Eight years ago in the foyer of a large ballroom in Boston, Dr. Lee S. Cohen appeared next to me as I looked at psychiatric books displayed by a vendor at the annual Psychopharmacology Conference of Massachusetts General Hospital. It was the lunch hour, and in a half-hour, he was to speak.
I took advantage of the moment. I approached Dr. Cohen and held out my hand and shook his. I said, "Thank you Dr. Cohen. I have been a psychiatrist long enough to remember saying to a woman, 'I don't know'. You changed that."
I spoke to the moments when a pregnant woman expressed anxiety about her unborn child and the medications I prescribed for her. In the early years of my practice, all I could do is express my ignorance. There were no easy discussions. Usually, a woman discontinued her medications. Discontinuation predicted a likely return of symptoms.
I have heard Dr. Cohen speak at least a dozen times. He is a modest man. He frequently gives others credit. Yet he and his colleagues at Massachusetts General Hospital lead the national and international effort to inform pregnant and breastfeeding women of the benefits and risks of their psychiatric medications.
Maternal Health Most Important
Attending the "43rd Annual Psychopharmacology Conference" of October 2019, I most anticipated Dr. Cohen's presentation. Once more I heard him say, "Nothing trumps keeping a woman psychologically well in pregnancy." He adds, "This is the most important lesson of the last quarter-century."
The implication is that dysregulation of the maternal-unborn child biology is a risk factor for poor outcome in the development of the child. Untreated psychiatric symptoms carry their own risks for the child in utero and postpartum.
As Dr. Cohen observed in 2017, "There exists more safety data on the selective serotonin reuptake inhibitors than any other medications, second to prenatal vitamins." The selective serotonin reuptake inhibitors include Prozac, Zoloft, Lexapro, and others.
In fact, worldwide research reassures that very few psychiatric medications are contraindicated, in other words, not to be prescribed for pregnant or breastfeeding women.
Informing and Reassuring
To quote Dr. Cohen, " No decision is risk-free. " He encourages a " collaborative and patient-centered approach. " Psychiatrists, obstetricians, primary care physicians and other providers now can be informative in addition to being supportive. They can inform women so that they can make the best decision for them and their babies. They can share extensive safety data.
Dr. Cohen has published over two hundred articles in the professional literature. Working with colleagues across the country, he and the team at Massachusetts General Hospital developed ongoing national registries to gather data on medication safety and maternal and offspring outcome. The more data accumulated on a given medication, the more informative a psychiatrist or primary care physician can be.
Empowering Women with Current Research
Dr. Cohen's colleague at Massachusetts General Hospital, Ruta M. Nonacs, M,D,, Ph.D. maintains the website, "womensmentalhealth.org". She updates the site with pertinent information within a matter of days of the publication of significant research. The blogs afford a woman the opportunity to educate herself much further than within the allowed time in her doctor's oﬃce.
In an example of timeliness and relevance, Dr. Nonacs posted on December 22, 2017, a blog entitled, "Good News: More Data on the Use of ADHD Medications During Pregnancy". The post began, " For women with mild to moderate attention-deficit/hyperactivity disorder, we often recommend discontinuing stimulant medication and switching to non-pharmacologic intervention."
She continues, "There are, however, women who experience more severe symptoms which interfere significantly with their daily functioning. In these women, we may consider maintaining pharmacological treatment. The primary reason for limiting the use of stimulants during pregnancy has been that our data regarding the reproductive safety of stimulant medications, including methylphenidate and amphetamines, have been sparse. "
Dr. Nonacs summarizes an article published on December 13, 2017, in JAMAPsychiatry. The article analyzes two huge data sets. She comments, "All in all, I think the findings of this study are quite positive. If there is a risk, it is quite small. Our primary goal is to maintain mental health stability and functioning during pregnancy, and this study provides useful information to women taking stimulants who are pregnant or planning to conceive."
As a psychiatrist who prescribes stimulant medication to women, I appreciate the reassurance coming from Dr. Nonacs. In turn, I can convey this information to my patients, giving them a chance to make informed decisions.
At the time Dr. Cohen started his work four decades ago at Massachusetts General Hospital, some physicians were skeptical regarding the potential usefulness of the effort. Now Dr. Cohen and colleagues stand as quiet and very impactful advocates for women.