Welcome back & introducing Dr. Susan Zink

Kerry 0:28

Hi everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have Dr. Susan Zink coming to us from New Jersey. Why don't you tell us a little bit about who you are and what you do?

Susan 0:41

Hi. Thank you for having me. Like you said, I'm Dr. Susan Zink. I am a board certified adult psychiatrist. I have a private practice here in New Jersey in Linwood, New Jersey. My focus is on reproductive psychiatry and integrative psychiatry. So I like to approach women's mental health with that integrative approach, helping women who are going through transitions

Dr. Zink’s background in reproductive and integrative psychiatry

Susan 1:09

that, that often occur during their reproductive lifespan, like preparing for pregnancy. During pregnancy, postpartum, and perimenopause when they can really struggle with mood or anxiety or sleep issues and helping them to just feel a lot better and, and, and to thrive during those periods.

Kerry 1:30

Definitely some complicated periods in life where hormones are going crazy, so that's super helpful. How did you get into such a I guess, niche, is that the right word?

Susan 1:40

Yeah, sure. Yeah, it's interesting. When I was in my residency training and during my fourth year, we had the opportunity to do what we called a maternal mental health elective. I don't know that there were any formal reproductive psychiatry fellowships back when I was in residency training. So this was kind of a mini, mini fellowship. And I think my interest started just because I'm a woman. But then actually I was pregnant during that rotation. So I think, a lot of my patients' experiences really resonated with me as I navigated my own pregnancy and then the postpartum period. So I, I really learned a lot, but I think that really solidified my passion for the field. And then I had two more children kind of in short succession after that. Each pregnancy, each postpartum period, each baby was so different. And it was easy to relate to my patients. It was really easy to have compassion for what they were going through. Just as I, I navigated everything by of my own pregnancies, my own experiences, myself too. And I just continue to be really interested in it. It's a really. Under recognized underrepresented area of medicine. I think it is growing more recently, but women make up half of our population and we have a pretty long reproductive lifespan. And these conditions are really common. And so I think we need more people who are, are experts and know how to help women through these transitions.

Kerry 3:05

Yeah, I think, I think you're right. I think it's growing. I think it's great. I also think having that personal experience is obviously really helpful as well. Like going through it yourself. had my first in residency as well, and I think I'm more bonded over newborn care. So I was on like my newborn rotation right before I had my baby. And I think it really helped me, you know, talk with my patients and the infants that I was also, you know, taking care of at that time. So.

Susan 3:31

right.

Kerry 3:31

Definitely helps to have that personal experience as well. So what are some of like common misconceptions about mood changes during these stages of life that you kind of mentioned? Like pregnancy, postpartum, perimenopause.

Susan 3:45

I think there are so many misconceptions but probably the, the, maybe the two most common ones are. Number one, the misconception that it's not your hormones. So I think a lot of women have this sense, they kind of feel that something has changed all of a sudden and they think it's hormone related and, and sometimes they'll go to a doctor and be brushed off and say, no, it's not your hormones. And, and I think absolutely sometimes

Common misconceptions about mood changes in pregnancy & postpartum

Susan 4:13

it can be, or the changes in the hormones are really exacerbating something else that was already there. So that's number one. And then I think the second one is that these mood changes, maybe the increase in anxiety, the sleep problems. A lot of the symptoms that we see are very common, and so sometimes people mistake common for normal. So just because something is common doesn't mean that it's normal. It doesn't mean that it's something you have to suffer through or something to be endured or something that should just be ignored and, and then you kind of wait for yourself to feel better. So I think that that's really important for people under to understand that postpartum depression and anxiety, for example, occur in about 20% of people. So it's very, very common. But that doesn't mean that it's normal or, or not worthy of treatment and attention,

Kerry 5:07

I mean, I was gonna ask exactly that. How common are they? And then kind of why are they still under recognized or that we kind of alluded that to that earlier, but, any follow up on like why they're still kind of under recognized?

Susan 5:20

I think a lot of it is access to care recognition. So I'll see a lot on social media that someone will say, oh, I have this postpartum rage, is this normal? And, and then you get, you know, 20 people who respond and say, yeah, I, I had that too. So it's normal. And there's a lot of course on social media, a lot on the internet where you can get validation for what you're going through. And then it feels like, okay, well I guess this is how it's supposed to be, even though it feels really terrible.

Why postpartum depression and anxiety are still under-recognized

Susan 5:48

And I think that's one reason. I think another reason is that. A lot of times women don't want to divulge that they're experiencing these things. There's sort of this expectation that once you have a baby, everything is unicorns and rainbows and you should be over the mood and you should be really happy. And if you're not, then there's something wrong with you. And so that can, I think, cause a lot of shame or embarrassment, and people don't necessarily wanna bring it up on their own. And of course, having a baby can really turn your world upside down. So it can be hard to remember to take care of yourself when you're really focused on taking care of this new living being that is totally relying on you.

Kerry 6:28

Yeah. I like how you kind of said the thing about social media, like it's, they're looking online and you know. They validate what they're feeling, but it's not necessarily helping them take the next step to realize that, well, it's common. Like you said, it's not normal and they should be seeking help for it, I think. What do you think about those screeners? So every time I went to the, you know, doctor postpartum for the pediatrician, they were always screening the mom for, you know, postpartum anxiety and depression. Do you find that those are useful and helpful?

Susan 7:00

I think in a lot of cases they can be. So where I work in the hospitals, every postpartum mom gets that EPDS, the Eden Edenborough Postnatal Depression Scale. And I think, I think that that can be really helpful to recognize and identify any postpartum mood shifts or depression or anxiety. Certainly. Often the first doctor that a postpartum mom sees is the pediatrician or the OBGYN.

Postpartum screening tools (EPDS) and what happens after a positive screen

Susan 7:29

And so I think that can be a really important first place to pick up on some of these symptoms. The issue then becomes what do you do with the information? So a lot of primary care doctors and OBGYNs feel comfortable starting treatment, but sometimes they don't and they don't have anyone to send the patients to us. So I think that's. That could be a barrier sometimes.

Kerry 7:50

Mm-hmm. And by treatment, what do you, meaning like medication or something else?

Susan 7:56

Typically, I think a primary care and OB GYN will prescribe medication if they think it's warranted or give referrals to therapy or if they have other support, resources may, may give those out.

Kerry 8:10

So you mentioned medication, so what if someone was already on a medicine or they're gonna be breastfeeding or something like that, how would you counsel that patient on whether they're, you know, worried about having that medication in their system with the baby or breastfeeding or something like that?

Susan 8:25

It's such a good question. So you mean before pregnancy or during pregnancy, whether they should be on the, on the medication. Right. So it's, this is a really, of course, individualized discussion, but I think in general. And of course this is, this is for education. You should talk to your own doctor about, about your own medications. But generally what we're doing is a really careful risk benefit discussion. So of course, I think most people recognize that there are, or there can be

Medications in pregnancy & breastfeeding: real risks vs. untreated illness

Susan 8:53

risks of taking a medicine during pregnancy. They recognize they're taking something and then that can expose the baby to whatever medication they're taking. But where I think a lot of people don't understand is that there is also a risk of not taking medicine. So untreated depression and untreated anxiety are themselves risks. They're themselves exposures just like untreated gestational diabetes can have. Effects on, on a baby and effects on the pregnancy. Untreated depression and anxiety often is more risky than taking an antidepressant during pregnancy. So we have a lot of really reassuring safety data on antidepressants, especially SSRIs during pregnancy. And, we know, or, or, or the data really support that there is no increased risk of birth defects. There's no increased risk of cognitive or behavioral problems long-term in babies. There are some overlapping risks, maybe with antidepressants and depression and anxiety, like a smaller birth weight or earlier earlier labor, but. We have really reassuring safety data for these medications during pregnancy, where on the other hand, we also have a lot of data to suggest that untreated depression and anxiety can lead to poor pregnancy outcomes. A lot of women with depression and anxiety don't take as good care of themselves during pregnancy, so their prenatal care may not be as good. If their nutrition may not be as good, babies often are born smaller or they have preterm labor. And we also know that or, or I should say the data show that there's a higher risk for cognitive and behavioral problems in children who are exposed to untreated depression and anxiety during pregnancy. So depending on the severity of a woman's symptoms, it can often be much less risky to continue a medication during pregnancy. And then in the postpartum period, if often women will also worry about breastfeeding and exposing a baby to medication through breast milk. But if you were on a medication during pregnancy, the amount of medication that crosses the placenta. Is more than what crosses through breast milk. They're both very small, but, but the amount that crosses through through breast milk is so much smaller than what has crossed through the placenta. And now you have a fully developed baby. So the risk is really, really, really small of taking any medication. Most medications during breastfeeding.

Kerry 11:23

That's really reassuring because there's lots of medications that just aren't studied in pregnancy. 'cause you know, most people don't wanna do the test. So I think that's very, very reassuring. And I didn't really think about the, you know, impact on the fact that if someone isn't doing well with their anxiety and depression while they're pregnant, that it could really impact the, the fetus or child as well. Meaning that, like you said, they could be, you know, malnutrition and things like that. So that's a interesting definitely important part to make sure that they're being treated and, you know, getting effective care so that they can do their prenatal. Visits or, you know, keep themselves healthy as well. So it's really important. Yeah. Do what are some things to be looking out for in that period or maybe the postpartum period that maybe partners or family members should also, you know, look out for and help support that those patients.

Susan 12:15

This is such an important question too, because the family and the support are so important always, but really especially in that, in that postpartum period. So almost all women postpartum will go through something called the baby blues, which is considered to be normal. It's like at least 80% of women will have this period of baby blues, which is the first couple of weeks after delivery where you might feel kind of weepy or moody for no really apparent

Baby blues vs. postpartum depression and intrusive thoughts to watch for

Susan 12:43

reason, but that, that resolves after two weeks. If it's just the baby blues, it's, it resolves and that is considered to be normal, probably related to just this huge plummet in, in all those reproductive hormones after delivery. But I would say that after two weeks, if, if those symptoms persist for much longer, if, if you're feeling very sad or you don't feel like doing anything or you're not really enjoying anything anymore, having difficulty bonding with the baby or responding to its needs having difficulty sleeping even when the baby is sleeping. So if you feel like you have to stay up all night to make sure the baby is breathing or the baby's doing okay, that can be a sign. Also, we see a lot of irritability as a, as a symptom of postpartum depression and anxiety. So sometimes women don't feel sad, but they're excessively irritable more so than than ever, or it's really out of character for them. And then interestingly, there's also a phenomenon of intrusive thoughts. So having an intrusive thought every now and then can be normal. for both parents, really, for the mom and the dad. I'll explain what I mean by intrusive thoughts in a minute. So sometimes they'll have this brief, intrusive thought and they can dismiss it and kind of move on. But when the intrusive thoughts are repetitive or you're changing your behavior or not functioning as well because of the thoughts, this is a really sort of nuanced symptom of postpartum depression and anxiety. And what, what that can look like is, for example a new mom might have the thought that if I walk down the stairs carrying my baby, I'm gonna drop the baby. Or if I pick up this knife to cook dinner, I might harm the baby. And they're very unwanted thoughts. They don't want any harm to come to the baby. They're very bothersome. These are thoughts that when they cross that line into a disorder, they happen a lot. They're repeatedly happening. They can't be dismissed, and they're affecting the way that you take care of the baby. So if you, if you're worried you're gonna drop the baby down the stairs, and maybe you're not carrying the baby down the stairs, you have to do everything on the ground floor, or you have someone else do it, or you don't go upstairs with the baby or you stop cooking or you stop leaving the house because you're just so worried. that something bad might happen. And these are often thoughts that women will not disclose on their own because they feel like, what I often hear them say is, I feel like I'm going crazy. Because they know that they don't want to hurt the baby. Why are these thoughts keep, why do these thoughts keep coming into my head? That's probably not gonna happen. But they're so powerful and so bothersome that they feel ashamed or they feel like there's something wrong with them. Or if they disclose the thoughts that someone will tell them that they're not fit to take care of the baby or try to even call CPS or something terrible like that. So these are, these are things that we actually have to really ask about, but if someone, tells a family member or a support person about the thoughts, that's definitely a time where, where you should seek treatment and, and get help. And, and ideally from someone who's familiar with that phenomenon so they can really be supportive and helpful.

Kerry 15:50

Yeah, those are definitely very important warning signs to be, you know, referring and getting help Absolutely. We scoot on over to perimenopause. Is there anything else you wanna say about the postpartum period

Susan 16:03

I think the, one of the most important things to recognize in the postpartum period is that annoying cliche, it takes a village. It really does take a village there. It's not meant to be a one person job or even a two person job. It really takes a lot of support to take care of a baby, especially a newborn. So, I think we really need to normalize asking for help accepting help. Whatever help you can get in that postpartum period can really be helpful. You can't pour from an empty cup. There's only so much you can do as one person. So definitely get help in that postpartum period.

Kerry 16:38

Yeah, definitely good advice. I mean, I feel like that could be any walk of life, but definitely

Susan 16:43

Absolutely

Kerry 16:44

yeah. So um, many women experience new anxiety, irritability, or sleep issues in midlife, but don't realize it's hormonally related. Why do you think that is?

Susan 16:56

Yeah, I think I, I guess we can talk about why in midlife women experience these, these hormonal or these mood and anxiety and sleep problems sometimes for the first time in midlife. And then we can also talk about why they don't realize that it may be hormonally related. So of course as we age, our reproductive hormones go from that nice, predictable usually cycle where they kind of fluctuate up and down in a predictable pattern monthly.

Perimenopause 101: hormone fluctuations, mood, anxiety, and sleep changes

Susan 17:24

But then as we age and head into the transition toward menopause, there's really, it's kind of like the wild west of reproductive hormones and, and mostly I'm referring to estrogen, progesterone, testosterone. So they, they really wildly fluctuate and it's really unpredictable in that perimenopause period. And all of these hormones are involved in the production and metabolism of neurotransmitters that we typically associate with maintaining mood and regulating mood and anxiety and sleep. And so when the, when the levels are fluctuating, that can affect the levels of neurotransmitters that are typically regulating our mood systems. Estrogen and progesterone are really protective of mood and of sleep. And so when their levels drop, sometimes you can see problems with sleep, problems with mood, problems with irritability, and increased anxiety. Sleep apnea increases a, a ton during perimenopause and that can really affect mood and sleep and anxiety and just functioning in general. And I think a lot of women probably don't recognize that it could be hormones contributing to the symptoms because I, I think there's still a lot of just under recognition, under education about what perimenopause even is and when it can even start. 'cause it can start in your mid thirties. And. Maybe you just had your last baby in your mid thirties and now you're headed into perimenopause already. And I think that can be kind of a shock for people. And it can kind of come out of nowhere. So you may not notice in other ways that your hormones are fluctuating other than in your sleep quality or your mood, or suddenly you're having trouble concentrating or you're more irritable than usual. So I think educating people more about, about what perimenopause is and when it can start can help them recognize that their symptoms might be related to those hormone fluctuations.

Kerry 19:24

So is there any way to know the difference between like a mood disorder and a hormone related mood fluctuations?

Susan 19:31

Right. It's such a good question. I think it can be, it can be one, it can be the other and it can be both, right? So they overlap. The symptoms really can overlap. A mood disorder has certain symptoms, so feeling sad or, or feeling like you're not as interested in things or not sleeping well or feeling more fatigued or not enjoying things as much, and you can have more anxiety or sleep problems as well, I think when we may have clues that the hormones are related is when you also have other more physical symptoms. So hot flashes, night sweats genital urinary symptoms. A lot of muscle achiness can happen during perimenopause too. Hair loss. So if you're noticing physical symptoms in addition to the mood and the anxiety symptoms, then that's probably a clue that the hormones may be contributing to whatever mood or anxiety or sleep problems you may be having. But I'll also say that during this period in life. Is often a kind of high stress period too. I don't know if there's ever a low stress period in life, but, but typically in perimenopause, it can be kind of a high stress period where maybe you have children that you're taking care of or they're doing college visits or a lot of sports. Also, a lot of women are taking care of elderly parents during that time, and they're also kind of in the thick of their careers. So there are a lot of other psychosocial stressors that can contribute to the mood and the anxiety symptoms too. So I think that's something also important to consider. You really have to look at the, kind of the big picture and, and what's going on in the mind and the body.

Kerry 21:07

How do you kind of take an approach to like tra helping your patients, you know through this time of perimenopause. And then I also wanted to ask like, do you often. Get the patient first before they're being worked off by their primary or like for, for like perimenopause versus like anxiety or, you know mental health mood condition.

Susan 21:30

Yeah, that, that's a good question too. So, i'll answer that one first because I can't remember your first question, but the I would say it's kind of a mixed bag. I think there are, I think there are times where I see the patient first. But I think there, there, I can think of also some other patients where they've tried some hormone replacement therapy already and then they're coming to see me. Or you know, I have a patient who isn't a good candidate for hormone replacement therapy because of a history a medical history of breast cancer. So, i, I think it really, it, it just, it depends. It, it really depends on who their doctors are and, and their own kind of education about, about what's going on. And then, what was your other question?

Kerry 22:12

It was just kind of like your approach to helping women navigate through the Yeah.

Susan 22:17

Right. So my approach generally is that I first take a really careful history. So I really listen carefully to what their symptoms are, kind of from head to toe, what, what is going on, what is their history of any mental health treatment? What has changed? What is going on in their life right now that could also be affecting mood or anxiety or sleep problems. Of course any other medical conditions that might be

Dr. Zink’s integrative psychiatry approach: history, labs, lifestyle, and supplements

Susan 22:45

contributing because I think it's really important to do the best that you can with coming up with a clear diagnosis because when you have a a, a pretty clear diagnosis, as clear as we can get in psychiatry then. Then you can really tailor your treatment to treating that diagnosis. And then I like to be really systematic about it. So, so in an integrative approach, I am considering really deeply that mind body connection. So we're, we're considering traditional psychiatric treatment, but also thinking about other things in the body that could be contributing to what their mood symptoms are. And so I'll often do blood work lab work. Sometimes I recommend a sleep study. So that we can really get a comprehensive view of what could be going on so we can kind of tackle everything. But also not doing too much at once. 'cause sometimes if you do too much at once, you don't know what's helping or what's causing side effects. So doing things, kind of prioritizing what's most important and maybe addressing the most important things first. And then sort of moving down the list. And really being systematic about how we address each, each symptom and each issue.

Kerry 23:58

So, yeah. You mentioned that you kind of operate as like integrative psychiatry, and I think I've had some integrative medicine doctors on here before, but maybe not in a while. Do you, can you kind of like briefly tell us exactly what that means?

Susan 24:12

Yeah, absolutely. Integrative psychiatry essentially blends traditional psychiatric treatment, so medication and therapy with alternative holistic options. And those can be things like research backed, natural supplements that have evidenced to help with mood or anxiety or sleep. Nutrition optimization, exercise, lifestyle changes, sleep optimization, even things like yoga, acupuncture. The blood work is typically involved because there are a lot of nutrients and minerals that if they're deficient, can, can make it hard to treat depression or anxiety or, or that can really help with any lingering symptoms too.

Kerry 24:53

Can you give us some examples of like the supplements that you think are useful?

Susan 24:58

Yeah, absolutely. There, there are a lot. So the list won't be exhaustive. I think the best. The, the most evidence that we have are probably for fish oil and, and more recently probably magnesium. So fish oil has been studied for probably decades at this point, and it really repeatedly has shown benefit for a lot of things, but it can really be helpful to support treatment for mood disorders especially when. There's kind of like an inflammatory component. So fish oil has anti-inflammatory properties and there's a theory that depression is an inflammatory illness. So especially when people have kind of inflammatory symptoms, like a lot of joint pain or hair loss or generalized pain, fish oil can be really helpful especially when you get the right ratio of the EPA to the DHA. And then also magnesium has been studied lately. More lately, but, but for, for a while now. And. Has been shown to help with sleep and anxiety. And, and it's interesting 'cause we use magnesium to treat things like preeclampsia. So we have a lot of data for its safety in, in pregnancy. And so magnesium can be really helpful in pregnancy for, for sleep issues, anxiety, restless leg syndrome, but, but also for non-pregnant people and especially in that menopause transition. It has kind of a nice calming effect for a lot of people and can help with sleep quality, anxiety, and mood too,

Kerry 26:28

Yeah, but I think those are probably one of my two favorite ones as well. Yeah. So are, can you share like an a success story or an example of how like your integrative approach has transformed someone's wellbeing?

Susan 26:41

Absolutely. I hear, I would probably say like the most common thing I hear from, from people is exercise. How important exercise is to kind of maintain their mood. I've had, I've had a lot of patients who say once they're kind of feeling a little bit better, they get back to the gym or they like to go on walks and they say how, how much that helps to maintain a good mood. Conversely when maybe they are not prioritizing exercise as much, they notice that their mood dips a little bit more. So I think exercise can be really, really important to maintain mood. I don't necessarily think that exercise alone is all that you need. If you have really a mood disorder or an anxiety disorder, often, often you need more than just exercise. But I think it's absolutely a helpful. Piece of the treatment for, for depression and anxiety. And then more in the, in the sort of natural supplement side. I have seen, I've seen the magnesium help a lot of people personally magnesium helps me sleep. Especially if you have other things like migraine, which it can be helpful too for a lot of conditions. And then, you know, I had an example of a young woman who was on medication for depression and anxiety and, and pretty much all of her symptoms were controlled except she just had this sort of lingering fatigue. She was really still tired. So we did some blood work. And it was her vitamin B12 and vitamin D levels were low and she started supplementing with B12 and vitamin D and after a couple of months she came back and said, oh my gosh, I feel so much better. I can't believe this is all it was. So there are kind of some simple things that, that we can do that sometimes aren't done routinely or they're not standard, but that can really have a big impact in really helping people thrive and really not just feel okay.

Kerry 28:28

I think one of your favorite health tips that I, you filled out on the form was the importance of sleep. So why is that so important for mental health?

Susan 28:38

Sleep is important really for everything. So that's when our bodies and our brains heal and rejuvenate and. Encode all of all of our experiences. And so I think just from personal experience, we all know that if we don't get it one good night's sleep, we're kind of grumpy and irritable

Sleep, daily habits (like getting outside), and final message: don’t suffer in silence

Susan 28:56

and sluggish and maybe not concentrating as well or don't feel like doing as much the next day. So when you add up chronic sleep problems over many weeks or months or years, you can see how it would have kind of an additive effect. Sleep is just really protective for, for mood and anxiety and concentration, and so that's something that I really try to optimize in treatment as well.

Kerry 29:20

Mm-hmm. Yeah. So what I guess what is one small powerful daily habit that can support emotional balance for these patients in perimenopause or postpartum.

Susan 29:32

It is really hard to pick just one, but I would say something small and that's pretty accessible to most people is to get outside a little bit every day. So. Getting outside, especially I think in that postpartum period when I think you can feel kind of confined a lot of the time. Like you have a baby attached to you all the time, or you're sleeping a lot during the day. I think it can be very important to get outside, walk a little bit, get some bright light. And that's true also, I think for everybody, just in general, but also in that perimenopause period can be very helpful, especially to set the circadian rhythm. There are a lot of studies also about how being outside and being in nature can really do a lot to boost your mood. So I think that that's something pretty accessible to most people to do every day.

Kerry 30:20

Mm-hmm. I like that. So I was gonna ask you about your practice and where patients can find you. Is there well, let me tell, ask, answer that first and then we'll ask.

Susan 30:30

Yes, thank you. So my practice is called Elemental Integrative Psychiatry. I have an in-person office in Linwood, New Jersey, so I can see people in, in-person here, and also via telehealth through New Jersey and, and very soon telehealth to Florida as well.

Kerry 30:49

Awesome. And you have, well, we'll list all your social things on the show notes and things like that, but is there any final message for women who may be struggling silently with mood, anxiety, or sleep changes?

Susan 31:01

Yes. I think the, the final and most important message is don't wait. Don't suffer, get help. There's no prize for suffering and you can't pour from an empty cup. In a lot of times, women will prioritize other people's. Health and wellbeing over their own. But if you are not doing well, you can't take care of anyone else. So take care of yourself and make sure that you're doing well. Lots of people go through this. You're not alone. There is help available. So absolutely get help if you think you need it.

Kerry 31:36

I think that's a perfect message to end with for sure. Well, thank you Dr. Zink for coming on the PO podcast today. I think this was a great. Great discussion and hopefully everybody will get very much out of it as much as I did but thank you so much and everybody tune in next week and get healthy Tampa Bay.

Susan 31:54

Thank you so much for having me.