How Access to Reproductive Mental Health Can Improve Maternal Health

September 18, 2023 - In this episode of Healthcare Strategies, Associate Editor Veronica Salib chats with Dr. Sarah Oreck, a reproductive psychiatrist and co-founder of Mavida Health about the comprehensive reproductive mental health program. The conversation focuses on challenges in accessing reproductive mental health care and the need for better education and support networks. Additionally, the discussion touches on global disparities in maternal mental health and the potential of the drug Zuranolone while emphasizing priorities for improvement.

TRANSCRIPT

Veronica Salib:

Hello everyone and welcome back to Healthcare Strategies. My name is Veronica Salib and I'm the associate site editor for LifeSciencesIntelligence and PharmaNewsIntelligence. Kicking off our first episode of season five, we are here with Dr. Sarah Oreck, a reproductive psychiatrist and the co-founder of Mavida Health, which is a comprehensive reproductive mental health program. Dr. Oreck just launched Mavida Health about one week before this podcast episode is going up. So Dr. Oreck, welcome and thank you so much for being a guest in this episode. Last time we spoke, we had such an insightful conversation about comprehensive reproductive mental health care and I wanted to bring you back on so we could discuss it even further.

Dr. Sarah Oreck:

Thank you so much for having me. It was a wonderful conversation and I'm really excited to be back.

Veronica Salib:

Awesome. I'm going to go ahead and just hop into my questions. Can you start by describing some of the most pressing issues in reproductive mental health?

Dr. Sarah Oreck:

Absolutely. I think the first is access, truly. Most people don't know that this specialized field exists. Actually, my co-founder who herself struggled with mental health issues after a second trimester loss never even knew about this until she met me. And I think this is a real problem because often people bounce in and out of the mental healthcare system who have these specialized needs and they're not addressed. We can go on and on about this, and I think we did a little bit in our last conversation, but there's also a lot of misinformation around the safety of medications and often people don't get the evidence-based advice and are often left on their own or to make decisions like stopping SSRIs abruptly, let's say, during pregnancy. That leads around 70% of people to relapse into depression.

So I think it's a lot of misinformation out there and just truly difficulty accessing really specialized care where the practitioners know what they're talking about and have the expertise to really help people along this pretty complex journey from trying to conceive through pregnancy, through lactation in the postpartum and really through a huge inflection point in many women and birthing people's lives where they are the most impacted by mental health issues or are impacted for the first time with a mental health issue.

Veronica Salib:

So we discussed a lot about the access part, and that actually feeds really well into my next question. Your specialization is reproductive psychiatry. It's not a super well-known field. You just mentioned that your partner didn't know about it up until kind of looking at your profile. I didn't really know about it, and there aren't many programs in the country for that specialization. Can you talk a little bit more about the educational limitations and how they could maybe be addressed by new initiatives?

Dr. Sarah Oreck:

Yeah, absolutely. So really this is about 30, maybe 30, 35 year old specialty, so it isn't very old and we see it in just a few academic centers. I had the privilege of training at Columbia University where they had this specialty, but it really felt like if I hadn't done the fellowship or for people who had the general psychiatry training, they really didn't feel well-equipped to treat someone who was pregnant per se or to give the advice on medication safety during lactation.

And so it was really interesting, I would start to see my co-residents tap me for advice or to sort of help consult on some of their cases. "Oh, I just got this pregnant woman. Sarah, could you help me?" And I would get all these text messages. I'm like, this is such an interesting phenomenon. We're training at one of the best programs and the general psychiatrists that are graduating from these programs don't feel well-equipped when they see pregnant patients.

I remember seeing some of the most read, most esteemed professors kind of put up their hands when they saw someone that was pregnant. And so I think this is simply, it's not part of the general curriculum enough. This includes, first, psychiatry residents but I would also say all the way back to medical school, I would say that this is also something where OB-GYNs don't necessarily get the most up-to-date training either, and it's really a space where we have to invest more time and energy and education because mental health issues are the number one complication of childbirth. We are training OB-GYNs, so well in treating gestational hypertension or diabetes during pregnancy, and yet this is kind of a blind spot.

Veronica Salib:

And that is so important to emphasize that it is the number one complication. Everybody talks about hypertension, gestational diabetes, preeclampsia, all of those conditions, and it's really important to talk about them, but it's just as important to talk about the mental health aspect of it.

Dr. Sarah Oreck:

Absolutely right. Not nearly as many people are impacted by gestational diabetes, but every pregnant person will tell you, "I had to take that really gross drink." That is in every pregnancy, and people who get prenatal care, they have that experience. But if you ask people if they've been screened for mental health issues during pregnancy, you are going to get a very diverse set of answers.

Veronica Salib:

Yeah. I want to pivot a little bit. Mavida champions this concept that it takes a village and the general understanding of that is that it takes a community and support to raise a child, but I wanted you to describe what that means in the reproductive healthcare setting and space and how it can inform collaborations between different specialties and physicians.

Dr. Sarah Oreck:

Yeah, I think that's exactly what we mean is that we focus a lot on the child, especially in the postpartum. We see this in the pediatric visits for example. Those are the ones that moms and new parents are going to with such frequency and maybe they go to one or two for themselves. And I really like to think about it takes a village to raise a mom and a mama, and by mama we really like to be inclusive. And here we mean woman, parent, birthing person. It really doesn't... It's not something we've were meant to do alone. It's something that in the past and in different societies we did with extended family, with those with more wisdom would be handed down and really that birthing person or that those new parents would be taken care of and sort of ushered into this new part of their lives.

And what we really mean is that if you're having mental health struggles, or even if you are not and you're just having a difficult time transitioning to motherhood, that you deserve that support. And that support really for us means collaborative care and integrated care. And so what we mean by that is that we have therapists, prescribers, a whole team that's there to wrap around you and they all communicate with your OB-GYN. So this forms that village that we've often lost. But we really mean creating a mental health village.

Our app also connects you to people who are having shared experiences and who are maybe going through something like this in a completely different state, in a completely different place. But this is because you're not alone in this. We all have had some sort of struggles as we become parents and we really think it's so important to be able to talk to peers who have had these issues

Veronica Salib:

And you and I have talked a little bit about the applications of group therapy and how that can be especially important in this setting.

Dr. Sarah Oreck:

Absolutely.

Veronica Salib:

So definitely something that needs to be looked into and kind of established a little bit more. We have seen poor maternal mental health in the United States alongside other factors that are not doing well and it is unacceptable, but we've also seen it in comparison to other well-developed countries. We have similar resources to these other countries. Why are we not doing as well as them? So if you could talk a little bit about what contributes to these kind of differences across the world.

Dr. Sarah Oreck:

Yeah, listen, I think it's really complicated. Our healthcare system has a lot of complexities. We are very heterogeneous population where we're not a one size fits all, which many of those cultures, I think about Scandinavian countries and their outcomes and how different those are, but also they're very different societies. With that being said though, I do want to say that the things that start to stand out to me are the supports, right? We're talking about you and I and Mavida is really about mental health support. But I always think it's important to not forget this is one component and the other components are sort of societal and are something we have to really decide as a culture, as a society if we want. And what I see in those cultures is more support around childcare, longer and more supportive parental leaves. And really those are essential and part of the equation.

And I've always been a huge advocate for those because I do think that those can be really helpful if mom is not worried about how she's going to afford to be able to take care of her child or go back to work or how that transition is going to be, a lot of the stressors are alleviated. And I do want to say one of the biggest stressors that comes up and contributes to mental health issues are financial, are who's going to support me while I am going back to work? Is childcare going to be affordable? There are so many childcare services that are closing in the US and that's really challenging. And the pandemic has made it very clear that our infrastructure in terms of supporting parents is simply not there. I'm also thinking back at formula shortages, how horrific that was for our parents in this country. And so when that infrastructure falls apart, it's going to be really hard to maintain mental health

Veronica Salib:

Yeah, for sure. And then even people who do have access to affordable childcare or can afford certain levels of childcare, they don't necessarily want to not go to their child's checkup.

Dr. Sarah Oreck:

Exactly.

Veronica Salib:

They don't want to necessarily miss out on these major milestones. So it's not just about accessibility, but also about acceptance.

Dr. Sarah Oreck:

Or not be able to pump because you work in a fully glass partitioned office where you'd have to pump in a bathroom stall or something.

Veronica Salib:

Yeah. So there's definitely a lot of different areas that can be worked on. I want to talk about an area that we have had recent work, which is this really successful new treatment for severe postpartum depression. We talked about it last time and you had some really interesting insights on it. So what are the benefits versus the limitations of the research on this new product?

Dr. Sarah Oreck:

Yeah, we're so excited about Zuranolone. I think some of the highlights are, it works in a matter of days. We think in three days of taking this medication, which is an oral pill, you have some benefit or decrease in depression and you only have to take it for 14 days. And the results, or so that efficacy last for about 45 days, maybe even more. Sometimes if the depression is severe enough, you have to do a second course, but that's really miraculous and with very low side effect profile. And this is really up against what our gold standard is right now. So I think I wanted to make it really clear because some of these articles made it seem like we have no treatments, but we do. Our treatments right now that are gold standard are called SSRIs, and these are selective serotonin reuptake inhibitors, and they are kind of like the antidepressants or anti-anxiety medications that many people take. And they take about four to six weeks to work, have a good amount of side effects, and you have to continue to take them in order to have effects.

And so this is a huge difference from a medication that can be taken for just 14 days. I think one of the biggest questions I have when someone is deciding to take an SSRI, which is what I can prescribe now is, "Oh my, how long do I have to be on this?" And to be able to offer Zuranolone sometime in the future, hopefully in the next few months is really exciting. I think what I'm really concerned about is the cost and that the cost will be inaccessible to most or will require potentially pre-authorizations from insurance, which will mean that you might have to have failed different treatments before you're able to get that treatment.

Veronica Salib:

That's always a really crazy concept to me because why would we give someone a less effective treatment first? Why would we put them in that position?

Dr. Sarah Oreck:

Right. Or more complicated or bulkier or had more side effects. But this is unfortunately the game so many physicians have to play and want to really help their patients get the best treatment, but often it's just not accessible. And again, it might be a limitation because of cost. Brexanolone, which is the infusion version of Zuranolone, which has existed for a couple of years, I think the out of pocket cost was something around $30,000. So you can imagine how inaccessible that was and still is. I can count on my hands the number of patients that I've met who have ever had that treatment. So I'm bracing myself. I'm hoping that it's going to be accessible, but I'm not sure.

Veronica Salib:

Yeah. And then another thing about this treatment is that it is pretty much unheard of for any mental health treatment to work this fast, especially reproductive mental health. We've discussed a little bit about how you think it's going to help inform our understanding of how hormones impact mental health. So I wanted to ask where you see this research going in the future and what other studies could build off of the existing studies that have proven the efficacy of this drug.

Dr. Sarah Oreck:

Yeah. We're so excited that this is a byproduct of progesterone, and we always thought that postpartum depression was different from the general population feel. So what we call major depressive disorder, we know that the inflection points are sort of the worst points for the postpartum depression really happen right after birth when you have that precipitous fall in hormones. And so we're excited that this is really a hormonal mediated medication that sort of gives us some insight of, "Hey, this might be exactly what's going on."

 We also saw, which I think was disappointing and actually might affect the cost of this medication that they didn't get the general population approval, but it seems like it's not that effective for major depressive disorder. So that's some insight. I am so excited about this because the next inflection point in many women's lives is really perimenopause. And again, we've had a lot of discussion, many startups and venture capital money going into treatments for perimenopause, but they've really focused on the physical aspects and not as much on the mental health aspects.

And after pregnancy and postpartum, perimenopause is that time where people experience the most amount of depression and anxiety. And so I really think there's an opportunity, A, to talk more about mental health issues and perimenopause, but also to potentially have targets that are really specific. And let me tell you right now, we mostly use hormone replacement therapy and say, "Oh, this might help you, this might not for your mental health issues," and SSRIs. And again, it's sort of the same attrition rate because of side effects. SSRIs, particularly in women, really have a lot of effects on their sexual health. And perimenopause is a time where there's huge effects on your sexual health. So that's sort of a double hit during that time.

And then we don't know, it's not that effective. Sometimes they help with hot flashes, sometimes they don't. And so I'm really excited about hopefully more research and development both during that time. And I think we haven't talked about this enough, but Zuranolone has really just been approved for the postpartum, but we see that a lot of depression and anxiety actually starts during pregnancy. And so we really want to figure out more targets and of course safe targets because we have the fetus to also take care of during that time. And currently Zuranolone is contraindicated during pregnancy. We also don't know if Zuranolone is going to be effective for those with mild to moderate depression or those with anxiety, which is much more common than depression.

Veronica Salib:

And we haven't seen it in lactation as well.

Dr. Sarah Oreck:

Exactly.

Veronica Salib:

And breastfeeding individuals aren't necessarily going to be able to use it. So there is that limitation.

Dr. Sarah Oreck:

Yeah. Or they can decide to take two weeks off. But that will often, if you've had experience with breastfeeding, that may mean your journey is over because your body maybe won't know to produce more milk after that.

Veronica Salib:

So I'm going to ask you my final question, which is just kind of a good note I feel like to end on, if you could list three priorities for improving reproductive psychiatric healthcare, what would they be? And if you could also kind of describe if there is progress so far, or if we kind of are starting from the bottom.

Dr. Sarah Oreck:

You said three targets.

Veronica Salib:

Yes, I know. Narrowing it down.

Dr. Sarah Oreck:

Yeah, let me think. The first is access to care. We really want to make this affordable for most people. We find that right now a lot of mental health practitioners, especially those that are specialized, are all out of network and don't take insurance. And we know that people want to use their insurance to pay for their mental health. And so at Mavida Health, we really want to make that super affordable and accessible.

Also, we know that people in rural settings or outside of big major academic centers sometimes don't have access to the most specialized care. So being able to bring the specialized care through telehealth, through an easy to use app to those areas is really exciting, especially because we know that in rural settings there is sort of decrease in quality of all maternal health.

And then in terms of innovation, I think that's a huge one. Zuranolone is sort of going a step into that direction, but we certainly need more research on safety of medications during lactation. That data exists, but it's so small, so we really want to make that more robust. I think generally a lot of pregnant patients have been excluded from research, and it's really a disservice. I understand the complexities of it, and I think we all do. A fetus cannot consent to be in a study, but as a result, really pregnant patients suffer because they don't have high quality research behind a lot of the decisions that we make. We really have to look at retrospective studies. And so I think that's a huge issue that really needs to be addressed in addition to research and development in the area.

Veronica Salib:

Thank you, and thank you so much for being here today. It's always a privilege to talk to you. I'm always so impressed by every single one of our conversations.

Dr. Sarah Oreck:

Thank you so much, Veronica.

Veronica Salib:

As for our listeners, we would love to hear from you. Feel free to reach out with any healthcare related questions or subjects that you think we should cover by emailing us at vsalib@techtarget.com. And if you'd like this episode, please consider rating and reviewing us on Apple Podcasts, Spotify, or wherever you're listening. Thank you so much for listening, and we'll catch you next time.