Ep 272: Anxiety, Anger and Baby-Making: Let's talk Mental Health

In this episode, Dr. Abby Eblen from Nashville Fertility Center, Dr. Carrie Bedient from the Fertility Center of Las Vegas, and Dr. Susan Hudson from Texas Fertility Center are joined by special guest Dr. Ida Eden, a reproductive psychiatrist in private practice and an adjunct faculty member at Weill Cornell Medical Center in New York City. Dr. Eden shares valuable insights on coping with infertility. She explains how anxiety is common for many and can be managed positively. Sometimes it can manifest in unexpected ways such as anger or intellectualization (doing lots of Google searches) and how different defense mechanisms—good and bad—play a role. She discusses the importance of recognizing whether anxiety serves a purpose and emphasizes optimizing mental health through simple but effective strategies, such as exercise, social connections, and proper sleep. We explore the use of medications for mental health during pregnancy and how doctors assess whether to continue or adjust treatment. Finally, the conversation delves into the cost of mental health care, resources for those without insurance coverage, and the availability of telemedicine options. Tune in for an insightful discussion on mental well-being and practical ways to manage anxiety.

This episode was brought to you from ReceptivaDx and IVF Florida.

Transcript

Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Susan Hudson MD (00:22)

This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test used to help detect inflammatory conditions on the uterine lining, most commonly associated with endometriosis and may be the cause of failed implantation or recurrent pregnancy loss. Take advantage by learning more about this condition at receptivadx.com and how you can get tested and treated, providing a new pathway to achieving a successful pregnancy. ReceptivaDx, because the journey is worth it.

Carrie Bedient MD (00:53)

Hello everyone and welcome to another episode of Fertility Docs Uncensored. I am one of your hosts, Dr. Carrie Bedient from the Fertility Center of Las Vegas, joined by my two deliciously delightful, delectable, darling co-hosts, Dr. Abby Eblen from Nashville Fertility Center and Dr. Susan Hudson from Texas Fertility Center.

Abby Eblen MD (01:10)

Hey, everybody.

Susan Hudson MD (01:14)

Hello everyone.

Carrie Bedient MD (01:15)

And we are joined this week by Dr. Ida Eden. She is a psychiatrist in private practice and is also faculty at Weill Cornell residency program for psychiatry. At least I didn't ask you that specifically. I'm assuming that. But I know that there's a lot of overlap and certainly psychiatry spills into absolutely everything all of us do. And so you could probably legitimately be faculty in just about every residency program.

But there was a long-winded way of saying, hi, and we are so glad you're here.

Ida Eden, MD (01:41)

My gosh, hello. I'm so excited to be here. I'm really thrilled and this is gonna be fun. I can already tell.

Carrie Bedient MD (01:52)

So I think all of us have just a tiny bit of secret trepidation when we're talking with a psychiatrist, because we feel like you can see into our very souls. And so you gave us a tiny little tidbit about yourself when you go out with your friends. And so we are going to flip the tables for three minutes before you see into all of our deep souls and what we're worried about and all of those things. So tell us what you do when you go out with your friends.

Ida Eden, MD (02:19)

I love it. Honestly, I deserve this. So one, I'm a big dessert person, obsessed. And two, I love to embarrass my friends. So the two really merge and come together when we go out to dinner with friends. I am that person who is trying to get free dessert and I will throw my friends under the bus at all times. So it's either my birthday, or is a friend's birthday, I have no shame. So I am always telling restaurants it's my friend's birthday is when we're out. And I have no shame, but also some shame.

Carrie Bedient MD (02:53)

So what is the best dessert that you guys have ever gotten while you have been out? And does it always include the happy birthday song from the staff or all of you or whatever?

Ida Eden, MD (03:08)

I wish it always did. Unfortunately, it doesn't always because that is really the cherry on top. I think the best dessert, I mean, I'm a big chocolate gal. I think the best dessert is like some kind of like chocolate chip cookie skillet. Like.

Abby Eblen MD (03:11)

Okay. And in what restaurant gives that, let me ask, because I like chocolate too.

Ida Eden, MD (03:28)

BJs. Have you heard of BJs? Yeah.

Carrie Bedient MD (03:29)

Yes, yes.

Abby Eblen MD (03:30)

Uh-uh, what's BJ?

Carrie Bedient MD (03:31)

And they're so good.

Abby Eblen MD (03:31)

No BJs in Nashville, unfortunately.

Ida Eden, MD (03:33)

It's so good.

Carrie Bedient MD (03:35)

You'll have to come tonight.

Ida Eden, MD (03:36)

You might have to move. You might have to move. Yeah. Yeah. Yeah.

Abby Eblen MD (03:37)

I might have to.

Susan Hudson MD (03:39)

I love, they've changed their menu recently and their lunch menu. You can get a burger and a side and a pizookie and it's like $13. It's crazy. Yes, it's the same price as if you just bought the burger. I'm like, why would you not get the pizookie too?

Carrie Bedient MD (03:50)

Whoa!

Ida Eden, MD (03:52)

Wow.

Right, Yeah, those prices are not New York City prices. I'd love to hear that. Yeah, right now.

Carrie Bedient MD (03:58)

Yeah. So. Not even close. So, doctor, can you tell us why you behave this way when you are out with your friends? Is there a deep-seated something or other that you have far more technical terms to describe than I could ever dream of?

Ida Eden, MD (04:19)

I am sure the answer is yes. We will have to phone in my psychiatrist and ask her what she thinks. I'm sure she has a lot of material. It's a good, it's a really good question. I think people are always, I am, I'm so curated, I'm such a professional and this is my time to let loose. It really is, it's just to let loose.

Carrie Bedient MD (04:25)

Good. So is there any truth to the fact that all psychiatrists have their own psychiatrist, or that all therapists have their own therapist?

Ida Eden, MD (04:46)

Ton of truth. Actually, it's really recommended in our residency program at Cornell where I trained because you have to know about yourself in order to really be curious about other people. So it's a good fit. A lot of us kind of naturally gravitate, I think, to having our own treatment.

Abby Eblen MD (04:49)

interesting.

That's true. Yeah.

See, me personally though, if I went to restaurant, I would feel so guilty that I pretended it was my birthday. Cause I like to follow rules and that is not what you do when you follow the rules as you lie about your birthday. And Susan is not, Susan pushes the boundaries and I love that. That's what I like about people when they're the opposite of me.

Susan Hudson MD (05:13)

Abby is the total rule follower.

Ida Eden, MD (05:16)

I will say.

Carrie Bedient MD (05:21)

So.

Ida Eden, MD (05:21)

I will

say we do tip extra extra. So for the trouble, that is something I will add. Yeah.

Carrie Bedient MD (05:28)

So

Abby, I'm pretty sure the next time all three of us are together, it's gonna be your birthday.

Abby Eblen MD (05:32)

No! Thanks. Yeah, maybe why? Who knows? Yeah, that's okay. Yeah, maybe sooner. Who knows?

Carrie Bedient MD (05:35)

Like, I will put a reminder in my phone. Now, granted, I don't know when the next time all of us are gonna be together, but we'll.

Ida Eden, MD (05:35)

Yeah.

Susan Hudson MD (05:43)

Maybe sooner, we'll think.

Carrie Bedient MD (05:47)

Yeah, excellent. Okay, so...

Abby Eblen MD (05:49)

All right. Thank you. Thanks

for having have a window into your soul, Ida.

Ida Eden, MD (05:53)

I love it.

Carrie Bedient MD (05:54)

All right, so Susan, what question do we have?

Susan Hudson MD (05:56)

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Susan Hudson MD (06:28)

Okay, our question today is, Hi, I'm awaiting my second FET transfer. I'm a former smoker and have officially stopped smoking as of two months ago. One month prior to my first transfer, but was a smoker through the retrieval process. My first transfer failed and I was thinking it may still have to do with my former smoking. Do you have any thoughts of how long it takes the body to bounce back after quitting smoking?

Carrie Bedient MD (06:38)

Good for you.

Susan Hudson MD (06:54)

and when I might be able to stop thinking I've ruined my chances of a baby because of smoking. I'm afraid to go into my next chance for still thinking it's too soon after quitting. I already feel like I've wasted an embryo.

Abby Eblen MD (07:06)

Two months pops into my mind because it's about two to three months. Like when we say, for example, like if you're not on prenatal vitamins, we'd like you to go on those, folic acid, we'd like to give it a couple of months or so. So I would say two to three months should be adequate. I don't know what your all's thoughts are, but.

Carrie Bedient MD (07:21)

I'm pulling. go ahead, Susan.

Susan Hudson MD (07:21)

I would probably

say around three months is what I would think would be the amount of time it usually takes to get most of the cotinine, which is the byproduct of nicotine that ends up in the fluid of the follicles. And if we're using that as a marker of getting everything out of your system. And I think even when you're talking about lung issues and those types of things, it's usually, like you said, a two to three month process of kind

Abby Eblen MD (07:31)

in here.

Susan Hudson MD (07:49)

clearing the body. Carrie, are you looking up kind of official nicotine clearance rates for us? But while she's looking that up, realize that when we're talking about smoking, we're talking to all of you other nicotine users, whether it's patches, pills, gums, creams, vaping, however you are getting it into your system, nicotine is nicotine. And so what do we got Carrie?

Abby Eblen MD (07:52)

You

Carrie Bedient MD (07:55)

you better believe it.

Abby Eblen MD (08:03)

That's right.

DAPE.

Carrie Bedient MD (08:13)

Okay, so there's two different things to look up. One is the nicotine half-life, and then there's the cotinine, which is the metabolite of nicotine. And that's actually what I'm going for, because that lasts a little bit longer. And that's what, when we're doing a nicotine test, that's what we're measuring. And so blood is up to 10 days, urine is three weeks, and hair is 90 days. So hair, I don't know that we really care about all that much, because that just hangs around a lot longer. I would say urine is probably the most reliable

that we're looking at here, because if you think, okay, it's gonna take three weeks for it to clear out of your urine, and then whatever the eggs are doing takes about three months to factor in, pardon me, that's probably about four-ish months total. And so now the bigger question here is to what degree does that actually make a difference when you are getting a transfer?

Abby Eblen MD (09:05)

Right.

Carrie Bedient MD (09:06)

and how long is that out? Because the transfer is not the same deal as the three months working with the ovaries and the eggs, because that's already there, that's already been affected, and your uterus resets itself each month. And so that's actually probably a little bit quicker turnaround than four months, because it has the convenience of being a self-cleaning oven every month. And so my guess is by this point, you're probably in the clear, because it's gonna be a solid three to four months before you...

hit your next transfer date anyway so you're probably okay.

Abby Eblen MD (09:36)

Yeah, and one thing I would say too about the egg retrieval, we feel like that smoking causes vasoconstriction of your blood vessels, constricts your blood vessels, decreases blood flow to your ovaries. So it also has some long-term impact in terms of potentially decreasing your egg quality and your egg number, but the fact that you got eggs and you're doing more than one transfer suggests that you overcame that part of it and hopefully did pretty well with the number of embryos that you have.

Susan Hudson MD (09:58)

I would say that for people who are listening outside of the person who wrote in this question, which this is a great question, is that we do recommend stopping nicotine use before doing an egg retrieval because that's probably where you're having kind of the most impact when it comes to things that we can't measure. Like we can measure what the embryo looks like. We can measure whether it's

Abby Eblen MD (10:06)

Mm-hmm.

Yes.

Susan Hudson MD (10:25)

chromosomally normal or not, but how the mitochondria work, the little powerhouses in the cells and how all of the further divisions are going as things go on and the formation of organs and different things like that, those things really aren't as tangible. And so the sooner you can stop your nicotine use, the better. And that goes for both partners.

Carrie Bedient MD (10:49)

And Ida, the part of this question that's much more applicable to your corner of medicine is she's feeling horribly guilty about all of this. And so we might as well just kind of segue into our greater topic here, which is you're a reproductive psychiatrist. And if you want to move to Las Vegas, you just let me know and I will have a whole group of patients for you. Because there's so much that goes into

these cycles and there's a ton of medicine, which we're very good at, but there's a lot of holistic parts of it. There's a lot of emotional and psychiatric parts of it as well. So to deal with this question specifically, before we launch into the greater topic, which is going to be a smorgasbord of all the questions we all have, what do you think about the continuous guilt that she's having and how does she let go of that? Because it's not helping her. And so what do you do about that?

Ida Eden, MD (11:43)

It's a really good question. Listen, I think even for the healthiest person, and by healthy I mean psychologically healthy, going into any kind of fertility treatment is so challenging, right? It is just such uncharted territory, the ultimate exercise and lack of control. I think for this person calling in, I always tell my patients, we don't talk in shoulds, because shoulds breed shame.

Abby Eblen MD (12:00)

Yes.

Ida Eden, MD (12:08)

So when the narrative is I should have stopped or I should have done X, Y, or Z, well, you're here now in present day. And it sounds like you've already made this ginormous change in a positive direction. It's tempting to demonize yourself. And is that really helpful, like you just suggested? Is that actually helping me? What is it doing? Is it allowing you to avoid a much larger anxiety, which is what might happen with fertility treatment

by focusing on all that you can control? But zooming out, you have objectively made a really majorly positive step. And so I would really focus on that.

Abby Eblen MD (12:43)

do you train, and this may be a huge question, but how do you train people to think in more of a positive way? And I know that's not easy to do when you're under lot of anxiety and pressure, but I see so many people that ruminate over things and go over and over in their minds, and they just, you just want to say, gosh, if you could get yourself out of this and start trying to consciously think in a more positive way, and I know that's easier said than done, and that's a huge question, but what are some just easy things that you can tell people to do to help with that?

Carrie Bedient MD (13:10)

Without falling into the realm of toxic positivity, which I hear an awful lot about of just being positive to the point of you want to jump off a cliff because you're just so positive.

Ida Eden, MD (13:15)

Yes.

Abby Eblen MD (13:20)

Yeah.

Ida Eden, MD (13:21)

Yeah, mean, my style and how I trained at Cornell is very psychodynamically oriented. And what does that mean? It's all about sort of what are the motivating factors motivating all of us subconsciously or sort of beyond our awareness. And oftentimes when we ruminate and we obsess or we worry to everyone else, even to ourselves on some level, it feels really maladaptive and problematic, which it is, but it is also a tool in our toolbox, right?

Ruminating and obsessing and worrying, sometimes we have a fantasy that by doing so we are preventing a negative outcome. If we think of the negative outcome before it happens, we may have less of a likelihood of actually experiencing it. And so

Susan Hudson MD (14:05)

We as doctors

do that all the time. We go into something and we're like, make sure we have this, make sure we have this, make sure we have this. So we're gonna make sure we have no bleeding because we have all the end, all the coagulant stuff with us. So it's gonna ward off the evil spirits. We do it all the time.

Ida Eden, MD (14:07)

Yeah.

Abby Eblen MD (14:10)

Worst case scenario is this.

Ida Eden, MD (14:20)

Exactly, and that's a perfect example of why it can be adaptive. Anxiety is adaptive, right? If we weren't anxious when a bear was chasing us, we wouldn't have made it. To answer your question, my way of thinking about it and being curious about it with my patients is wondering how it's serving you because none of us want to suffer. And if we could not be anxious, we would.

So what is the anxiety doing for you? What is it allowing you to avoid? How is it allowing you to feel more in control? That's often the topic that comes up for patients who are going through fertility treatments. So it's wondering what the anxiety is doing for you. So rather than abolishing it or kind of being Pollyanna toxic positivity, being almost like an anthropologist, being very curious about what's going on.

And oftentimes when you give patients that is the ultimate form of empathy. When you give them a neutral curiosity, you notice that they're able to kind of back away and they feel less of a need to be anxious. They feel so understood by you that they sometimes can allow themselves to be positive. Remember, being positive is a luxury, right? It's a psychological luxury to allow yourself to be positive and to think positively.

Susan Hudson MD (15:31)

So, Ida, how psychologically burdensome is infertility?

Ida Eden, MD (15:37)

I think you all know as much as me, right? Enormously so, enormously so. Fertility is often for so many women, this kind of black box of unknown, and it only becomes known when you want to look for it. And so the psychological themes and conflicts that come up for women around this time are just really, really striking, right? So questions around, will my body fail me?

And if it does, where does that anger go? Am I angry at myself? Am I angry at the medical system? Am I angry at the fact that I used to be a smoker? Am I angry at who knows what? Where does that anger and anxiety land? How do I advocate for myself? If you're someone who has difficulty advocating for yourself or asking questions or taking up space, so to speak,

when you are interfacing with the medical system and with with obstetricians such as yourselves in this space, that is a conflict that you have to contend with what daily if not more. And then often times the the kind of dilemma can be around hope and feeling as if hopelessness is a major threat to the success. So we have a lot of these psychological fantasies I I often talk about the delicate orchid

syndrome and I've coined this myself so I am am ready to workshop it but oftentimes for these folks right when when you are putting in such investment and you have such a longing for something that is so beyond your control. Let's say you do become pregnant now that pregnancy that fetus is this delicate orchid and all of the conditions of the petri dish have to be perfect.

Abby Eblen MD (16:57)

Cool.

Ida Eden, MD (17:15)

The fear is that there could be such a backsliding. You can lose something that you have worked so hard to gain. And that fear and anxiety impacts mental health, right? It impacts your attachment to the baby that's forming and it impacts how good you feel moving through the world. So all of this is the same and I could talk about this forever, but it is a tremendous psychological strain.

Susan Hudson MD (17:37)

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Carrie Bedient MD (17:51)

So how do you help people who, for example, I have a patient that I have been working with this week who is a very high achieving professional who from the very first time that I saw her, I could see the anxiety and frankly what's probably depression written all over her and that has only gotten worse. And over the weeks that we've been working together, because we've been taking small steps, which is what she is

wanting to do at this point. And so it's taken probably two to three, if not more months to say gently hey, here's here are the numbers of the psychologists and therapists and psychiatrists that I work with. Would you like me to have some of them call you? Would you like to reach out to them? And she finally said yes, for which I'm very grateful because I'm worried about her. But to what degree

do we help somebody get to that point where they can get that outside help? How do you phrase that? How do you think about that so that it's a little bit more acceptable to someone who is otherwise in really perfect control of their life?

Ida Eden, MD (18:56)

I'm so glad you're even asking that question. I think you all are who gets patients to people like me, right? And you all normalizing, optimizing mental health and seeking treatment already is therapeutic in and of itself. And I really want to stress that actually, because I hear it with my patients time and time again, that providers who they interface with who are sensitive and attuned and who aren't scared to bring this up.

That is a therapeutic act in and of itself. Now, the way I talk about with my patients is that you are at the center of the family unit. Your partner can't be well, future baby can't be well, no one can be well if you were unwell. And there is no such thing as psychologically white-knuckling it. There is no patient I've ever met or seen who is suffering and is white-knuckling it and that doesn't have lasting impact. It absolutely does. It just doesn't work. And the longer we leave anxiety and depression,

untreated or suboptimally treated, the harder it does become to treat. We have a lot of good data around that. The other kind of sticking point is that in my field, we talk a lot about exposures and limiting exposures to the developing fetus. Now, what a lot of people have a harder time, I think, sitting with is that maternal anxiety and depression are exposures in and of themselves. Again, we have a lot of good data around this actually, that just as much as

Lexapro is an exposure or Lamictal or whatever psychiatric or psychotropic medication we're talking about. Maternal anxiety and depression are very much exposures in and of themselves and they are risky exposures. They lead to worse obstetric outcomes. They lead to worse neurodevelopmental outcomes in baby and they do impact fertility and they impact attachments. Again, we have a lot of good evidence around that. I'll often say

Abby Eblen MD (20:26)

I don't know.

Ida Eden, MD (20:42)

seeking treatment for yourself when you are trying to conceive or when you are on the path to being a parent yourself, it is often the first parenting decision you make is how do I approach and really optimize my mental health? Maybe that includes medication. Ideally, it includes some kind of counseling, but that is the first parenting decision you make and what an amazing one to make. And so I really empower, yeah, I empower my patients about that.

Abby Eblen MD (21:04)

Yeah, that's great.

Ida Eden, MD (21:07)

The peripartum, as we all know, is a negatively vulnerable time, but it's also a very positively vulnerable time. It's often the first time that women want to be curious about themselves with depth. They want to better themselves because they're about to, embark on this incredible journey that is a difficult one. But so it's a negatively vulnerable one. It's a positive one. I really do. I encourage and I celebrate my patients who come to me. And how amazing that you have

that you have wanted to help yourself in this way.

Susan Hudson MD (21:39)

When we have people who are listening to our podcast and they're listening to us talk about these things like anxiety and depression, what are things that they can ask themselves to be like, hmm, maybe I should ask for help? Like what are internal questions that you could provide that could be signs that you need to seek help, whether it be through counseling or medication?

Ida Eden, MD (22:08)

It's a good question. And there are the more anecdotal or the questions I may think of as a mental health professional, but also as just a human moving through the world. And then, of course, as you all know, we have objective measures. We have objective tests. And you can just Google EPDS, the Edinburgh. That's the rating scale for depression that we give patients. The EPDS, Edinburgh Postnatal Depression Screening. Yeah.

Abby Eblen MD (22:28)

What's that called again? Say that again.

Ida Eden, MD (22:34)

And so that is a really good marker. Folks are curious, what might I score on an EPDS. You can Google it and take it yourself, right? Ideally, you're...

Susan Hudson MD (22:43)

And that's applicable

even if you're not postpartum but trying to get pregnant.

Abby Eblen MD (22:47)

even if you're trying to get pregnant.

Ida Eden, MD (22:50)

Correct, correct. And then, of course we have like the GAD7, that's an anxiety questionnaire. So there's these objective measures. So if folks are curious, you can always, you these are well studied and really good clinical tools that you can access just by Googling them. I would say also, how hard is it for you to move through life? Are you finding that it is hard to feel content

and it is hard for things to mount a joy in you? Does it feel really burdensome moving through the day? Does work feel really burdensome? Is it hard to derive joy from being around your dog or from things that you normally like to enjoy? Do those things feel harder to take pleasure in? And then also oftentimes, a postpartum depression, that's not exactly what we're talking about, but a depression and the peripartum too, often

includes a great deal of anxious distress and irritability. So are you feeling really on edge? Are you feeling like you're lashing out at the people around you in a way that is uncharacteristic? I hear that time and time again. That I feel so on edge and just so irritable and that irritability is often a good marker of okay maybe I should maybe I should talk to someone.

Abby Eblen MD (24:02)

Can I ask real quick, what are some things, and I think we see this in our practice, some people understand and know that they're anxious or they're depressed. There's other people who come to us and that emotion is disguised as another emotion like anger. Or the other emotion that I see sometimes is I see patients who bring tons of paperwork and reams of information and they Google and they Google and they Google and they look for all this stuff and they compare and contrast.

And I see that as a lot of anxiety and a lot of times it's really hard for them to understand. Like, I'm just trying to advocate for myself. I'm just trying to look up stuff, to give you more information. And so can you speak a little bit about how sometimes depression can be disguised in a different way?

Ida Eden, MD (24:43)

I'm sure you all have heard of defense mechanisms. So what you are describing is intellectualization. Which is topics or experiences that feel really psychologically threatening. Often they get masked and they get turned into something that is really intellectual. So it's that person who gets diagnosed with a horrible medical illness and instead of having an emotional response, just like you're describing

Abby Eblen MD (24:46)

Hahaha!

Ida Eden, MD (25:05)

comes to the appointment with WebMD printed out, they have done 10 hours of research, they are intellectualizing what's going on to avoid the anxiety of what does it mean that I'm in this cross-section of my life. So we can have empathy when we think about it that way, right? Because the person you're describing sounds like a hard person, relatively speaking to have empathy for. They're coming in, they're somewhat defended, they're not leading with emotion and vulnerability, but that really is what's behind it.

And we see it all the time. I'm sure you all see this all the time. I think that oftentimes we feel, I say we because again, this is a part of being human, that should we allow ourselves to feel anxious or sad, that it might consume us. And oftentimes the first lesson of psychotherapy, of a good quality one, are the things that we're really shameful or angry or anxious about. We don't implode

when we explore them, we don't implode. The other caveat I'll mention is in my training, we had this old school psychoanalyst, Freudian type who would say to us as residents, when a patient comes to you and says, I'm angry, you ask, what are you anxious about? And when a patient comes to you and they're anxious, you ask them, what are you angry about? So anger and anxiety live right alongside one another. They are brother and sister, and they often kind of take the

Abby Eblen MD (26:21)

Interesting.

Ida Eden, MD (26:26)

place of the other. So it's a good thing to know that when you see the patient who is a bulldog or who is really, really angry on the surface, that person is feeling incredibly anxious, most likely, most likely.

Abby Eblen MD (26:41)

Just as a quick follow up, what are some other defense mechanisms besides anger? And since you mentioned them, people may be going, wow, that's me.

Ida Eden, MD (26:49)

My gosh, there are so many. There's the healthier ones, the more adaptive ones, and then the less than healthy ones. Believe it or not, humor. Humor is a defense mechanism, and it's often considered to be a really healthy one. There are other ones, I'll give you examples of ones, right, like splitting. So folks who have a harder time appreciating that there's gray or nuance in people or situations.

They may have a tendency to think a person or situation is either all good or all bad when really we all are a mixture of good and bad and we disappoint and we love and we're envious and we're angry. We're complex people. But that is another defense of, it's hard for me to appreciate or to tolerate all of that nuance. So I need to have clean buckets of good and bad.

Abby Eblen MD (27:34)

Good nurse, bad nurse, right? Good doctor, bad doctor.

Ida Eden, MD (27:37)

Exactly, exactly.

Yes, right, right. And so you run into issues. But, but defense mechanisms are normal or normal parts of our psyche. Projection is another one that you may have heard of too. So when there is a feeling or experience or a thought that feels almost unacceptable to us, we might beyond our awareness, right? All this is beyond our awareness, place it onto someone else or something else.

Carrie Bedient MD (28:02)

So how do we approach people where there's a need for psychological awareness, potentially for therapy, but also potentially for a medical approach to it with medications? Because I see so many people who maybe they've got a track record of, yeah, I have been on sertraline, Zoloft, Prozac, Wellbutrin, name the med throughout the...

course of my life and I've done really well on that but now I'm gonna get pregnant and I just cold turkey'd off of it. And then I look at and and everybody is feeling it like my entire clinic is aware whether they know it or not that this person went cold turkey off of medications that were really helpful for them. It's a very complex set of discussions of like you were talking about anxiety and depression are exposures it's not just the medications that are exposures so

Abby Eblen MD (28:37)

good.

Susan Hudson MD (28:36)

and you're all feeling it.

Abby Eblen MD (28:40)

you

Carrie Bedient MD (28:55)

how do you think about that and are there any practical tips for approaching these medications of, in general, and I know this is way oversimplification, so I apologize for asking you a horribly complex question and wanting a simple answer, but how do we help our patients approach this?

Ida Eden, MD (29:10)

This is often why I interface with patients, right? Is this exact dilemma, this exact question of I want to be well in my pregnancy and in my just kind of peripartum and by that sort of an umbrella term, right? Trying to conceive pregnancy postpartum. I want to be well and yet I want to diminish any kind of threat. And I have a couple of mantras and the first I've already shared, which is no one else can be well if you are not well. That's just not possible.

There's no such thing as putting your mental health on the back burner to make it through this sort of vulnerable time window. You will not make it out in that way. That's a recipe for disaster. And in this field as reproductive psychiatrist, you may be used to hearing the risk benefit discussion. I am constantly framing decisions in a risk, risk discussion. Now, how do I do that? What are the risks involved of you continuing

Abby Eblen MD (29:56)

Hmm, yeah I like that.

Ida Eden, MD (30:03)

let's say you're pregnant, continuing pregnancy, this depressed, what are the risks? Maybe you have to take a medical leave. We already know there's a ton of risks, that we in broad strokes, I've just mentioned to you into baby and obstetric outcomes, those are very well known risks. Your relationship with your partner, I imagine that that also becomes a big problem with and often is with untreated maternal mental illness. So we create that bucket. Sometimes I even write it out with my patients. What are the risks

of untreated or suboptimally treated depression for you? And then what are the known and what are the theoretical risks of continuing, let's say, Zoloft, for example? And I will list those for patients, right? And then I'll say, it is up to you to decide which risks you're willing to tolerate. I will always make a recommendation. My recommendation is X, Y, or Z, and here is why, but it is not my job to convince the patient to continue the Zoloft or to stop the Zoloft.

It is my job to give my patient all of the data and all the information and to make a recommendation. And so I phrase things and frame them in a risk risk way. The thing I'll say is we have a lot of good data, actually, a lot of reassuring data on the reproductive safety profile of SSRIs. Those are the kind of most studied medication class with pregnancy and with lactation. And by and large, the data that we have is so reassuring. We as a field

generally think of these medications as compatible with pregnancy and with lactation. Now, there's no binary as amazing as it would be. We never think of a medication as safe or unsafe. In pregnancy, it's always framed in this risk-risk discussion. Like, think of a quote-unquote riskier medication relative to Zoloft, lithium. I have many patients with bipolar illness who come to me wondering, I need to stop my lithium?

And this is obviously going to be a smaller subset of patients relative to those who come about SSRIs. But that is a much harder question to answer. And again, it is framed in a risk-risk discussion. If you stop your lithium and if you're someone who becomes psychiatrically hospitalized, mean, think of how much more disruptive can something be? So we have to always weigh the known and theoretical risks of whatever medication we're talking about to the risks of mental illness

falling off the wagon.

Abby Eblen MD (32:15)

What would you say about newer medications? Because I usually tell my patients, and I may be wrong in saying this, but if it's a newer medication that had been on the market for very long, I usually encourage them to talk to someone before they change their medicines, not just do it on their own. But generally, is it true that we try to get them to medicines more like Zoloft and SSRIs as opposed to like medicines that are newer on the market that we just don't know a lot about?

Ida Eden, MD (32:37)

I think it so depends. Sometimes those folks who come to me with quote unquote newer medications have maybe tried several older ones and quote unquote failed them, right? And so if you're coming to me and you are really optimized and you're like, Dr. Eden, I have tried 18 medications, Vibrin, which is one of our newer serotonergic medications, doesn't have a ton of reproductive data, but Vibrin has been life-changing. Okay, this is a totally different calculus. My threshold for messing with the Vibrin is going to be much higher than if you were to come to me

Abby Eblen MD (32:43)

Yeah. Right. Yeah.

Mm-hmm.

Ida Eden, MD (33:06)

you're 21 years old, it's the first medication you've tried for maybe a mild depression. So it is so individualized and it so depends on the set of circumstances that you come to me with.

Susan Hudson MD (33:16)

Kind of to change tacks a little bit. I know there's been over the past five, 10 years, quite a few individuals in psychiatry and psychology have migrated away from being on insurance contracts. How should people who are wanting to seek care for their mental health

going into infertility care or pregnancy, navigate how to choose somebody? Do you have to have somebody who's on your insurance if there's nobody available? How does that work from a practical standpoint?

Ida Eden, MD (33:56)

Yeah,

it's a really important consideration. I will say here in New York City, for example, unless you're affiliated with an academic center, which is a great option, by the way, providers are often not taking insurance. But for folks who need to use insurance and who really want excellent care, especially with sort of more niche psychiatry, like reproductive psychiatry,

academic centers are a great place to go. We often have women's centers here in New York City. We have Cornell, obviously. Columbia, Mount Sinai has an excellent program. So looking into the academic centers near you is often a great thing to do. The other thing to know is that oftentimes, and I do this, psychiatrists even in private practice will offer sliding scale. Depending on what patients can financially afford.

So that doesn't necessarily mean it's not possible, but to reach out to folks. And if I have a patient who says, I actually can't afford this rate, I will often connect them to resources. One of them is as Weill Cornell's Women's Reproductive Center. But there are more of these telehealth companies, I'm not sure if you all have heard of them, but there more of these telehealth companies cropping up and more of them have reproductive psychiatry niches or are building them, which is great to see.

Susan Hudson MD (35:05)

What some of the other resources that you can recommend that our listeners might be able to web search?

Ida Eden, MD (35:13)

Yes, absolutely, my absolute favorite is Mother to Baby. I'm not sure if you all are familiar with Mother to Baby. Love Mother to Baby. So essentially what I use it for is I will give my patients often times, and I did this in my fellowship in my residency too, they have these amazing PDF printouts, one-page PDF printouts for any medication that you're curious about, whether that's Lamotrigine or Sertraline, or even I'm sure like Tylenol, whatever you're curious about.

Carrie Bedient MD (35:17)

Yes! I love that site.

Abby Eblen MD (35:18)

No.

No, tell me about it.

wow.

Ida Eden, MD (35:42)

and it will have looked at all of the available data to date and synthesize it in a very digestible way. It's amazing. So I always give my patient mother to baby handout. And then the other, I love the folks at Harvard, the MGH consortium, their women's mental health website is incredible. If you use their search bar and you're just, okay, what's the data out there on Adderall and lactation? You can type in Adderall and lactation and it will pull up

their most recent, writings about that. They actually have folks who, again, will read the literature and the data and will digest it in an amazing way. It's something I do when I'm like, I forgot. What is the lactation safety profile of, of Lamictal? And I'll look that up myself. with the MGH website is, is, is excellent.

Abby Eblen MD (36:27)

Wow.

Ida Eden, MD (36:31)

Stay away from Reddit. That is what I tell folks. Stay away from Reddit. I'm sure you all are having to tell folks that all the time too.

Abby Eblen MD (36:33)

Hahaha!

Yeah.

Susan Hudson MD (36:39)

I always try to encourage people to be very careful when they're on things like blogs, because in my opinion, it's like writing a review about your refrigerator. There's nobody who's ever written a positive review about their wonderful refrigerator. Okay. It's only people who are unhappy, who are generally writing things in these types of forums. So you really have to make sure that you're getting

Ida Eden, MD (36:58)

Thank

Susan Hudson MD (37:08)

balanced information.

Abby Eblen MD (37:09)

Yeah, and I always say too, nothing ever dies on the internet. So you may look and there may be some tests that we did 20 years ago and you have no way of knowing if that's something we do now and why didn't my doctor do this? And so there's no way that you can weigh in your mind what's really important and what's not in your care.

Ida Eden, MD (37:10)

I love that.

I

This is actually a major issue in my field, as you can imagine, all data gets published. Good data, bad data. In reproductive psychiatry, we may see a signal come up, right? And it might actually be due to confounding bias, but you have to be incredibly, and this is an issue specifically in reproductive psychiatry, it might be that there's been a signal like, I'm making this up, totally making this up.

Abby Eblen MD (37:49)

Yeah.

Ida Eden, MD (37:49)

But that moms who take Zoloft might give birth to babies who have a higher chance of having cleft palate. I have made this up. But really when you take a look at the data, they have not accounted for the maternal illness. They have not accounted for the way in which baby comes into the world. They have not accounted for smoking status or for body habitus. So all of this data, and so you'd be surprised, so much of my job is in psychoeducation and in telling patients and folks

Abby Eblen MD (38:00)

Yeah.

Yeah.

Ida Eden, MD (38:13)

that we have to be really, really good detectives when we look through the data. Everything gets published and we have seen signals. This is just a theme that comes up in my field. And really when we go deeper into these potential signals, they end up being nothing burgers a lot of the time when, when, because the methodology tends to be poor. And so, we're always looking for good data, but, you'd be surprised how much poor data is out there.

Carrie Bedient MD (38:37)

This is fantastic. What else should we have been asking that we haven't touched on? We could do a full podcast on any one of these things that we talked about. And we have hit on all of these things. And so my brain is very saturated with, well, I need to think about this and I need to think about that. I know a question. What do you think about the quote unquote natural approaches to depression? Think like St. John's Wort or some of the other

Abby Eblen MD (38:42)

Hahaha!

Ida Eden, MD (38:43)

you

Abby Eblen MD (38:46)

We could.

Great question,

Gary. Great question.

Carrie Bedient MD (39:06)

herbal

methodologies or the acupuncture, reiki, those types of things. How do those things fit in? Are there ones that are harmful in ways that nobody really thinks about them being harmful?

Abby Eblen MD (39:09)

acupuncture.

Ida Eden, MD (39:21)

Great question. I'm actually really glad you brought this up because often times people will think, okay, psychiatrists, your wheelhouse is in medication. And yes, that is my expertise is in knowing the compatibility and the literature and the data around medication use in pregnancy and lactation. But all of my patients, I'm always talking about low hanging fruit. What can we optimize. Whether that's exercise, diet, and you have a lot of good evidence around fatty fish, omega-3s have really

really, really good, robust mood stabilizer, positive mood boosting properties. So I'm always telling folks have at least one to two servings of fatty fish a week. Believe it or not, sardines are incredible. They're very low mercury fish, very high omegas. know sometimes you can... Fantastic. So again, these are low hanging fruit, exercise, social contacts. Acupuncture is great. I mean, think about it. Is it really a risk to acupuncture?

Abby Eblen MD (40:04)

flexing time to make us

Ida Eden, MD (40:15)

Not really, and if it helps you, incredible. So if I'm meeting with a patient and they're saying, Dr. Eden, I have optimized all of this low-hanging fruit and yet I'm still suffering in this way, okay, that might be a good time to discuss the use of medication. Would that be a good fit for you? But it is one piece of the puzzle. It is never the only answer to what's going on. So I'm always talking about the sort of more complimentary and integrative

modalities of health and wellness. Some of those other supplements, you mentioned St. John's Wort. Again, that's not huge in terms of what we learn in our training, but I always often have patients coming to me on these kind of supplements. So I always just do my own data and my own sort of research on this and brush up on it and sort of see what is the reproductive safety profile. I wouldn't even know off the top of my head what it is for St. John's Wort.

But I would be very cautious, right, for anything that you're taking in pregnancy and with lactation. But I would look it up and say, usually it's some iteration of, don't have a ton of data from what we have. It seems to look okay, although there are some case studies of X. I will be very transparent. This is what my digging has looked like, has come up with.

Susan Hudson MD (41:29)

Wonderful. So Ida, if there are people who are listening and they'd like to contact you potentially visit at your clinic or have a telemedicine consult or something like that, how would somebody reach you?

Ida Eden, MD (41:42)

Great question. So you can reach me through my website, idaedenmd.com and there's a little submission form if you're interested in meeting with me or having a consultation. That's probably the best way. My email and my phone number are there. And yeah, that's the best way. I welcome referrals, of course.

Carrie Bedient MD (42:02)

Well, thank you so much to spending time with us today. This is going to be a very well used and well referenced episode. I have no doubt. I'm to put a little sticky note on this one of like, okay, send people to this one. So thank you so much. We've been talking with Dr. Ida Eden, who's a reproductive psychiatrist in private practice and is faculty at Weill Cornell.

Abby Eblen MD (42:10)

Yes.

Ha ha ha.

Ida Eden, MD (42:18)

Thank you. Thank you.

Abby Eblen MD (42:20)

This was great.

Carrie Bedient MD (42:28)

residency program and medical school. And to our audience, thank you so much. Thank you for listening. Subscribe to Apple Podcasts to have next Tuesday's episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.

Abby Eblen MD (42:41)

you

You can also visit us on fertilitydocsuncensored.com to submit specific questions you have and sign up for our email list.

Susan Hudson MD (42:52)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye!

Carrie Bedient MD (43:01)

Bye!

Carrie Bedient  MD (43:01)

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