Women's Behavioral Health

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: May 1, 2026
Expiration Date: April 30, 2027

Estimated Time of Completion: 30 minutes

Women’s Behavioral Health 2026
Adele Viguera, MD

Description
Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.
  
  Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Andreas Alexopoulos, MD, MPH
Epilepsy Center

Additional Planner/Reviewer

Ari Newman, BSN

Faculty

Adele Viguera, MD
Center for Adult Behavioral Health

Host

Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Women’s Behavioral Health 2026
Adele Viguera, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Glen Stevens, DO, PhD	DynaMed Consulting
Adele Viguera, MD	Up to Date Consulting

All other individuals have indicated no relationship which, in the context of their involvement, could be perceived as a potential conflict of interest.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast May 1, 2026 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org.

Copyright ©2026 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neurorehab, and psychiatry.

Glen Stevens, DO, PhD: Women's mood and anxiety disorders evolve across the lifespan, shaped by reproductive and hormonal transitions that can significantly affect mental health. In this episode of Neuro Pathways, we examine these disorders highlighting emerging treatments and the importance of integrated care.

I'm your host, Glen Stevens, neurologist, neuro-oncologist in Cleveland Clinic's Neurological Institute. And joining me for today's conversation is Dr. Adele Vaguera. Dr. Vaguera is a psychiatrist in the Department of Psychiatry and Psychology and co-director of the Women's Behavioral Health Program at Cleveland Clinic. Adele, welcome to Neuro Pathways.

Adele Viguera, MD: Thank you very much, Dr. Stevens. Pleasure to be here.

Glen Stevens, DO, PhD: So Adele, I've known you for a number of years in other capacities, but for those that aren't familiar with this, tell us a little bit about yourself, your background, how you came to Cleveland and what you do here on a regular basis.

Adele Viguera, MD: So, I did my internship at Massachusetts General Hospital in medicine and then completed a psychiatry residency at McLean Hospital in Belmont, Massachusetts. And that was followed by two fellowships, one in consultation liaison and another one in perinatal psychiatry. And I was in Boston for about 10 years, and then my husband and I came here to the clinic in 2007. So I've been here for quite a while now. And just recently appointed co-director of women's behavioral health, along with my other colleagues, Maureen Sweeney and Dr. Lulu Zhao.

Glen Stevens, DO, PhD: Well, we're happy to have you and look forward to our conversation today. So to start off, what are the most common mood and anxiety disorders affecting women across the reproductive lifespan and how do they differ by life stage?

Adele Viguera, MD: So, the most common diagnoses that we see are major depression and anxiety disorders. And what do we mean by anxiety disorders? That's generalized anxiety, panic disorder. And what we find is that women are at increased risk for these, especially starting from puberty all the way up until menopause. And for some women in particular, they are particularly sensitive to these hormonal transitions and can experience a recurrence or a new onset of mood and anxiety disorder during these times of hormonal fluctuations. And again, it's not about the hormone levels, it's about the sensitivity to normal hormonal levels.

Glen Stevens, DO, PhD: So, in females, difference between puberty, pregnancy, menopause, do you see variances in anxiety and mood disorders there?

Adele Viguera, MD: Well, what we see as sort of a common theme, we see that a lot of women are not affected by these periods of hormonal transitions, but there is a subgroup of women who are particularly sensitive and it's a period of vulnerability for them to develop anxiety and mood disorders during those hormonal transitions. So we have, during the menstrual time, we have a disorder called premenstrual dysphoric disorder. Pregnancy and the postpartum are also times of very high risk for women and the perimenopause. Now, the women that are more predisposed to these subtypes of reproductive related mood and anxiety disorders tend to be those that already have a preexisting diagnosis of depression or anxiety.

Glen Stevens, DO, PhD: And we'll go right into the premenstrual dysphoric disorder and the pathophysiology of it as it relates to, and I know there's this controversy of hormone sensitivity versus absolute hormone level. Why don't you tell us a little bit more about that?

Adele Viguera, MD: So it's not about the levels. And I think intuitively we like to think, "Oh, maybe it's too much, too little."

Glen Stevens, DO, PhD: That's what I would think.

Adele Viguera, MD: Yes. Most people think that way. But what we found was that it's actually, there are subgroup of women, they have an abnormal response to normal fluctuations in hormones. So there's this very specific group that are particularly sensitive. And we actually see this play out in the other periods of time when there's hormonal transitions like postpartum depression or during the perimenopause. So again, it's not about the levels, it's about sensitivity. And women with PMDD have an abnormal response to normal fluctuations in hormones. Now, what is the etiology of that? Now, that's a complicated question. And in short, we don't have the full answer, but over time we're sort of putting the pieces of the puzzle together. So we know that the serotonin system is involved because the first line treatment for PMDD are the treatment with serotonin reuptake inhibitors like citalopram, fluoxetine, escitalopram, and some of the SNRIs as well, venlafaxine in particular.

That gives us a window into that serotonin is likely involved. But also the other big player is a neurosteroid called allopregnanolone, which is a metabolite of progesterone. And that works on the GABA-A receptor, which is the same receptors that benzodiazepines work on. And we know that allopregnanolone has a calming effect at high concentrations, but there are a subgroup of women where at allopregnanolone levels that are either low to moderate, they actually develop a paradoxical reaction. They get more irritable and have anxiety.

Glen Stevens, DO, PhD: So, digging a little bit deeper into this PMDD disorder, this premenstrual dysphoric disorder, what percentage of women would suffer from this?

Adele Viguera, MD: It's actually a small percentage. It's about 3 to 8% in the population. What's more common is PMS. About, oh, I would say maybe 70 to 80% of women will complain of some kind of behavioral or physical complaint related to the menstrual cycle. But the important difference here is that PMDD is a disorder, and that means that it interferes with your day-to-day functioning. The symptoms are severe enough, and usually it involves irritability, sometimes extreme suicidal ideation, tremendous anxiety, and those tend to really interfere with someone's quality of life. And remember, this is occurring monthly, so it can be a big, big strain.

Glen Stevens, DO, PhD: And then it will stop abruptly once menses starts, or does it take a little bit of time?

Adele Viguera, MD: By definition, it's like a faucet. When the menses starts, the symptoms should resolve. It's a clinical diagnosis. So we have women do prospective ratings of their mood and physical symptoms throughout the month for two months in order to look at the very specific pattern, which is what you're alluding to. Sort of all these symptoms are occurring during the luteal phase, and with the onset of menses, they disappear. So that's the classic PMDD. Now, we do have other scenarios where women might be struggling with, let's say, underlying major depressive disorder, and they can experience what we call premenstrual exacerbation of mood. So you can see an elevation in some of the anxiety and depression premenstrually, and then the symptoms will improve, but they're still there. They're lasting throughout the month. So that's not the classic PMDD pattern, but premenstrual exacerbation of an underlying mood disorder.

Glen Stevens, DO, PhD: I assume one option for treatment would be to stop the menses using some type of birth control. What percentage of women would opt to do that?

Adele Viguera, MD: That's actually very rare because there's problems implicated in that. You basically are throwing a young person into menopause and you have to worry about their bones and their heart and other long-term issues. So that's sort of at the extreme. But what we tend to try first is treatment with the serotonin reuptake inhibitors like we've already mentioned. And it's interesting, there's different strategies of approaching this. If a woman has a very predictable cycle and you can see her symptoms, she can track the day that they start and then with the onset of menses, they disappear. We can treat her just for that period of time. And for others, for example, who are on a maintenance antidepressant like fluoxetine for their depression, but experience sort of this worsening premenstrually, we can bump up the dose. Let's say they're on 20 milligrams of fluoxetine. We can bump it up to 40 just for that period of time, which is usually two weeks to a week before the onset of menses.

So those are some strategies that we use. And what's unique about this is that you would think that an antidepressant takes several weeks to kick in. This is a different mechanism because women get relief pretty much right away. So, we think it has to do with the fact that the serotonin reuptake inhibitors are increasing allopregnanolone, which can have that, remember we talked about that calming effect.

Glen Stevens, DO, PhD: Well, the good thing there is you're going to know pretty quickly if it's going to work or it's not going to work.

Glen Stevens, DO, PhD: So, let's move away from the PMDD and move to pregnancy. One difficult scenario to the next one. What are the common mood and anxiety disorders associated with pregnancy and in the discussion maybe when they appear? Is it in the first trimester, late trimester? What do you see?

Adele Viguera, MD: We see a lot of major depression as well as anxiety disorders, specifically generalized anxiety disorders and panic disorder, as well as OCD, obsessive compulsive disorder. And my experience, what we often see are women who come into the office who are being treated for major depression and they're doing well, they're stabilized on their SSRI, and then they find out they're pregnant. Now, two things can happen. Either they stop the medicine abruptly because they're scared or the doctor has advised them to stop because they're pregnant and they stop it abruptly. That is probably the worst thing to do is to stop something abruptly because that in itself can precipitate relapse. And so in general, our approach and our overall philosophy is to keep mom well. We call it euthymic, keep her stable and maintain her throughout pregnancy on an SSRI or whatever antidepressant has kept her well and continue that into the postpartum because one of the key factors that you have to consider is that illness in pregnancy, being depressed, being overly anxious is the biggest predictor of not doing well postpartum.

So, we really make every effort possible to stabilize the mom as best we can. That includes both medications and therapy together, which is the most potent combination, and then we follow her through delivery and into the postpartum period. So, stability is critical, critical.

Glen Stevens, DO, PhD: Yeah, I like your approach with that. And of course, lack of sleep, stress of the pregnancy, the uncertainty of how it's going to go, especially if it's your first child and all the uncertainty will add to that anxiety, I'm sure.

Adele Viguera, MD: And right now, we're in a very good place. I've been in this field since 1995, and there's really been such an explosion of research with respect to the risk of major malformations associated with SSRIs and some of the other antidepressants. And I'm very pleased to say that we have not found any signal. There doesn't appear to be an increased risk for major malformation above what we would expect in the general population. And that's something that I like to educate my patients on is that in nature, bad things happen. So the spontaneous rate of major malformations, if you do everything correctly, is around 2%, hovers two to 3%. And so in order to evaluate these medications as to whether they're teratogenic causing a birth defect, you have to ask the question, do they increase that baseline risk? And none of the antidepressants that I can think of have shown that they increase that risk. So we're in a very different place in 2026 than we were in 1995.

Glen Stevens, DO, PhD: Yeah. I think we have a broad audience that listens to the podcast, and I think this is a real teachable moment. I'm curious, and maybe we don't know the answer to this, but in general, what percentage of physicians would tell patients that are pregnant to stop their medication? If they're on an SSRI or something.

Adele Viguera, MD: I think the majority, a big percentage of them will likely-

Glen Stevens, DO, PhD: Yeah, so a very teachable moment then.

Adele Viguera, MD: Yes, yes. A very teachable moment. And I think for a long time, there was a lot of fear around treating women during pregnancy and not recognizing if we had a patient who had diabetes who was pregnant or hypertension, there would be no hesitation in managing that. The same with major depression or panic disorder. These are recurrent illnesses, chronic illnesses, and we can't just leave them untreated. There's a lot of negative consequences to untreated illness, whether it be mood or anxiety on both the mom and the developing baby. And so I know that's a question I'm sure you're going to ask me what are some of those adverse effects, but we really view it, untreated illness is a toxic exposure and it's something, again, we strive to keep the mom well, stable, euthymic, whatever term you want to use.

Glen Stevens, DO, PhD: Yeah. I mean, the consequences of not treating are risk of injury to the mother, I'm sure, risk of injury to the unborn child.

Adele Viguera, MD: Right. You see, for instance, a lot of moms who aren't treated may turn to substances to self-medicate, more alcohol, other drugs. They may not follow up with their prenatal appointments, poor nutrition, a host of things. And also it can have significant impact on bonding, the mother's relationship with her baby that can be very much affected by untreated depression. And conversely, for the developing infant and for the neonate, there are also adverse effects. You see more preterm labor, low birth weight, cognitive and language, developmental issues, and long-term developmental issues.

Glen Stevens, DO, PhD: So, I guess those people out there that are listening, that are seeing these patients and a little nervous about it, then should see someone like yourself.

Adele Viguera, MD: Don't be afraid. Don't be afraid.

Glen Stevens, DO, PhD: Don't be afraid. Don't be afraid.

Adele Viguera, MD: Don't be afraid.

Glen Stevens, DO, PhD: The term that we use in medicine all the time now is shared medical decision making. Of course, when I started training in the old days, it was a lot more you would just, you know, this is what we do and this is how we do it and this is just the way it's going to be. But of course we don't do it that way anymore. It's all open discussion. How open are patients to this in your practice?

Adele Viguera, MD: They're extremely open. And having done this for a long time, you realize that everyone has a different sort of threshold for the risk that they can tolerate. And what I've seen is that if a mom comes in, she's a new mom, she may be more hesitant to be on a medication. But let's say this is her second pregnancy and she has a toddler at home, and let's say she had a very bad experience with the first baby, she'll often say, "I can't afford to be ill like I was last time. So please, let's find a plan where I can remain well." And so we have these discussions of the risks and benefits. And what makes our job a little bit easier is that we have this wealth of reproductive safety data for the SSRIs, antidepressants, some of the other mood stabilizers that really show no increased risk for major malformation. That has completely revolutionized how we approach treating women who have these severe depression, anxiety-

Glen Stevens, DO, PhD: Yeah. So I imagine if there's a lot of fear in practitioners out there about stopping these medications, women are pregnant, then I'm sure if they develop these symptoms de novo during their pregnancy, they're going to be even more concerned about starting a medication. What are you seeing in your practice there?

Adele Viguera, MD: Well, really, again, we try to get on top of that as fast as we can and get the mom, again, the same philosophy, get her stable as fast as we can. And the history is so important. Oftentimes they'll come in with a clear history that they've been treated with other medicines that have been successful. That's often our guide. So if fluoxetine worked for you in the past when you were in college, you had a depressive episode, that's the one that we're going to choose. But if we are starting, let's say de novo, this is the index episode, it's really we just have to present the various medications and some of their side effects and have that discussion with the patient as to which one they feel they would be comfortable with.

Glen Stevens, DO, PhD: Is there any difference in the trimesters first, second, or third in terms of risk of developing mood disorders or anxieties? Or ...

Adele Viguera, MD: Well, what we see because of that common knee-jerk reaction, to stop your medicines abruptly when you find out you're pregnant. We see that that drives the risk. So usually within the first trimester, they're already sort of not doing well. And usually by then, they declare themselves, they come see us, we try to get them better. I think it's usually in that setting, it's very early on in the pregnancy. But the reality is, a lot of these women, there's stigma associated with it. They're ashamed to reveal that they're depressed during their pregnancy, which everyone, their family and everyone is so excited about, but they are not. So it often takes, there's a delay in women getting treatment. And about 50% of women, they're not diagnosed with a problem and they have a problem.

Glen Stevens, DO, PhD: Yeah. It sounds like when in doubt, refer.

Adele Viguera, MD: Yes. And I think I'm very encouraged to see that a lot of our colleagues in OBGYN are actually getting more involved in treating mood and anxiety disorders during pregnancy. In fact, one of our co-directors here at the Cleveland Clinic of Women's Behavioral Health, Dr. Lulu Zhao is an OBGYN. So it's a very unique situation where we have both a psychiatrist and an OBGYN leading women's behavioral health.

Glen Stevens, DO, PhD: But I think it makes sense.

Glen Stevens, DO, PhD: I'm a brain tumor guy and we're multidisciplinary and it just makes better care for everybody.

Adele Viguera, MD: It's wonderful.

Glen Stevens, DO, PhD: Excellent. So let's move now from pregnancy to babies born postpartum depression. And I remember the term from years ago, the baby blues.

Adele Viguera, MD: Right. Right.

Glen Stevens, DO, PhD: And you could probably tell me what the specific definition is, but I assume it's just where the symptoms are for a short period of time. What defines that I'm actually having postpartum depression?

Adele Viguera, MD: So, believe it or not, in our diagnostic manual, which we call the DSM-5, there is no formal term called postpartum depression. Even though we use it clinically and in the research world, how the DSM-5 defines it is as a major depressive episode with peripartum onset. It used to be with postpartum onset, but they realized that 50% of women who presented with postpartum depression had the onset of symptoms in pregnancy, hence the name changed to peripartum, meaning pregnancy postpartum. So now the definition is onset within pregnancy or within the first four weeks postpartum, and that's the peripartum onset. But technically there is no formal diagnosis of postpartum depression.

Glen Stevens, DO, PhD: I'm just curious. I hear a lot about postpartum depression. I don't hear postpartum anxiety. Is that a thing or it's not a thing?

Adele Viguera, MD: Absolutely is a thing. And what distinguishes postpartum depression from other depressive episode outside of the postpartum is that postpartum depression is often one of the hallmarks is both depression and high levels of anxiety. And that's really kind of what distinguishes it a bit from your just run-of-the-mill major depressive episode occurring at other times. And that can include what looks like sort of obsessive thinking, sort of an OCD-like obsessions about either harm is going to come to the baby or the mom will think accidentally she'll cause harm to the baby. And that can lead to behavior such as avoiding the baby, having other people take care of the baby and the mom sort of retreating because she's so distressed by these thoughts, will often get better with treatment or the depressive episode.

Glen Stevens, DO, PhD: And I'm sure there'd be risk of suicide, all these types of things, right?

Adele Viguera, MD: Absolutely. Absolutely. And in the extreme situation, we have something called postpartum psychosis, which is one of the few psychiatric emergencies. They often make the headlines, sadly, and usually associated with a lot of maternal and also maternal morbidity, mortality, and also infanticide as well, sadly. And so that we consider an emergency. And again, we try to do our best to stabilize the patient. Usually it requires inpatient psychiatric hospitalization, sometimes ECT, but the good news is that they will get better and they return to their baseline. So it has a very good prognosis if it's well managed.

Glen Stevens, DO, PhD: So, Adele, I'm not sure if you're aware, but in 1978 in Canada, I worked on a locked forensic ward. It was combination of men and women. And as you were sort of discussing with postpartum depression and psychotic episodes, the majority of the women that were in there had done harm to their child in relationship to what you had discussed.

Adele Viguera, MD: And I think it's relevant to what I was talking about with the obsessions and the OCD-like behaviors, because it's important to make the distinction. Usually moms with sort of this obsession, they don't want those thoughts. They're intrusive, they don't want them, they're often very embarrassed to admit them. We call it ego dystonic. They don't want them. Whereas if someone is in a postpartum psychosis, they don't question that thought and they don't find it distressing. And that really is a very important differentiation to make because one leads to definite hospitalization, the other one, you try to reassure the patient that we often see this with postpartum depression, this will get better and reassure the patient.

Glen Stevens, DO, PhD: So, we started this conversation on starting with menarche and hormonal sensitivity issues. Perimenopause, menopause, I'm sure again, probably estrogen is our culprit here. Talk to me about that a little bit.

Adele Viguera, MD: Again, another sort of transition point where a lot of women will experience depression and anxiety, and those at greatest risk are going to be those who already have a prior history of depression or anxiety. And why is that? Because the perimenopausal period in particular, which is the four to seven years before the last menses, is a time of incredible variability in estrogen and progesterone. And it's those fluctuations again where these women who are affected by it have this abnormal response to these normal fluctuations. So it's a time of very high risk. Now the menopause in general, that's with the cessation, there's no further sort of variability in the hormone levels. That's actually for a lot of patients, they can do quite well during that time.

Glen Stevens, DO, PhD: Hormone replacement therapy with menopause, thoughts about that for using in conjunction for mood?

Adele Viguera, MD: In general, and I think this comes up all the time, and there's a lot of exciting developments now with the FDA removing the black box warning on HRT. Again, that was a label that was scaring a lot of women away from HRT and causing all kinds of havoc. But now, thanks to some, I think very progressive women physicians out there, urologists from all different disciplines, they really push the FDA to remove that label. We're very excited about that. And that just happened recently in the fall of 2025. But with respect to treating mood disorders, we would never treat a primary mood disorder occurring at that time with hormones alone. We're not there yet. The jury's still out. We're not there yet. So the first line treatment, if someone is experiencing depression or anxiety during that time would be, again, treating with a SSRI or SNRI.

That would be our first approach. Now, if that depression anxiety were accompanied by vasomotor symptoms, so either hot flashes or night sweats, then we might do the both in combination. Now, interestingly, the SSRIs and SNRIs are also used to treat hot flashes. They're not as efficacious. So if you treat hot flashes with estradiol, the improvement is about 90%. If you treat with an SSRI, SNRI, it's about 50%. But during that time when we had that black box warning, that was one of the best alternatives we have to help manage the vasomotor symptoms. So now that the black box warning is no longer there, I'm hoping that there's going to be more studies as to ... Right now, there's no head-to-head studies. What should we start with? Should we start with the hormone replacement or the antidepressant? But just to make it clear to the listeners out there, we really, the first line treatment would be an antidepressant, not hormones right away.

Glen Stevens, DO, PhD: Okay. And just for our listeners out there, HRT is hormone replacement therapy.

Glen Stevens, DO, PhD: And it's hard to believe we're up against the clock here, but a couple of other things. Your interaction with endocrinologists, 'cause everything sounds very hormonal, sounds very endocrinologic. Do you guys work with endocrinologists much? Do they get called on for these types of things?

Adele Viguera, MD: I think closer relationships with our GYNs who work in this area would be wonderful. But in general, no, we actually have more conversations with our colleagues in OBGYN, but not endocrinologists. You bring up a good point. I don't know why that is, but it just hasn't been the tradition.

Glen Stevens, DO, PhD: So key takeaways for the general psychiatrist out there, the neurologist, primary care folks?

Adele Viguera, MD: The key takeaways are, please don't change any of a patient's maintenance medications. Please don't do that. If you want to do that, consult the psychiatrist or whomever is following the patient. I would see that all the time in our resident clinic, where another physician from a different discipline would stop a medication. They usually stop it abruptly and then the patient doesn't do that well. So please don't stop it. Consult your colleague in psychiatry. Don't be afraid of treating mood and anxiety disorders during pregnancy as you would treat hypertension or diabetes. Don't be afraid. You're doing everyone a favor. You're helping the patient. You're helping the family unit if she has younger kids at home. You have a mother who's functional, who's stable. You're also helping her prognosis postpartum because you're keeping her well. So that's a major takeaway. And also recognize that during the perimenopausal transition, be very vigilant for those patients who have a prior history because they could relapse during that period of time.

Glen Stevens, DO, PhD: Anything that we've missed that you think is important?

Adele Viguera, MD: Oh, I just wanted to add for the perimenopausal hormone treatment. In general, for mood, we like to use estradiol patch, not the tablet, because it bypasses the liver and produces more stable estrogen levels. So for mood in particular, estradiol patch is what psychiatrists would recommend.

Glen Stevens, DO, PhD: Excellent. Well, Adele, I've learned a lot today. I'm sure everybody out there has learned a lot and people hopefully will change some of the behaviors that they've been doing. So appreciate your joining us today.

Adele Viguera, MD: Thank you for having me.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's @CleClinicMD, all one word. And thank you for listening.