms that present during this midlife transition may feel impossible and often does require a collaboration of specialists. At Flourish, we commit to supporting your midlife mental health needs and validate your experiences so you don’t feel alone on this journey.

Here are a few of my favorite resources to help you start learning more about this important milestone:

References:

  • Faubion S. et al. (2023) Impact of Menopause Symptoms on Women in the Workplace. Mayo Clin Proc; 98:833-845. doi: 10.1016/j.mayocp.2023.02.025.pubmed.ncbi.nlm.nih.gov/37115119/
  • Study of Women’s Health Across the Lifespan Website https://www.swanstudy.org/
  • Women’s Health Initiative Website  https://www.whi.org/

 

Pregnancy & Infant Loss: Is My Grief ‘Normal’?

Written by: Cynthia Jacinthe, DNP, APN, PMHNP-BC, CNM-FPA, PMH-C ~Psychiatric Advanced Practice Nurse

A pregnancy journey has its peaks and valleys. Pregnancy loss is a valley that can be challenging to navigate. You may experience moments of disappointment, anger, shame, or guilt. You may also experience both acute and complicated grief.

Acute grief is commonly experienced after a pregnancy and infant loss. This grief can look like reflecting on what could have been, feeling sad or upset about the loss, or a sense of disbelief or shock about what happened. Eventually, those intense feelings lessen over time as you accept what happened and begin to feel more hopeful for the future. This normal type of grief continues to be a part of your ongoing life but it doesn’t overtake your mood or your ability to function throughout the day.

Complicated grief, on the other hand, is persistent and intense. It can look like intense sadness, ruminations focused on angry or guilty thoughts about the loss, or the constant need to reminisce about the pregnancy. This could include viewing or touching items that were brought for the baby. You may be emotionally numb and no longer have the ability to see happiness for yourself. Complicated brief is typically identified at least six months or more after the loss. There is no perfect timeline for grief but the intense and persistent feelings of sadness and loss are what differentiates acute grief from complex grief.

Here at Flourish, we have therapists who can support you through grief and acceptance. The goal is not to forget what happened but how to process the loss, hold space for memories, and look forward to future pregnancies. Postpartum Support International PSI also offers support and resources for those who have experienced a pregnancy loss.

In your moments of grief, I want you to remember that you are not alone. Do not suffer in silence, reach out to the ones you trust, and seek professional help if it becomes overwhelming. Sometimes there is a rainbow after the storm.

 

New Treatment for Postpartum Depression: Why all the hype about Zuranolone?

Written By- Amy Wasserman, MPH, MSN, APN, PMHNP-BC, CNM-FPA, PMH-C

On August 6th, the Food and Drug Administration (FDA) approved the first oral medication for the treatment of postpartum depression. The last time we had a medication approved for postpartum depression was in 2019 when the FDA approved brexanolone. While many were very excited about brexanolone’s release, patients had a hard time accessing the treatment as it required administration through an intravenous infusion over the course of 60 hours; requiring an individual to be admitted in a hospital during the infusion and in many cases, separated from their newborn and families. Shortly after the approval of brexanolone, a worldwide pandemic occured which led to most individuals fearful of any kind of hospital admission.  Brexanolone was ground-breaking for its unique mechanism of action compared to traditional antidepressants used for perinatal mood and anxiety disorders but access to the medication has been very limited.

Zuranolone, like brexanolone, is a neuroactive steroid with antidepressant activity with a novel mechanism of action as positive allosteric modulators of GABA-A receptors.  This difference in “how it works” is one of the advantages of this medication in that individuals can expect improvement in symptoms as early as 3 days after starting the medication.  Individuals take a 50 mg capsule in the evening for 14 days and can expect sustained symptom improvement for up to 30 days after taking their last dose. It is recommended to take the medication with fat-containing food (400 to 1,000 calories) for improved absorption.  Zuranolone will be available in three capsule dosage strengths (20 mg, 25 mg and 30 mg) to allow for flexibility to adjust dosing if CNS depressant effects (i.e. somnolence, confusion) occur or if the individual has hepatic or renal impairment.  Participants in the studies most commonly reported somnolence, dizziness and sedation as adverse events while being treated with zuranolone 50 mg. As a result, there is a warning in the prescribing information advising patients not to drive or engage in other potentially hazardous activities until at least 12 hours after administration of the dose for the entire treatment course.   

Zuranolone is anticipated to make its debut on the market before the end of 2023 and will be marketed under the name Zurzuvae.  It is estimated to be released after a 90-day review by the Drug Enforcement Administration (DEA); sometime early November.  At this time, we do not have any information about how much the medication will cost, which insurance companies will cover it or if individuals will have to show previous failure on antidepressants before being prescribed this novel medication. In other words, it may not be considered a first-line treatment medication for women who have taken alternative medication treatments with proven symptom improvement.

Many questions still exist about the efficacy and safety of zuranolone.  Individuals in studies were asked to refrain from breastfeeding so we do not have any data on whether or not zuranolone is safe during breastfeeding. Further studies will need to be conducted to determine what percentage of medication transfers to breastmilk, whether or not the medication will have negative side effects for the baby and whether or not it will impact milk supply. At this time, zuranolone is not recommended to be used during pregnancy as it is considered a teratogen.  The highlights of prescribing information for Zurzuvae (zuranolone) can be found here: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/217369s000lbl.pdf

Other remaining questions we do not currently have answers to include the following:

  • Will patients need to repeat treatment or some form of a maintenance course after completing the initial 14-day course? 
  • Should patients be started on an alternative psychiatric treatment (i.e., antidepressant) once completing the 2 weeks of oral zuranolone treatment? 

While we wait for more details to be announced from the FDA and DEA, we should still celebrate this ground-breaking achievement in maternal mental health. Hopefully, the FDA approving this medication for postpartum depression will help to spread increasing awareness about a subject that so often is not given the attention it deserves. 

I participate every Wednesday in the virtual grand rounds at the Mass General Hospital (MGH) Center for Women’s Mental Health. To read the latest insights posted on August 24, 2023, on zuranolone for postpartum depression by Dr. Lee S. Cohen, Director of the Ammon-Pinizzotto Center for Women’s Mental Health at MGH, please click the link here: https://womensmentalhealth.org/posts/zuranolone-for-postpartum-depression/

References:

Deligiannidis, K. M., Meltzer-Brody, S., Maximos, B., Peeper, E. Q., Freeman, M., Lasser, R., Bullock, A., Kotecha, M., Li, S., Forrestal, F., Rana, N., Garcia, M., Leclair, B., & Doherty, J. (2023). Zuranolone for the Treatment of Postpartum Depression. The American journal of psychiatry, appiajp20220785. Advance online publication. https://doi.org/10.1176/appi.ajp.20220785

 

Sleep Deprivation

Written By- Amy Wasserman, MPH, MSN, APN, PMHNP-BC, CNM-FPA, PMH-C

Let’s talk about Sleep Deprivation… there is a reason it has historically been a method used for psychological torture as prolonged deprivation can have a wide range of negative health effects, especially on mental capacity. While the terms we use to refer to the deprivation may differ, “sleep regulation”, “sleep disturbance”, “sleep adjustment”, “insomnia”, “night wakings”, the impact to the individual who is struggling is all the same.

During a visit, sleep quality is one of the most important symptoms we will discuss because we know deprivation can affect an individual’s daytime energy level, cognitive function, mood stability, immune function, appetite and more. The longer the deprivation continues, the worse the health effects can be, often contributing to long-term health complications including diabetes and heart disease.

Depending on the season in your life, you may need more or less quality hours of sleep in a 24-hour period of time to feel rested but the average adult should be aiming for 7 hours. These hours can vary based on an individual’s daily activity, immune function and work or shift schedule.  The majority of clients I work with are suffering from some sort of sleep deprivation whether they are struggling to fall asleep, waking up multiple times through the night or waking up earlier then they would like to.

Pregnancy can impact restful sleep related to hormonal changes, the need to wake in the middle of the night to use the bathroom or finding it hard to get in a comfortable position.  Postpartum parents often are sleep deprived related to a frequently waking newborn and some suffer from postpartum anxiety or obsessive-compulsive disorder which can make falling asleep (even when the baby is sleeping) more challenging.  Individuals who are transitioning through perimenopause or hormonal treatments may also suffer related to increased anxiety symptoms that keep the mind awake, thermoregulation changes (i.e. hot flashes) and/or pain.

As a midwife for 11 years, my body often needed more sleep and rest the first few days after being awake through the night during a labor and birth. Over time, I learned what helped my body to recover in a healthy way but this took practice, some trial and error and implementing healthy sleep hygiene practices.

Whether you are struggling with acute or chronic sleep deprivation there are many options for improving your sleep including cognitive behavioral therapy insomnia (CBTi), various supplements, hypnotic medications, sleep devices/products and behavioral changes. In some cases, meeting with a sleep specialist and completing a sleep study may also be indicated.  No matter what the root cause for the sleep deprivation, consider making some changes to your sleep routine and see how this can have a positive impact on your overall mental health and well-being. Read more about sleep health topics from the National Sleep Foundation here. Additionally, you can read this article from the Sleep Foundation about behavioral changes that you can start implementing today to improve your overall sleep quality. Sweet dreams!

References:

Does winter make you SAD?

Written by: Cynthia Jacinthe, DNP, APN, PMHNP BC, CNM-FPA, PMH-C Psychiatric Advanced Practice Nurse

Do you notice a pattern where your mood changes when the weather gets colder? The fall and winter holiday seasons do not always make us feel our best. The cold, dark, and shorter days can make us want to hibernate. We can sometimes feel depressed, angry, and lack motivation. These mood changes can be normal but other times these feelings can be severe and become a condition called Seasonal Affective Disorder (SAD).

SAD is mood changes or a type of depression characterized by depressive symptoms that last 4-5 months. Symptoms can start in the late fall or early winter and last until the spring or summer. SAD seems to be triggered by a drop in sunlight exposure. Research suggests that sunlight affects the level of molecules that help maintain serotonin levels. Serotonin is the chemical in the brain that helps to regular mood. A drop in sunlight exposure leads to a lowering of these molecules contributing to lower serotonin levels. Some symptoms of SAD can be similar to depression including persistent sadness, feelings of hopelessness, irritability, guilt, loss of pleasure in hobbies or activities you usually enjoy, and in some instances thoughts of death or suicide. These symptoms must persist for over 2 weeks and have occurred for 2 consecutive years to be diagnostic of SAD.

How do we treat SAD once identified? Similar to nonseasonal depressive conditions, SAD can be treated with psychotherapy such as Cognitive Behavioral Therapy (CBT) or anti-depressive medication such as an SSRI (selective serotonin reuptake inhibitor). An alternative and effective approach is Bright Light Therapy (BLT). BLT is considered first-line therapy for SAD. Light therapy involves sitting in front of a lightbox (10,000 lux) for 30-45 minutes a day, usually in the morning. This helps to allow for more sunlight exposure that can be decreased during the winter months. In addition to being an effective treatment option, light therapy has been shown to improve depression symptoms within one week.

If you feel you may be experiencing symptoms of SAD, reach out to the amazing team at Flourish for support and guidance.

Sources:

Psychiatry.org Seasonal Affective Disorder (SAD)

National Institute of Mental Health: Seasonal Affective Disorder (SAD)

Campbell, P. D., Miller, A. M., & Woesner, M. E. (2017). Bright Light Therapy: Seasonal Affective Disorder and Beyond. The Einstein journal of biology and medicine : EJBM, 32, E13-E25.