#45. Maternal Depression and Antidepressant Use - Dr. Stephanie D'Souza

There is often a tendency to focus on physical rather than mental health during pregnancy. While rates can vary by country, research suggests that about 10 - 20% of pregnant women experience depression during pregnancy. This is higher than the average rate of 6% seen in the general population. The changes during pregnancy can also make it hard for mood disorders to be detected and treated. Dr. Stephanie D'Souza of University of Auckland joins to discuss her research as maternal depression and antidepressant use. Dr. D'Souza goes through her research as we talk about some key things to be aware of and why research in maternal health is hard to undertake.

Important links:
https://pada.nz/
https://www.helpguide.org/find-help

Dr. Stephanie D'Souza Bio: https://profiles.auckland.ac.nz/s-dsouza

Chapters

• 0:00 Disclaimer and Introduction
• 6:37 Risk Factors and Prevalence of Depression During Pregnancy
• 16:23 Antenatal vs Postnatal depression and Treatment options
• 27:58 Importance of Reliable Data
• 33:37 Maternal Mental Health and Considerations for Offspring
• 43:44 Challenges in Finding the right antidepressant
• 50:39 Outcomes of Antidepressant use on Child Behavior
• 56:57 Key findings from Antidepressant use during pregnancy
• 1:09:45 Final Thoughts

Transcript

0:00

Just as a disclaimer, this episode contains discussions around mental health and maternal mental health. There are support services that will be provided in the show notes. One great website is the Perinatal Anxiety and Depression Association website. It's a New Zealand based website. I think it's pada.org.nz, or pada.nz, I think. And they've got some great resources available. as well as some links to support services too, if that's something you wanna check out. Welcome everybody to the Smooth Brain Society. Today we will be talking about depression and maternal mental health, specifically use of antidepressants during pregnancy. To talk about this, we have Dr. Stephanie D'Souza, who's a senior lecturer at the Center of Methods and Policy Application in the Social Sciences. or Compass at the University of Auckland, New Zealand. She has a wide ranging amount of interests with an overarching theme of using administrative and survey data to promote equitable and sustainable outcomes in society. So her particular focus is on supporting maternal mental health, which we'll be talking about today, treatment and outcomes associated with psychiatric conditions over the lifespan, understanding the health needs of Asian New Zealanders. and exploring long-term health outcomes of context with athletes, which is another thing we wanted to talk to her about, and we will do it at some other time. But welcome, Steph. It's great to have you. Thank you for having me on. It's good to be here. And as you guys know, the format of the show is always we have a co-host on who has no real idea about the topic. Today we have Dr. Liza Bolton on. If some listeners remember, she was on before speaking about her work in statistics. Um, and giving us an overview of certain things, which we should know as people who are new to statistics. So it would be great to have her on for this chat about mental health. So welcome back, Liza. Thank you. It's so nice to be back into, you know, be cozying up in this co-host chair and getting to enjoy Steph's knowledge. Awesome. Uh, all right. So thank you guys for coming on. Um, well, first question I should ask Steph is you said you had, we saw that you had a Maybe we should talk about a little bit of your background and how you got into what you're doing. So I leave it to you to take us on a journey. Cool. Yeah, so I started with my undergrad study in psychology. I majored in psychology. And I think typical probably anybody who goes into psychology goes into it thinking, what am I going to do? Maybe be a clinical psychologist? And then you get into it and... realized, hmm, I don't think so, that's all for me. And I also had to do statistics as part of my psych degree. It was a crime and I actually enjoyed it and decided to, yeah, I was surprised, and decided to do a double major in psychology and statistics. And so I think that kind of brought on this real interest in using kind of larger data sets to look at health and wellbeing outcomes in New Zealanders broadly. And so when I decided to do my PhD, there was this study known as the Growing Up in New Zealand study that it's one of the well-known longitudinal studies here in New Zealand. There's several of them and it's the largest contemporary study here in New Zealand. So for context it follows children from before they were born and they will be something like 14-15 years now. So they were born in 2009 to 2010 across the Auckland counties, Manukau and Waikato DHB regions when we have district help boards and It was like 6,800 mothers that were recruited while they were pregnant. And they tracked the women and then their children once they were born every few years. And that had this real variety of data that was there. My PhD supervisor, Karen Weldy, was focused on, particularly interested in... behavioural and cognitive outcomes and had worked with the Dunedin Multidisciplinary Studies, so she had that sort of expertise. So it fit really well with my interests as well. And so I kind of got into, yeah, I started getting into that focused on child behaviour, but then there was also some work focusing on maternal depression as well with the cohort that I, you know, was involved in some of those papers. So my PhD itself was actually more focused on child behavioural outcomes. and the impact, particularly that maternal wellbeing can have on that. And from that then connected with Compass, who work with much larger data, population level data, using something known as the integrated data infrastructure. And so that sort of led to me looking at more longer term outcomes over the lifespan and in the population as well. Yeah, that's my little, little background there. Yeah, very nice. I find it funny usually because I taught research methods and stats to some extent while I was doing my PhD and most kids run away from it. So very fun to see someone who went. Yeah, it is like that as well. This is what I want to do. Yeah, yeah, it is like that as well. Like I teach research methods and stats to public policy students now and it's the same. sort of thing. I think I try, I think Liza you're similar probably with it where you try to be like it's not it's okay. It'll be fine. Yeah it'll be fine. And I do think they eventually appreciate it but yeah I liked it. It worked, I like the kind of, I guess I'm a problem solver in the way that I am and I felt like clicked really well with working with that sort of you know methodology. Should we get to why you're here? And let's talk about maternal mental health and your research with it. So like you said, you joined onto a longitudinal study looking at children, both the mothers first and then children. Was your PhD project and your first research itself looking at maternal mental health or was it more about the children and then you moved into like looking at the mothers? It was more. Yeah, it was more about the children. My focus was particularly in child behaviour and how that developed over the early to mid childhood period and what factors influenced that. And one thing that did come out was maternal mental health as being a key influencer. And then in addition to that it was just with those sorts of studies as well you do tend to do a lot of group work and like a research assistant as doing some of the number crunching and stuff with looking at what affects maternal mental health during pregnancy and the postpartum period, so looking at the predictors of that. And so that's how I got involved there as well. So it was sort of separate to my PhD, but obviously linked to it as well. And it was really good in terms of the opportunity that I had to, because it did tie in really well and gave me a really good understanding of... of what happens in that kind of perinatal period during pregnancy and postpartum and the implications that can have for the women as well as the children too. Yeah. I'm happy to talk about as well what I guess what we found. Would that be helpful in terms of discussing, at least in terms of the predictors of maternal mental health? So four, it might exactly it is first of all, which I'm sure most of us know, but depression is typically characterized by low mood, feelings of hopelessness and despair, irritability, appetite changes, sleep disturbances. And it's something that for a diagnosis, it would be present typically for at least two weeks for more than half the days and it would be impacting your day-to-day functioning. We kind of found when we first started doing this work was that there was a lot of focus on postpartum depression as there should be, but there wasn't a lot focused on the antenatal period and what women were experiencing and whether actually we were seeing depression happening from earlier on. And when we started to look into it a bit more, we found that something like 11% of women were experiencing a high... so we used a screening tool, it wasn't a diagnosis officially, but basically over a threshold that indicated likely depression during pregnancy. And more broadly when you look at the literature, the estimates vary, but something like 10 to 20 percent of women appear to, yeah, quite a large proportion relative. So, yeah, that experienced depression during pregnancy. And they do seem to be, I guess there does seem to be more of a susceptibility during the perinatal period if you think about it. There's a lot of change happening, a lot of physical changes, hormonal changes, social changes could also be economic factors. You're, you know, taking time off work and maybe experiencing a reduction in income. And then obviously considering the additional amount that you have to feed as well. So the reasons can vary and we found actually, maybe I'll share my slide now. Yeah, so in terms of the risk factors for depression, so we were involved, this is from the Growing Up in New Zealand study and we looked at risk factors that were specific to antinatal, the antinatal period, specific to the postnatal period and then kind of shared risk factors across both. And for the antenatal period in particular, having a lower education level was a risk factor. A lot of them, well, they both had shared risk factor. This included being single, which I guess would relate to a lack of support, which was the next point as well. Having a lack of social support, lower income, or socioeconomic status, a previous history of depression, as well as other mental health challenges, problems as well, stressful life events and having an unplanned pregnancy. And then the postpartum period, the risk factor for depression, there was antedatal mental health problems. Although not every woman, interestingly, that had depression during pregnancy went on to experience depression postpartum. There was quite a bit of overlap. But yeah, it wasn't, interestingly, it wasn't all women. I think it was something like 40% who had postpartum depression, experienced antidebital depression as well. And then the infant temperament was a risk factor, lower self-esteem, and then also if they had any obstetric complications related to the pregnancy and delivery as well. Yeah. Two of those indicators, I'm quite curious about like how they get measured. So infant temperament, I would love to know how that gets measured. And I'm also quite interested in the low education level for that sort of singular antenatal only one. So yeah. All right. So with the infant temperament that was measured using a scale known as the infant behavior questionnaire at around nine months. And it asks, I guess around... the way that the child behaves. And I know the specifics of the questions, but it does kind of get at the idea of if the child's maybe a bit more emotional, like shows more negative affect, maybe their responsiveness to the parent and their ability to like regulate and orient towards the parent, and kind of just a bit more social. But it is taught to be a little bit different from children's behavior in that temperament is thought to be a little bit more innate and something that you're sort of born with rather than behavior which is a bit more, which is related but more influenced by your experiences. Yeah so it would have been sort of more I guess higher negative affect in the child and more challenging temperaments in the child. And then with the education, that was just kind of your standard, you know, high school bachelor level degree and beyond bachelor's degree that would have been asked. So what was your highest level of education? Yeah. Is there any sense of why? And I mean, I know that sometimes you can see the effect in the data and how to disentangle the mechanism. But was there any sort of theory? on why education was popping up? Like, is it education itself or is it because it's a proxy for some of your other things? Do you think? Yeah, good. Great question, actually. I do wonder, we weren't sure or really considered that in more detail. It could be kind of awareness perhaps or related to some of those other factors there in terms of if you are perhaps have a lower education, you may also have of more financial stresses potentially. There are other factors that have been linked to say lower education in terms of having children younger, having perhaps more children and maybe just being more in having circumstances that perhaps may be a little bit more stressful. Perhaps, so I don't think it's necessarily the education itself but it could be something that could act, I guess, as a protective factor in a way because of what else you maybe are able to get access to. Also just knowledge about getting help, right? So perhaps if you're more educated, you might realize, hey, what I'm experiencing isn't great and perhaps I should go see my doctor and check to my doctor about what help I can get or my midwife. And... go get those sources of support. Whereas if you are, perhaps, if you have a law education, you may not have the awareness of what, to kind of proactively do that. Yeah, which kind of highlights, I guess, why it's so important to make sure that, I think, all women are able to get accessible sources of support, and aware of what's out there as well. from the pregnancy period, not just postpartum. I found it very interesting when you mentioned that not everyone who shows antenatal depression shows postnatal depression. I think you said 40% roughly. I know generally speaking, depression in itself shows many forms when we just talk about depression in general. Does that mean we should be... sort of looking at antenatal depression and postnatal depression as sort of slightly different things? Like there might be some overlap, but should we be thinking of them as completely different things in terms of how we approach them as a society if like mothers want to take care of themselves and how I guess clinicians want to approach it? Should we be looking at it? Yes, that's a great question. I think that it's definitely something that you'd want to start thinking about or supporting from the antinatal period. So just being aware that it's not just something that can be experienced postnatally because there is a lot of kind of discussion around the postnatal depression, postpartum blues, and it is quite normal I will say to experience those postpartum blues just because of your hormones fluctuating and it's a very normal experience. It's when it sort of gets to that persistent kind of level that it is of concern. But it is also something that can crop up for some women from pregnancy. And so in terms of a way of addressing it, it is, I would say from a kind of clinical standpoint or a health kind of support standpoint, it's something that you probably, I would advocate the screening it from. from pregnancy and asking moms how they're doing from pregnancy in terms of their wellbeing. Because there are postpartum screeners that women are given after, you know, during the, they can be given it during the children's health trial checks, for example, when they're gonna go see the pocket nurse or whoever. But it is something I think it would be good to have access to. say from your midwife or your obstetrician, whoever you're seeing from the pregnancy period, just so that there is that awareness and support given from as early as possible so that you're having a smooth pregnancy as possible. So yeah, I do think it kind of needs a little bit more attention. I do think there is increasing attention towards it, but in terms of kind of support and what's available. definitely something that you would want to, I think, pay attention to right from, you know, once a woman's aware of the fact that she's pregnant and is receiving those kind of health checks. And yeah, and in terms of treatment too, they may differ slightly. I know we've kind of talked about antidepressants and you've kind of said we'll talk about antidepressants and that. taking that during pregnancy. There is, I think, sometimes a hesitation to prescribe antidepressants during pregnancy, and understandably, because it is a medication and you want to be mindful of side effects that you could have. But there may be more of a willingness to prescribe it postnatally just because of the less of a concern over side effects. And there isn't. even if you're breastfeeding, it is considered generally safe to be on most antidepressants while you're breastfeeding. But there are still some questions around kind of side effects in association with antidepressants or pregnancy. Yeah. Kind of related to that, you had mentioned, I think, before that the 10 to 20% was the And I can see from your chart here, you were sort of saying it's not one-to-one, antenatal, postnatal, but there's like maybe a relationship. And you've got a history of mental health under that sort of shared one. What does that look like for women or sort of young people in general for some of that depression, like just in the population? Yeah, great question. So I went and had a look at some World Health Organization statistics around that. And it is something like 5% of adults. experience depression. It's slightly higher for women around 6%. So yeah, it is lower than obviously what you see during the perinatal period more generally. Yeah, so it does seem to be kind of a period in your life where you are probably going to be a little bit more susceptible. Yeah. Do you have a, or off the top of your head, do you remember how much the previous experience of mental health ended up feeding into or driving the antenatal or postnatal? No, I don't. That's a good question as well. A lot of these effects, I will say, aren't huge effects. It's more of a sort of cumulative kind of sense of risk factors, yeah. But it is, I think, again, perhaps from a clinical standpoint, good to be mindful of. If you have a, if you're connecting with a woman who has a history of depression or either mental illness, you would want to check in perhaps more frequently and make sure that adequate support is there or they have access to that. Yeah. No, it makes sense, right? Because, what's it? that and then combine it with, as you said, it's a period of lots of changes during pregnancy, hormonal changes and so on, which can leave you more susceptible and taken together. Makes sense that if you combine all these factors, that the risk of depression or any other mental health issue might be higher during and just after pregnancy. Yeah, yeah. I wanted to ask you about generally your opinions on this research space in general because I do not work directly in that space but when I've done research I've found a lot of work looking at pregnancy in the terms of maternal immune. infections or maternal infections during pregnancy and that being related to a development of mental health disorders or risks, increase in risk of mental health problems in their offspring. But I do not know if you have any data or information about, well, the impacts on the mother's mental health in general in that regard, and then also how sort of child development, if there's any link between those? Yeah, so excellent question. So there's a few different, I guess, mechanisms that you can think of in terms of the impact that it can have on the mum and the child as well. So I should say that the kind of not ideal outcomes that have been associated with maternal depression and pregnancy. for the mother tends to be, you know, kind of certain maybe behaviours or exposures that can be, you know, not the most healthy or helpful. So consuming less nutritious food, there's an increased likelihood of smoking and drinking, in very extreme circumstances trigger warning, of course, that there is a risk of maternal suicide. And then for the child, there is the risk of preterm birth and low birth weight for women that experience depression. In terms of whether that's the depression itself, like the symptoms being experienced, or perhaps the associated behaviors like smoking and alcohol exposure, that's hard to really tease apart. you know, because a lot of this research is going to be very observational. You can't really do a randomized control trials and assign women randomly to depressed and not depressed or whatever. So it is something that we do look at more observationally. It's difficult then to kind of fully understand what the mechanism is at play. One of them is thought to be related to the kind of environmental stresses that the child is exposed to in utero. So that could either be, you know, things like smoking, alcohol, the kind of chemicals associated with that, but then also the thought that perhaps experiencing depression can increase maternal cortisol and other kind of chemicals in utero and have this, it's called a fetal programming hypothesis. and it can have a programming effect. It's kind of related to epigenetics essentially. It's not an area I'm super well versed in, but the kind of idea is that it has a programming effect on the child's genes and their brain development, and that can have an impact on the child's growth as well, as well as later behavior, which is why there's sort of concern or thoughts on that, and the impact that can have. then there's also, so that's a very biological kind of hypothesis there. The other kind of hypothesis around this and thoughts of what could be happening is just that essentially women are, are they're experiencing risk factors that are affecting their wellbeing. And that in and of itself is kind of creating an environment. that isn't setting the mum up for perhaps the best, you know, possible place to be in for successful parenting. And so that could obviously impact say the attachment to their child, their physical health, the mum's physical health in other ways, which could also again, relate to those, you know, adverse say obstetric outcomes like a preterm birth, for example. So... I think as with everything, there's probably some level of a biological influence and then also a lot of social factors that are going to be at play that will affect the outcomes that the mum has and the child has. And so it just kind of highlights how important it is really to support mums and to kind of have that positive mental wellbeing and ensure that they're kind of able to have the best start to their parenting journey and the child's life as well. This might be a little outside, so tell me if it is outside your scope, but using the screeners. Cause I think you made that really clear point that they're not necessarily a diagnosis, but it's a screener for these types of experiences that are related to depression. You'd also mentioned that sometimes it's something like a plunket nurse might do with a mom. Are there any concerns with this data collection that people might be like intentionally? downplaying any of those experiences? Like, are there any sort of system trust issues that you guys have to sort of worry about in terms of your data? Oh, yes, definitely. That's a great question. And it is something that there will be, they would have to need, you need to have a consideration of, I guess, how those services are being offered and that they're kind of, for example, you'd wanna make sure that it's like a culturally sensitive or appropriate. service that's being delivered. I know they have some here in New Zealand that will be specifically targeted, say to Maori or Pacifica mums and such. So, it is also important, I think, if you are asking really sensitive questions, that the mum is feeling comfortable and safe to be able to express that and what they're feeling without worry of maybe they'll be judged or... or anything around that. That is a really tricky thing. I don't have the answer to how to deal with that other than, you know, making sure that the services are as supportive and, you know, appropriate as possible. But it is something that would be, you know, the risk of kind of, kind of undercounting or not picking up all women would be there. And it's something that perhaps you just need to maybe emphasize having a good relationship with the health care provider, which would be tricky. to do if there's healthcare shortages and whatnot. That's another story. It's not just for the health outcomes, it's for the data outcomes too. Yeah, yeah, that's true. Oh, excited. You want, yeah, you want reliable data too, yeah. That might be like health food or humanity or whatever. Yeah. You want the data. Yeah, yeah. No, it is something that I know that sometimes, because we work with, as you know, Liza, actually, we work with population level data and data from health services. So something like a well child check, which is typically run by Plunket. We have access to that, the age five data. And one of the things that they kind of assist there is that they use a behavioral screening tool to kind of just see how the child's behavior is doing, if they need any additional support essentially. And the aim of it is Obviously if the child's above a certain threshold, they might get a referral to kind of the relevant services that they need. But there is the kind of thing of some, sometimes not even the parent filling it out, the parent's supposed to fill it out, but it could just be, obviously from a nurse's perspective, they're just like, I need to see you. I've got a ton of moms and children to see, I need to see you. And so then they might just go, oh, tick, your child seems fine. When really it should be the mom completing it. So... But it is a really good reminder of the fact that you do need to think about the quality of the data that you're getting as well. Yeah. It's funny, to be fair, it might actually be a better appeal to people, appeal to their data and data clarity because some, I guess, some people clearly don't care about general public health. They might as well be like, we need clear data, so come on, we need good data to help us out. This is maybe the way to go. Maybe that's the appeal for you. Well, to me, it's like marketing anything, right? You have to think about who your audience is. And it's like, okay, do you care about public health? This is how, this is what you need to focus on, the long-term health of the mom and the child. Do you care about data and making good data decisions? This is, yeah. Do you care about the money? Like, this will save money because of the cost that you're saving and, you know. I mean, it's a safe bet if you look at, so I mainly do animal work, but if we go back, throughout history, the evidence of research being done, especially drug research, only being done on men or male rats or whatever, and then just being put into the general public and I think it's just easier to appeal to money as opposed to appealing to the sensibilities being like, please. Yeah, I think actually it's funny you mentioned. stuff around animal research because I think a lot of the work around that um fetal programming hypothesis was kind of originates from animal research where they where they kind of test you know they they'll kind of expose mums to mum maternal rats to high stress situations and see kind of what their cortisol levels are and then the impact that has on the um on the little babies yeah Cuban women were famously small men or big rats, and there's no biological differences other than that. Should we move on to the antidepressants part? Because I think that's the biggest part of the research I wanted to talk about because I found it very interesting. You already did touch upon it a little bit when we spoke about maybe in antinatal depression we should... Oh, there's more... people being more worried about giving antidepressants while not in postnatal period, so on. So could you shed a little bit more light on that? So maybe, yeah, I don't know where to start. Maybe I can let you take the rain and tell what the best route is. Yeah, yeah, no worries. Yeah, so I think probably considering what the treatment is for depression in general. In general, And actually in the case of in pregnancy, they're similar. For mild to moderate cases, the recommendation is typically psychotherapy. So that would be, you know, seeing a psychologist or counselor getting cognitive behavioral therapy. For moderate to severe cases, the recommendation is medication as well as psychotherapy. And I'll chat about the medications in a second. With... Pregnancy though, it is, it is, well, you want to be mindful of the potential side effects that you could be exposed to with taking an antidepressant for yourself and for the child. So for that, I'll also get into the side effects in a second too, the kind of recommendation if you are experiencing moderate to severe is to kind of... discuss this with your clinician and consider sort of risk versus benefit. So is sort of not receiving treatment and just experiencing your, you know, intense perhaps depressive symptoms, what is that actually going to be better than perhaps going on an antidepressant? What are the risk factors if you're going to go, you know, on an antidepressant? What would the outcomes be? Is that something you're okay with? and just kind of considering that making an informed decision alongside your clinician is really important. So with antidepressants, there's several different types. There is the most commonly prescribed one is known as selective serotonin reuptake inhibitors or SSRIs. Other ones are things like monoamine oxidase inhibitors or MAOIs, trisaccharide antidepressants, serotonin nor adrenaline Reuptake inhibitors a bunch of different ones, but SSRIs are the most commonly prescribed one and they work with the idea with depression is that essentially certain chemicals known as neurotransmitters are altered in your brain and These medications work to kind of balance these chemicals by increasing the levels in your brain essentially and how they're regulated. And so that's why they're prescribed. And of course with any medication you take, there are going to be side effects. So general side effects, not, you know, without being pregnant, just general side effects would be things like nausea, dry mouth, insomnia, or drowsiness, dizziness and sexual dysfunction, which might be a... getting jager for some people. And it can also take a few weeks to come into effect as well. So three to four weeks. With depression, if you are pregnant, sorry, it is again the same thing, psychotherapy plus medication. first line and in terms of treatment. The only exception for this is an SSRI known as paroxetine, which this isn't recommended because it has shown more consistent associations with congenital heart defects in children. So you definitely wouldn't want to take that and would probably if you are. actually already on medication and perhaps talking to your doctor thinking about getting pregnant you probably want to consider switching to a different SSRI. And a lot of the other things like TCAs, MAOIs for example, tend to have more side effects and so may be considerably safe during pregnancy and because they're also not as commonly prescribed it's harder to know actually what the outcomes associated are. So with taking medications during pregnancy and antidepressants, what the literature has shown here is that they're typically associated with preterm birth and low birth weight as well, which is also obviously associated with experiencing depression. So it's actually been quite hard sometimes with this research to actually tease apart. whether it's the medication or the underlying mental illness or something else altogether that is actually contributing to these outcomes. And then there's also a risk. So a lot of the SSRIs, they're considered generally safe, I will say, with the exception of peroxidine. And then the side effects are milder. But there are side effects and the most commonly cited one is something known as neonatal adaptation syndrome. So basically it's just within the first two weeks of birth, the child may have a bit of a jittery, maybe poor feeding, so harder, maybe harder to latch during breastfeeding, maybe a bit irritable or congested, maybe slightly shaky and have some respiratory issues. They are considered mild. It sounds scary, obviously, but generally mild, but it is really important to be aware of and kind of considering those factors as a parent and weighing that up with kind of, okay, is it worth going off it? Has my mental health actually been good? Maybe I go off the medication and I should be okay. But then also if you are experiencing symptoms, just being fully informed and knowing it's generally safe, but there are some side effects and yeah, just making that decision. I don't think there's any right or wrong answer there really. And it's just kind of a personal choice, but making sure that it's a fully informed choice is important. Yeah. And I will say, obviously, in an ideal world, because I don't want to sound like I'm a big pharma advocate or anything. in an ideal world everybody would have access to psychotherapy really easily but unfortunately it's just it's difficult to get access to it is something that especially as a long-term option it is something that you know you would you could you would get perhaps if you're kind of at the really severe end and at risk of hurting yourself Or you'd have to, you could get it through EAP or something like that if you've got, you know, workplace assistance like that. But again, that's normally three to five sessions. And so you typically would have to go private and pay quite a lot of money out of pocket, which is just, again, not accessible to so many women. So, you know, unfortunately, the next best thing, it would be best... to kind of have both options if that is available to women and it is something that I think would be great to be able to offer women, especially during pregnancy. But yeah, just if that's not something that's accessible to you, knowing that actually it's perfectly safe if you do go on, you know, broadly speaking, if you go on antidepressants and you will be okay, that may just be, you might just have a little bit of a cranky baby for a couple of weeks maybe. Just knowing that could be a reassurance for a lot of women as well, yeah. Are there any concerns separate to the maybe coming off a medication when it was actually working well for you? I know, or I think I know that for some antidepressants, it can be quite hard for the person to come off them from just some other decisions. Is there anything more you can say about that? Yeah, great question as well. Yeah, it is definitely something you don't wanna go off cold turkey. Yeah, so the recommendation if you are considering going off them is to talk to your doctor first off and they will be able to advise effectively how to do it but you need to taper yourself down. You can experience some kind of intense side effects from just going off cold turkey like Just because I guess it's a shock to the system in terms of suddenly you're taking away all these neurochemicals that were where they were getting and it hasn't had time to adjust to that reduction. So it just needs that. Yeah, so if it is something that people are considering they should really speak to their clinician to make sure that they're doing it safely and effectively. Yeah. Is that kind of what's happening with the baby if they have some of the like the in a way like withdrawal for a change of the levels? Yeah, great. That's the thought essentially, is they're just adjusting to not having that exposure anymore. Because it is something that is, that can get through the placenta barrier. So yeah, they are getting exposed to it. So it is sort of a withdrawal, but it is a mild withdrawal from the medication. It won't be the, you know, they're not getting exposed to the same level that's coming. getting into the mom, but there is some exposure. Yeah. Um, I, I'm very interested. Well, I have two separate questions. I don't know which I'll ask first. Okay, I'll ask this one first. Um, so we know that different types of antidepressants, as you as you mentioned, before certain have sort of worse side effects or so than others, certain can some can be more more damaging during pregnancy than others. But what and you did talk about changing, talking to your clinician and changing doses or changing the SSRI you're on and changing the antidepressant you're on. However, we also know that a lot of antidepressants don't work for certain people and then certain other ones do. What happens in that case where they probably need it? But we already know because a lot of people go through two or three different types of antidepressants before they find one which actually works. Yeah. What happens in situations like that? Great question. I imagine as a clinic, again, I can't say not being a clinician. As long as it's an SSRI, I imagine the doctor will be okay kind of shifting, trying, trialing different types of SSRIs. I think if it does get to the point of really extreme and you need a different medication, they will kind of switch to maybe ones that have lesser side effects in general, you know, so sort of going through the SSRIs, then maybe an SNRI and so on. So but it is something that they will probably want, they will monitor, I imagine, and there is maternal mental health services. There aren't. They will pop down as many as you like, but you know, they're done They would probably refer you on I think if there is sort of this treatment resistant effect happening Right inside hopes on that is what I would say should be done Yeah, so I think that is the best approach if you're finding that something doesn't work is to just communicate that effectively and And talk to your doctor try to see if there's options Talk to your midwife as well Yeah, and see what options are available and just, it is something that, yeah, you might, I agree, it is something that probably might need a little bit of experimentation over. And it's kind of not ideal to do it, you know, but I think, again, people could probably have some reassurance that the doctors will make sure that it's, they're starting off with, you know, the safer options. Yeah, yeah, the experimentation becomes hard because you only have a nine month window as well. Yeah. Yeah, yeah, yeah. For all of this as well to like see if there's an effect. Exactly. Well, at least when you first come on, yeah, when you first go on them, it can take up to not four months, sorry, four weeks to kind of actually feel like you're regulated a bit better. Yeah, so. It is tricky, but then I guess on the flip side though, at least it's nine months, then if it's still kind of crap, then you're at least off. Nine months is all right, I can take whatever I want after that. Yeah. So there's that, I guess, and just kind of powering through a little bit. Yeah. You were, I think, mentioning before some of that postnatal, whether there were considerations for breastfeeding. Is that another thing where like the SSRIs are the safest, but does it kind of... widen your options at that point? It does I believe widen your options. I don't know this area as much as with pregnancy but from my understanding it is considered to be, I think there's a lot more hesitation during pregnancy whereas it's considered generally pretty safe because I think it's also again such a small amount. Actually I don't even know so don't quote me on That is a really great question. But with that, it is considered, you know, okay, generally SSRIs, I think. And, you know, there is the, again, I know that a lot of people advocate for breastfeeding, but if you are, if there is medication that you're taking that you can't breastfeed with, at least there's formula in that case and the child's still being fed. So, you know, there are a lot of benefits to breastfeeding, but. there are other options here if that's not possible. Yeah. The other thing which I wanted to say on SSRIs, because I know that serotonin, which is the, which is the neurotransmitter which the SSRIs mainly act on, is very important for early brain development in the child. And I also know that serotonin A lot of the serotonin is not just in the brain, but it's in your gut and heart. Like I think about 90 to 95% of serotonin is around your body, not in your brain. Um, or something like that. A very high percentage. A very high percentage of serotonin is in other parts of your body. I know this because we had written a grant for it. That's why I remember. Uh, and so when taking SSRIs, I. I am actually slightly surprised that they're seen as safer or safest because I feel like if they could go through the placenta barrier and get into the child, then it might impact brain development in certain ways because I know it's very important for early development of foetus. Yeah, I will say they're considered safer than the other options. you know, not necessarily saying that they're completely obviously having out-feeds, but probably not as bad as say a tricyclic or an EOA. Yeah, but we did have a look, so we've done some research to look at what outcomes are associated with antidepressant exposure during you know, pregnancy for the child, as well as in the child. So it's, you know, whether they were exposed to antidepressants or just depression in the mum without any medication or neither. And so we were interested, you know, what we looked at behaviour at two and five. And then we also looked at, we haven't published this work, but we also looked at some cognitive outcomes as well later, kind of from middle to later childhood, prior to 10 years. And we don't actually find any sort of negative association with either in the end, once we control for other factors. So there's no kind of increased risk of behavioral challenges or cognitive challenges if they're exposed to both antidepressants. And also if they're exposed to depression that wasn't medicated at least. But we do find an association with depression in the mum at the time that the child was assessed. So if, so depressive symptoms in the mum. So say if we were assessing the child at five years, for example, or four and a half was when they were assessed. And the mum was also showing kind of concurrent high depressive symptoms, the child did perform kind of more poorer on the. cognitive measures or showed greater behavioral difficulties. So it does show that, you know, there is this sort of, I guess, broader impact on the child's development. And I guess there's some kind of, you can take some reassurance and you know, that the pregnancy isn't having that kind of long-term effect, but it does still highlight the need for maternal mental health support. and the kind of impact that can have throughout the child's lifespan, essentially. Yeah, from that early childhood period. So would I be right in sort of interpreting from how you described that study that the things that we already know are bad for kids, like living in poverty or food scarcity, are going to be way, way more important in the end than whether or not you're on a nature test as long as you've worked with your doctor to get the right settings. Yes. Yeah. There is a lot of literature that does say like the first 1000 years, so essentially from conception to age two are really important for the child. Sorry, 1000 days. 1000 days. 1000 years. I did this before, didn't I say four months instead of four days? I'm still working on that first 1000 years, so I totally get it. We have a lot of time. This is the first time. years of our lives are so important. We still do that really relatively. Sorry, thank you. I clearly need another coffee I think. But yeah, so here, thank you for that. Yeah, the first thousand days from conception through age two are really important, but there's so many factors that can influence that and, you know, that can be things like nutrition. in the mum and the child it can be your attachment to the child. I would say if you know there's a lot of different things that play a role and ultimately you need to do as a parent do what's best for you also your well-being so that you're effectively able to be you know there as a parent and look after your child whether that is antidepressants, psychotherapy, something else. It is an individual choice, but it is something to make sure you're fully kind of informed on and know what the pros and cons are. Yeah. I missed a follow up on that because you mentioned before infant temperament. And if I'm remembering correctly, you've also looked a little bit at like ADHD checks in children. Is there, and this might just be wrong. I might not know what this is about, but are there different sort of attachment, maybe expressions of attachment for children with neurodivergence? And can that make it more challenging for parents? Like, can there be sort of backwards and forwards effects there in any way? That's interesting. I haven't looked at the literature around this, but I would imagine that, because you'd kind of want, what the literature does say is you want to really like responsive attachment, and a secure attachment with the child. That means kind of responsive to their behaviors. As they get older, you know, establishing boundaries but showing responsiveness. I imagine that if there is neurodivergence that could be a little bit harder to do because it might involve a lot more regulation from both the people. Like, because as a parent, what you're doing in those first few years as well when you're forming that attachment is working to regulate, help the child regulate because they don't know how to do that. and I have a two year old, I am experiencing that lie right now. You don't feel it? And you know, so there's a lot of, they don't know how to do that yet, you're helping them do that, you're helping them learn to do that, but if there are, you know, there are kind of neurodivergent factors there at play, it is going to be a lot more challenging for the child to learn those skills, which means there's going to be a lot more effort from the parent as well to do that. And so that can be, I imagine, quite... difficult to establish. And yeah, it's difficult. He's actually pretty sweet. He's like got a great temperament, but man. It's so hard. Good idea. I also wanted to ask some clarifications about your study findings and things. So If I understood it correctly as well, it seems that as not just the mother's depressive state or mental health state, particularly when the child is growing up, some assuming postpartum depression and maybe just other depressive states later on seem to be more relevant to the child's immediate development at that time. We're not talking about earlier. Yeah. But then there are also certain risks. which you had mentioned previously at the start of the episode, you had mentioned certain risks such as a likelihood of earlier births or smaller birth weights and things which are associated with pregnancy. But those seem to be, it's like the child sort of counteracts for it in its development across the years as it grows older. Is that what I'm understanding? you know, like I said, the kind of low birth weight, preterm birth, etc. And there are risk factors for the child's development if it's very, sometimes very early birth or very low birth weight. Um, to in terms of, you know, the fact that perhaps brain development hasn't fully had the chance, it did depends on, you know, how early, but, um, I mean, it's great. We've got some really great technology now that supports kids and, um, NICU and what not, but, um, it can impact development, but what it does seem, what the research seems to suggest at least, is that what you experience as well after that can have potentially a protective effect or kind of reduce any negative impact that shows up perhaps earlier on. So, you know, like from the, it does seem like, say if you did experience depression earlier during your pregnancy or postpartum period, But you're able to get support, I guess, and then have a really great relationship with your child and your well-being is great and everything's going awesome. That looks great in terms of the child's outcomes. You're better placed there in terms of your parenting journey and to kind of work with the child to help them with their needs. I guess sometimes if those needs aren't being met earlier, it could also lead to kind of consistent poorer wellbeing. Or it could just be the circumstances that lead to both poor well, not great wellbeing and maternal mental ill health during pregnancy and postpartum, there could be the same sort of factors at play, like if you've got lack of support during pregnancy and lack of support, say when the kid's five, that could also. contribute perhaps to maternal mental illness. But yeah, it's one of those things that it's not set in stone, right? Like we've got a thousand days or whatever. A thousand days. Yeah, yeah. So again, I think a lot of, you know, there's some evidence, actually you can see it in one of the slides, the second slide. It's not a study I did, but another study that was conducted that looked at medication over kind of before pregnancy. I don't know how easy it is to see it. It looks at medication from before pregnancy, during the pregnancy period, and then after pregnancy. And you can see this real dip that happens during pregnancy. And then it kind of actually goes back to almost higher than the pre-pregnancy level, slightly higher than the pre-pregnancy levels. So there is obviously, there are a lot of women that do seem to be concerned about taking antidepressants during their pregnancy. And I think it's just important to make sure that... You know, people are kind of fully informed of the risk versus benefit before they just go and the clinicians as well before they kind of go off the medication and just make sure that that's that's, you know, the right decision for them. Because it can also, I guess, prevent recurrence if you are kind of getting adequate support. Yeah. Because this graph is up, I also wanted to ask, do you have do you have any knowledge on the dosage as well? Because I know Oh, a safer antidepressants one thing is a safer SSR is one thing but then also there is the amount you're taking. Yeah, yeah, yeah. Yeah, great question. I haven't got that it is again, I think quite difficult as well to look at this just because so with the growing up in New Zealand study, we just asked women whether they were on antidepressants. With We have, this is something we could potentially look into a little bit with the kind of data we have access to in terms of the population level. But I don't know, again, I'd have to actually see how good that dose information is. So I was working with this these health record data, like great in theory, but then you go and look at the data, it's just like a mess. So I don't know how helpful it would be, but it is something I guess one thing women could consider doing if they are. is to try and go on a lower dose but stay on it and see if that makes a difference so you know if you're in a higher dose you maybe reduce it by 5 milligrams or something so you're taking a 20 milligram SSRI you could go down to like five to slowly reduce it to 15 to 10 and see how you're doing at lower levels so that is yeah that is something I don't think that's actually been looked at or at least I'm not aware of of it if it has been looked at. It would be really tricky to, I think, to study. I realized actually the bottom graph there, I don't know if it's that easy to see on the screen, but it does have the proportions of the different types of antidepressants as well. So you can see like the dark grey bars at the bottom, the SSRIs, and then you've got cyclic as the next most common one. But they do... And then the kind of other antidepressants, it doesn't look like MAOIs are very, let's look at it on another screen, MAOIs are really prescribed very frequently at all. Yeah. And you do see kind of a real reduction of a pregnancy too, in terms of the non-SSRIs too, in terms of the breakdown. Yeah. Something I'm noticing, and I'll sort of describe it for anyone who's just listening, is one of the graphs, the first one you spoke about. which on the horizontal axis, it kind of breaks down the different periods of like pre-pregnancy, trimester pregnancy. And on the vertical axis, it is a proportion with at least one dispensing. And this is when you mentioned there's this big dip that you're seeing across pregnancy and then kind of the bounce back up and potentially even higher after pregnancy. You can also see in this chart though, that it's got four different years. in dispensing of these. I'm curious if you have any sense of like the longitudinal trends and is it better identification? Is it worse support? Is it all of the... Yeah, yeah actually this study did find an increase, they looked at over 2005 to 2014 year and they found an increase from about three percent to almost five percent in terms of the I think there will be, it will probably be a mix of like more support I imagine and more awareness and increased discussion around that. And I know a lot of this work that we published was done in actually around would have been thinking about when we did this now would have been around 2014-2015 so I think that was a bit more kind of discussion and awareness then and realizing that there was isn't just a postpartum thing it's an and you know an antenatal thing as well that in terms of depression so I think it might have coincided with perhaps greater kind of discussion around hey women are also experiencing perhaps mental health struggles during their pregnancy period too and that could be why yeah Yeah, I guess it would also be consistent with, well, yeah, I guess higher in the population, but also hopefully higher awareness of the safety, like where the relatives like weighing out those things. Yeah. Instead of just going, oh no, I'll put it. Yeah, they would have, because I guess it would link up if you're kind of starting to, if you're aware that this is something to address, then you'd also kind of start thinking about, right, what are the options and what can we do? And then. talking about the safety around this, yeah. Yeah, you'd hope there's sort of more, I think it would be cool to do some kind of qualitative study actually around this to see, talk to clinicians and talk to mums. Not a qual person, but it would actually be interesting to kind of get perspectives, like get that kind of like, what are people actually saying and like the more nuance, like not just the data. Am I, this is, it's a sacrilege, Liza, talking about qualm. I don't know. I don't love nothing better than a qualm romance. Me too. I love it. Yeah. I'm not, like I haven't had the chance to do a lot of it, but you know, like you do the number crunching and then sometimes you're kind of like, wouldn't it be good to just know the perspectives and the thoughts and what are, you know, what are the kind of themes when you talk to a clinician or a mom and. and actually get more at the nuance of it. Yeah. I think Tim you wanna make- I sense a study coming on. Oh yeah, I know. Watch it, we need to find some quality. Yeah. If anyone's listening and wants to do a quality study. We've got the quality though. Yeah. It strikes me that anything you want to produce change in usually has like a head's heart's wallets kind of component which was a little bit before. stuff about the politics change. And I feel like it's really hard to do the hard side well and even sometimes the head side well without sort of research. Absolutely. Yeah. This stigma song is still very present in mental health research. I've definitely heard some anecdotes from folks who, like in parent groups, thought they were the only one and then over at a dinner party or hang. everyone in the group had experiences of trying to get into depressants or being like, you know, having to work with a clinician and had all come into it thinking they were the only one. Yeah, yeah. That's such a good point. Like I've got a little mum's group and I think it's kind of too, you know, you've got to feel so comfortable being like, yeah, we're having a rough one this week. Because you kind of... I've just lost your audio. Sorry, there was background noise just then. Did you? Oh, that's why. Okay. No, it managed to mute you. Sorry, that was my husband ringing. I should have put him on. Like normally I have like a do not disturb. I have a do not disturb, but he's like the, you know how you can have your phone settings or whatever, but there's like favorites that can like override it. I did tell him I was doing a podcast. Hey, do we need an additional co-host? You know, get a surprise guest. If you don't mean mental health stuff, he might actually be a good one. He's he works for, um, not works. He, um, he's on the board of a men's mental health charity. So, uh, I've been wanting to do one men's mental health one for a while as well. So, Hey, next episode already. That sounds good. But since we're talking about next episode and we've been recording for over an hour, we should probably think about wrapping this one up. Um, so I'll. Steph, I asked this question generally. So I'll let you decide. Do you have any final thoughts? What are your future aspirations for this sort of field of research? What do you think is the next place for you? What you're going to go and what do you think is very important in sort of understanding or what research needs to be doing about maternal mental health? Yeah, so I've actually... kind of park this research a little bit because right after I'd sort of finished publishing some of the stuff I had a baby and then we know maternity leave came back and the last year's has been me kind of trying to readjust to all of that but we've I've been discussing with some colleagues around getting back into this work and actually looking so we've looked with the growing up in New Zealand study at kind of behavior and cognitive outcomes so we're discussing looking at that those birth outcomes. now, so birth weight, gestational age, potentially even going on to looking at using the population level data that we have access to see if we can see kind of these outcomes at a population level and we might be able to also get at a better idea of sort of when maybe dispensings were done because there is that sort of temporal information there with the data that we have, the health record data that we work with. And that might give us again a better understanding of outcomes and risk factors. Other things we're thinking of is maybe actually even seeing if taking antidepressants could be protective against postpartum depression, because I don't think that's actually been really effectively looked at. So that's something we're considering exploring. And then another set of colleagues and... and I are thinking of looking at also outcomes associated with postpartum depression, just for the mum specifically. So later mental health outcomes as well as like workforce and yeah job market outcomes too. So that's something we're in the works planning and discussing. So what's the space? Just need to find some funding and some time. No, that's excellent. And as before, if any qualitative researchers want to be part of the project, yes. Yes, that would be, it would be great, actually, it would be really cool to actually have someone that has qualitative expertise and connect with, you know, clinicians and moms and stuff and get those sorts of perspectives through that would be really valuable, I think. Yeah, I just, this is a slightly selfish question if I may, but Steph, if you were talking to, because I teach a lot of first year psychology students in my stats courses. And if you had like, well, something I find so inspiring and heartening about the kind of research you do is how you can directly see how it can link to creating like a better health system, a better country, better systems of support for, you know, all Kiwis. So if you were going to sort of talk to that, you know, front row psych student in a first year course. What kind of advice would you give them and why does it take more statistics? Ooh, you're putting me on the spot, Liza. I think I would, so one thing I actually ask my policy students as well to do is to think about how statistics could help address policy problems. So what I would, them to do I think is think about what is something that they're really passionate about, what is something where they are interested in, what is something that they want to make a difference in, right? And to be able to make a difference you need to have, in fact, you need to have evidence and that evidence can come in, you know, from all perspectives as I see it, but you also need kind of reps. One thing with statistics is that you can make these generalizations and inferences if you've got good data. So to know if there is, I guess, something that's important to address in the population or in a community that you care about, it's really important to have that kind of representative, generalizable evidence. And that's where statistics can come into play and kind of help you. And it is something that, again, if you're kind of wanting to advocate, say, to be able to do something, you can do it. the people at the top to make a difference, you need to have evidence there to show where the difference is needed and the impact is needed. So yeah, that's what I'd say, I think. Thank you. Thank you. I was just like, how do I influence best year's science students to not be scared? Yeah, that was actually a very similar question to what we asked all our guests at the end, which is if you had one piece of advice for the general population, it does not need to be about stats, don't worry. If you had a general piece of advice for our listeners, what would it be? I think it would link back to sort of this whole the topic that we're talking about around well-being and just I think my advice would be If you're, well, I think I'd be talking more to mums here. And I think that's probably both me coming as a researcher and as a mum. It's fricking hard work, man. It's hard work right from the get go, you know, growing the baby, looking after them. And so it's totally normal to kind of experience these fluctuations in mood and to experience down periods. And it's important to really talk about it. And and be transparent about it and find a midwife or a doctor that you can be really open with, which is I know easier said than done, but sometimes recommendations are great. I've shared the midwife that I use with other friends so that they can get that. And yeah, while it is also normal to experience those mood fluctuations, it shouldn't be something that's really... you know, impacting your day to day functioning. And if that is something that is, you know, a real struggle, it is important to make sure that you're talking to the right professional about it and getting support and really advocating for yourself to get support. Yeah, that's what I'd say. So look after yourself. Yeah, look after yourself. Talk about it, get some help if you need it. And you don't want to get great job. Awesome. That was awesome. So yeah, with that we can come to an end. So thank you so much, Liza for co hosting. Thank you, Steph for coming on and sharing your work. And thank you everybody for listening. If you want to listen to Liza's episode and all our other episodes, you can go on to smoo which is our website or otherwise they're on YouTube and Spotify and all those things. And yeah. Share it around if you're a lecturer, share these episodes with your students, if you're students, share this with your friends. Friends, share this with your other friends, parents, forever. And yeah, thank you, everyone. And yeah, take care. Thank you. Thank you for having me. It was good to see you guys.