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Alecia Greenlee, MD, MPH - Guest
Alecia Greenlee, MD, MPH is a board-certified psychiatrist who brings both rigorous training and deep humanity to her work with women navigating ADHD and co-occurring mental health conditions. After earning her medical degree from UC San Francisco, she completed her psychiatric residency at Harvard Medical School/Cambridge Health Alliance, where she served as chief resident in consultation-liaison psychiatry and developed expertise in collaborative care and mental health services for vulnerable populations. She went on to fellowship training at the University of Chicago, first in consultation-liaison psychiatry and then in reproductive psychiatry, gaining specialized knowledge in how the body and mind interact throughout women's lives. Alecia specializes in comprehensive psychiatric evaluation and evidence-based treatment for adults, with particular expertise in how hormonal changes throughout the female lifespan—from menstrual cycles to pregnancy to perimenopause—influence ADHD symptoms and overall mental health. Her commitment to health equity drew her to focus on women's and minority mental health, populations often underserved by research and clinical resources. She approaches each patient with cultural attunement and warmth, creating collaborative, safe spaces where people from all backgrounds feel genuinely heard. Her practice reflects a commitment to whole-person care that considers not just psychiatric symptoms, but the complex interplay of biology, identity, life circumstances, and medical conditions that shape each individual's treatment needs. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those. four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c):(3): nonprofit, so all donations are tax deductible. Today we'll be speaking with Dr. Alecia Greenlee, who is a board certified psychiatrist, who brings both rigorous training and deep humanity to our work with women navigating ADHD and co-occurring mental health conditions.
Keith Sutton, Psy.D. (02:19):
Today we'll be speaking with Dr. Alecia Greenlee, who is a board certified psychiatrist, who brings both rigorous training and deep humanity to our work with women navigating ADHD and co-occurring mental health conditions. After earning her medical degree from UC San Francisco, she completed her psychiatric residency at Harvard Medical School, Cambridge Health Alliance, where she served as chief resident in consultation, liaison, psychiatry, and developed expertise in collaborative care and mental health services for vulnerable populations. She went on to fellowship training at the University of Chicago, first in consultation, liaison, psychiatry, and then in reproductive psychiatry, gaining specialized knowledge in how the body and mind interact throughout women's lives. Alecia specializes in comprehensive psychiatric evaluation and evidence-based treatment for adults with particular expertise in how hormonal changes throughout the female lifespan from menstrual cycles to pregnancy to perimenopause influence ADHD symptoms and overall mental health. Her commitment to health equity drew her to focus on women's and minorities mental health populations, often underserved by research and clinical resources. She approaches each patient with cultural attunement and warmth, creating collaborative safe spaces where people from all backgrounds feel genuinely heard. Her practice reflects a commitment to whole person care that considers not just psychiatric symptoms, but the complex interplay of biology, identity, life circumstances, and medical conditions that shape each individual's treatment needs. Let's listen to the interview.
Keith Sutton, Psy.D. (03:50):
Well, hi, Alecia. Welcome.
Alecia Greenlee, MD, MPH: (03:52):
Thank you. Thank you for having me, Keith. Appreciate it.
Keith Sutton, Psy.D. (03:54):
Yeah, thanks for joining me today. So I know of your work because you're part of our Bay Area center for ADHD, and I was really interested in interviewing you because of the work you do in psychiatry with the clients with ADHD that we work with, but one of your specialties is also with women and women's hormonal issues. And so I think that's really interesting piece that I think maybe a number of psychiatrists or even therapists are missing at times, or even not seeing kind of that connection between the two. I know that I've had a couple clients recently where, as I was doing couples therapy or whatever it might be, they were struggling with depression, and then actually the hormones got addressed and that really shifted a lot. So I've got a lot of interest in this area. But first, before we even jump into that, , I'd love to hear about how you got to doing what you're doing and your kind of evolution of your thinking.
Alecia Greenlee, MD, MPH: (04:49):
Yeah, sure. So, for me, whenI look back over my life, one of the things I think had a huge impact on me was just the community I grew up in. And it was a very ethically, racially diverse community in Sacramento, California. And I didn't even know it was, you know, underserved, all these type of, you know, housing and instability, you know, different things. But as I got older, I realized a lot of the people that I was close to were struggling with physical illness, but then also underneath that there was mental illness. And so, once I got to medical school, I continued my interest in health disparities work and really grew an interest in kind of health policy and how do we structure access to mental health services. Because I just found, like with doing my rotations that, you know, when people were physically well, that's one thing, but you know, if they still struggle with their mental health, it is hard to really live a full life, you know?
Alecia Greenlee, MD, MPH: (05:48):
And so this would impact their housing, their ability to be employed, relationships, so on and so forth. And so when I think about the trajectory of where I am today, where I am doing a lot of work with people who have like ADHD as you said, but also other comorbid diagnoses as well, to me it just really feels like a kind of public health calling. But being able to do that work on the individual level to make sure people can take care of themselves, can take care of them, their families, they can contribute to their community. So that's how I got into this work. So yeah, that's where I'm at.
Keith Sutton, Psy.D. (06:26):
And had you, was your direction going into medical school in psychiatry, or was it more in other health and then you switched, or did, were you going into psychiatry and then you brought in the women's mental health and hormonal work? Yeah, because I think you, you've got training in two different areas than most psychiatrists do.
Alecia Greenlee, MD, MPH: (06:45):
Yeah. Yeah. So my initial interest in medical school was actually in geriatric medicine. So I really loved going back to the Midwest and spending time with the elders in my family and hearing their stories and being there to help, like, take care of them. So I grew up again on the west coast. So I went into medical school thinking like, "Oh, I'll be a geriatrician who does a lot of work with making sure people take care of their physical health." But on that particular rotation, I did a geriatric, internal medicine rotation at the VA in Fresno, actually. I love talking to people and hearing their stories and doing really well with patients who were struggling with depression, anxiety, and just really enjoyed my psychiatry rotation. But I was one of those people that loved just about every clinical rotation, which makes sense later on in terms of my training.
Alecia Greenlee, MD, MPH: (07:42):
But that was the big kind of push towards mental health, which just seeing how many patients I had who had these physical ailments, and as I got to know them more, it was like, "Oh, actually there were other things going on that could not be seen." So there may have been a history of substance abuse, and prior to that they may have had kind of history of trauma and so on and so forth. So I just saw how much mental health impacted people's physical health and really learned about, oh, all of the ways and all the difficulties that come with being able to access care. And so I knew I wanted to do psychiatry after that third year of medical school. So then I decided to go to Cambridge Health Alliance, which is one of the Harvard training programs in Cambridge, Massachusetts, where they really spent a lot of time teaching us about not just medications, but therapy.
Alecia Greenlee, MD, MPH: (08:37):
It was like, therapy was a huge component of that particular program, which drew me there, but it was also the last public health hospital in the state of Massachusetts. So it was very diverse, in terms of ethnic background as well as social economic status because we're serving patients who were students at Harvard as well as people who were from the area and surrounding areas. and at that particular time, what was happening there was a large, you know, substance abuse crisis because this is during the opiate, ECA epidemic at its peak. And so when I went there, a lot of the focus was really on, you know, addressing issues of trauma, substance abuse, things of that nature. Whereas the issue around ADHD wasn't as clear for adults, in that particular training, which is kind of true throughout psychiatry.
Alecia Greenlee, MD, MPH: (09:32):
And then another area that also wasn't really well developed was women's psychiatry. And funny enough is that a lot of psychiatrists actually are not comfortable treating women during pregnancy or postpartum. And a lot of us haven't had additional training in the hormonal aspects of mental health. And to be honest, part of it is because the research is just not fair to support it fully. Right? And the funding for that research has been a huge issue. And I don't even know if you know this, but one thing to be aware of is that reproductive psychiatry, which is about a year long, fellowship at most places, is still not an accredited fellowship program through psychiatry. Yeah. And so despite, kind of this huge need, there still needs to really be funding for the training, funding for the research.
Alecia Greenlee, MD, MPH: (10:32):
And myself, I actually chose to do what's called consult liaison psychiatry, which is basically you're the psychiatrist working on the medical surgical floors of hospitals, outpatient. You see people who need a transplant. You see women who are pregnant or postpartum, a mix of medical needs as well as psychiatric needs, which for me, going back to the beginning makes perfectly good sense. But I then chose to go on and do some more training, after that fellowship in reproductive psychiatry to kind of just strengthen the knowledge that I already had, but also just to understand a little bit more of the nuances and what are the treatment options out there for those who are assigned female at birth in terms of, psychiatric needs.
Keith Sutton, Psy.D. (11:19):
Yeah. Well, that's great. So you kind of came full circle. You went in at the medical end, and then were really kind of interested in seeing a lot of the mental health piece and then went through the mental health, kind of, angle and then ended up with the mental health and its interplay with the medical. That's great. That's a lot of complexity. It's amazing training. And I think that that piece, especially for women and women that are dealing with hormonal issues or pregnancy, I mean, pregnancy is oftentimes an issue that comes up for so many. It's about whether to stay on their medication, whether to go off their medication, whether it's antidepressants or treatment for OCD or, you know, all these kind of things. Because oftentimes that's what's really helping. And-- but you also want to make sure that the baby is going to be as healthy as can be.
Keith Sutton, Psy.D. (12:08):
Yeah. So I wanted to maybe focus, there's so much that we could focus on, but let's focus on, , ADHD and through the lifespan, as well as the kind of integration with what that looks like hormonally. Although I know also depression anxiety is all mixed in there because particularly folks with ADHD also have a lot of comorbidities that are going on. So as a psychiatrist, sometimes it's very straightforward sometimes, right, there's, there's multiple things going on.
Alecia Greenlee, MD, MPH: (12:36):
Yeah. Yeah. There usually are multiple things going on for a lot of people. But I would say even before we see this hormonal influence in terms of people's mental health, specifically women in mental health, one issue with ADHD that we all are aware of is the misdiagnosis of young girls. And like, why is that happening? Like, why is it that the rate of boys to girls is three to one when that then eventually decreases, like over the lifespan? And I continue to think about this, you know, partially probably because I have my own kids. I'm always like, you know, “Is everyone going to be okay?” I have two little girls. But also it has huge implications for someone's overall wellbeing, right? Is that we know that when girls are missed in terms of a diagnosis of ADHD that increases their risk for early pregnancy or early motherhood. That increases their risk for sexual, risky behaviors. That increases their risk for lower self-esteem.
Alecia Greenlee, MD, MPH: (13:42):
All these things that really have a huge impact on your life long term. So, you know, I do think about that and one of the conversations I had with a colleague who is a child adolescent psychiatrist, she was talking about this in that, you know, a lot of girls may have more inattentive symptoms as opposed to boys where they have more hyperactive. And I mean, the reality is this: the inattentive symptoms, you know, you kind of struggle with, whereas the hyperactivity is usually disruptive to the rest of the environment, which then prompts teachers, parents, you know, folks to kind of say, "Hey, something is going on here." Where unfortunately with girls, what we're seeing happen is that they often get diagnosed with like, anxiety or depression as opposed to someone really considering ADHD. What I hear most of in the patient population I work with is a lot of women, they then get diagnosed and they're like, "Oh, shoot, I think that my daughter might have this. Like, let me, you know, kind of go and get her some support." So again, yeah, even before the hormonal kind of piece in puberty happens, we do see that there is this difference in the ratio.
Keith Sutton, Psy.D. (14:55):
Yeah, I did-- I was interviewed on the news about the increase in diagnosis in adult women, because it's doubled in the last few years, although it's still significantly less than what the-- if everybody that was actually diagnosed with diagnosed, I think it went from 2% to 4%. But really the prevalence is about 7%. And, yeah, I guess the male chromosome, the Y chromosome is a bit more fragile, and that's why I guess there's more hyperactivity, impulsivity, autism. So we'll just come straight out with the male fragility from the beginning. And then, I was also looking into some research and that, in giving teachers vignettes, when they changed the pronouns and they put 'she,' or when they put 'he,' they were oftentimes referred for ADHD, but if put, 'she' referred for anxiety diagnosis. So many young girls, women, those identified as a female at birth oftentimes go undiagnosed. And exactly like you're saying, because it's flying under the radar, it's not the kid that's bouncing outta the seat. And although women can also have ADHD, hyperactive, impulsive, but it's more tending to be the inattentive.
Alecia Greenlee, MD, MPH: (16:08):
That's dismissed. Yeah. Yeah. Yeah, definitely. I think those social cultural kind of norms or expectations definitely impacts the diagnosis or lack there of a diagnosis or the misdiagnosis, unfortunately. But I even was reading a study recently that was saying that girls who are diagnosed with ADHD, even during this time period right, are less likely to receive medications still despite having the diagnosis and are more likely to kind of be put into this category of doing behavioral therapies, which are really helpful and useful. And sometimes, you know, maybe there are concerns around kind of the side effects of the medication, but what I often think about is like, "Oh, well, what are the implications of putting this girl who's struggling so heavily into behavioral therapy where they're being asked to learn how to manage their time and do all these things effectively without this additional support?" And I'm not saying that they have to do medication, but just what is going on there that we kind of feel like "It's okay, like they don't really maybe need medication as much as some of the boys." So, yeah.
Keith Sutton, Psy.D. (17:17):
I imagine it goes back to that like not a behavioral problem or so on and in that aspect. And that I talk about with parents, our goal is to help the kids get through their childhood without a great deal of shame. And, you know, when the person knows, like, I should be able to do this, but they can't put it into action because the ADHD, oftentimes there's that effect on shame and self, self-worth and so on. So, which yeah, the therapy can help with, but still, if you're still stumbling and coaching could help the person actually get up to the, where other folks are.
Alecia Greenlee, MD, MPH: (17:51):
Yeah, it's tricky. Yeah. But yeah, but then we move into puberty. Okay. So now the brain is, you know, producing these, what we call gonadotropin hormones. Basically these are the hormones that will then act on, you know, the ovaries to produce estrogen, progesterone. And then in males it'll go on to act on the testes to produce testosterone, but focusing solely on girls, what's interesting is that this particular time in life, we also see an increase of ADHD diagnosis. The ratio then eventually goes from that 3:1 to 2:1. And we do think part of it is hormonal, part of it is probably psychosocial, right? Again, maybe finally those inattentive symptoms are kind of being, I guess, essentially taken more seriously. You know, it starts to affect their schoolwork and things like that as there's more demands.
Alecia Greenlee, MD, MPH: (18:46):
But in terms of the hormonal piece, what we think is happening is that, you know, every month -- well, we'll say for everyone who has a normal regular cycle -- there is a fluctuation in estrogen and progesterone. Okay. You know, why do we think that impacts our mental health? Well, estrogen is thought to be neuroprotective so good for the brain, essentially. And what happens in the menstrual cycle is early in the luteal phase, you know, or right after ovulation, the release of the egg is that you have an increase in progesterone, and at the same time you have a little dip in estrogen. And what we're seeing from the recent research is that girls who have ADHD at this particular time of the month might notice they have more hyperactivity and impulsivity. And then later on in this phase of the cycle, right before their period start, like about a week or two before it starts, we also have another dip in estrogen.
Alecia Greenlee, MD, MPH: (19:50):
This time the progesterone is coming down also. And at that particular phase, what we're seeing is people have more inattentive symptoms as well as like, things like depression or anxiety. Because even for women who don't have ADHD, a lot of women can have what we call premenstrual dysphoric disorder. So have sadness, anxiety, you know, it can be so severe that they have even suicidal ideation, that one to two weeks before their period starts. And what we find is that women who have ADHD, they are-- have a rate of about 60% of them having PMDD or this premenstrual dysphoric disorder compared to the general population where it's around 20% or so. So again, there clearly is some type of hormonal impact that is starting to happen during puberty. And we see similar kind of patterns in pregnancy and the postpartum period as well as perimenopause.
Alecia Greenlee, MD, MPH: (20:55):
I'll take a step back though and say with pregnancy, what tends to happen is, well, a number of things. One, about 98% of women who say they have a diagnosis of ADHD already often don't continue taking medications. It's not clear if it's the women making that choice, or is it their provider who's concerned about medications during that particular time. But then right after pregnancy, you have this huge drop off in estrogen. Okay. And this is another time where we see an increased number of diagnoses of ADHD. One probably because you now have this little human who requires a significant portion of your time, as well as the change in hormones that are happening. And then similar, again, same thing during perimenopause. Estrogen starts to kind of eventually taper down, but it's a little bit more erratic during that time. And that's actually a lot of the population that I'm seeing now because their symptoms get so severe during that time that they are, like, at their wits end, where maybe years past, they were able to kind of manage the best they could. So it's really interesting.
Keith Sutton, Psy.D. (22:11):
Well, and I know that one of the biggest differentials for ADHD is whether or not the symptoms were they're in childhood and particularly prior to age 12. And I usually, when I'm doing an evaluation, I'm looking for those elementary school years, essentially pubescent years because once puberty hits, oftentimes there's a lot of, a lot of different things that are going on for the person. Is that something that, or-- I'm just curious about how you think about it. But maybe, you know, I'm relying too heavily on the pre-puberty time and that there's more onset, but typically the symptoms in the original diagnosis was seven years old or younger. But typically we're going to see, even if they're maybe not causing a problem, those--
Alecia Greenlee, MD, MPH: (22:54):
Are they present
Keith Sutton, Psy.D. (22:55):
--Inattentive or the hyperactive, impulsive, of course is more obvious. But, yeah. I was curious about your thinking about that.
Alecia Greenlee, MD, MPH: (23:03):
Yeah, yeah. Yeah. No, very much similar to you. I think about what was their life like prior to puberty. I definitely ask about that. And so for me, you know, one of the things that I make sure I spend a lot of time doing is really getting that narrative history from someone, is really understanding "Okay, school was okay, you know." And it's, "A lot of the people I see, you know, they've made it to graduate school in their life and they have pretty, you know, I mean, what some people might say high functioning kind of roles and, and things of that nature now." But when we take a look back early on, we see all these ways there were all these inefficiencies of doing things or making shortcuts to complete their homework in time and kind of masking behaviors and things of that nature.
Alecia Greenlee, MD, MPH: (23:50):
And I'd similar probably to you, is I still do a lot of collateral history gathering. So, you know, access to their parent or someone who knew them at that particular time can often comment on things, as well. And then similarly marching through middle school into high school, you know, and if they go to college and so on, it's very sim-- But yes, you'd still, I still expect that you would have symptoms prior to the age of 12 in order to have a diagnosis of ADHD in adulthood. And so that's a key differentiator. So I do see a lot of women who do have mood changes or cognitive changes during perimenopause, and we do have to spend some time kind of distinguishing, "Okay, this is ADHD, and then this could just be related to the hormonal changes." And so what I usually recommend actually in both camps is like, Hey, have you talked with your OBGYN or your primary care doctor about getting on hormone replacement therapy, making sure it's appropriate for you, you know.
Alecia Greenlee, MD, MPH: (24:50):
You know, in terms of risk factors and things of that nature. And then oftentimes we'll work together to figure out, "Okay, now does it make sense to make adjustments in terms of psychiatric medications?" And I find that to be like, pretty helpful. So I would say there's a percentage of folks that go on and get that hormone replacement therapy, and they're fine. They don't really, you know, need any, you know, psychiatric medication, the anxiety or depression improves. Or if they have ADHD already and they go and, and get that treatment and their symptoms have worsened, sometimes it does get better. But I would say there is still a good percentage of folks who I do see who are on hormone replacement therapy and have been say, three, four months or so before I see them. And they are really struggling.
Alecia Greenlee, MD, MPH: (25:38):
And for a lot of these women, what we often gather in their history is say, "Oh yeah, I have a, I have a kid with ADHD. But like, I thought maybe they got it from my spouse." You know, that type of thing. And then we talk about it and we really take a look. They're like, "Oh yeah. Been dealing with for a while." And what's the most kind of prevalent symptom that I see is that people actually are more coming in because they feel kind of depressed or demoralized because they haven't been able to kind of achieve the things that they feel is just like within their grasp. And so that for them is often what leads to them getting additional support from me.
Keith Sutton, Psy.D. (26:16):
Yeah. And as you were saying about the, doing the, you know, talking to the parent of a-- adult I think is so significant to really get that, you know, childhood symptomatology, you know, to kind of differentiate. And the piece that I'm curious about with the pregnancy as you're mentioning, I realize I haven't even quite dug into it, but the safety around being on a stimulant medication while pregnant if you have ADHD.
Alecia Greenlee, MD, MPH: (26:48):
Yeah. So, what we have kind of so far is that it's pretty safe, but I would say this, and most reproductive psychiatrists will tell you the same thing. It really depends on the individual, in terms of their severity of symptoms, in terms of the ADHD symptoms. Like, is the severity so bad that like you are someone who might more likely be to get into a car accident, you know, if you're off your medication or you keep forgetting your other child in the car. You know, all these like kinda little things that, yeah, it's a big deal, right, on the day to day, or you might lose your job without it. So we end up having a really like, robust conversation around kind of, the risk and benefits of treatment as well as not treatment. And for those who elect to go forward with treatment, we're often monitoring for kind of their blood pressure during the pregnancy, making sure, you know, they don't develop preeclampsia and things of that nature.
Alecia Greenlee, MD, MPH: (27:47):
And then also the growth of the fetus is what the OBGYN is monitoring. because one thing you have to kind of watch out for someone who is on stimulants is if they have signs of an intrauterine growth restriction, so the baby appears to be too small. But yeah, that's kind of the information that we have. And so some, what some women elect to do is they might be on, continue on a stimulant, but they may take it kind of more on an as-needed basis. They might lower the dose. And unfortunately a lot of the non-stimulants haven't really been studied in women during pregnancy for ADHD. But like I said, yeah, about 90%, 98% of women end up not taking a medication. But I will say this, I have heard stories from patients who have said, "Oh, I was told I needed to stop this medication during pregnancy. Like, I can't safely take it." And so then there's this huge fear that like, "Oh, if I do this, I'm going to do something to hurt my baby or hurt myself." But what we find, oh, go ahead.
Keith Sutton, Psy.D. (28:47):
I was going to say too, I know a lot of the research is kind of confounded because, you know, oftentimes they don't control for whether the parent had ADHD, so you know, when they're kind of looking at effects of different things on, you know, related to ADHD and, because the high edibility sometimes, you know, there's a correlation between something else and, and in utero and ADHD. But a lot of that is oftentimes accounted for by the parents' genetics of the ADHD. But I don't know how much the research has been done on the stimulant medication during that time. Yeah, yeah. Definitely.
Alecia Greenlee, MD, MPH: (29:23):
Yeah. I think there was a study that came out Sweden recently. Yeah, there was a Swedish study that came out that shows that they're likely safe. But again, there's just not a lot of additional supporting data to just say, "Yes, definitely continue." But I will say this, what we know for sure is that if you have a mental health disorder and you are pregnant, what the goal should often be is to, for it to be stable. Because what we know is when it's not, people don't do well no matter what the diagnosis is. And so we are often weighing, just like with every other psychiatric diagnosis, do you continue medication during pregnancy or not? And oftentimes for most of the other diagnoses, with the exception of ADHD, I would say most of the time we're recommending, like, you probably should continue treatment during this particular vulnerable period because the negative outcomes associated with poor mental health are so grand that we really do recommend it.
Alecia Greenlee, MD, MPH: (30:20):
And that can be just as simple as like, the mother's own physical wellbeing. Right? Like preeclampsia, again, is associated with mental health disorders that are not well treated during that time. You're at higher risk for developing that. And I've unfortunately seen pretty negative outcomes for women and their children when they haven't had their psychiatric diagnosis addressed during that time period. And so what we often are trying to do, is making sure, you know, if you're not going to continue medication, do you have other forms of mental health support? Like, are you able to see a therapist during that particular time? And is someone checking in with you regularly to make sure, like, "Hey, this may be a time where we might need to reintroduce the idea of talking-- of trying a medication." So there are times where I will have some female patients who will decide that they don't want to continue medications during that time, but we'll still check in to see, "Hey, how are your symptoms doing this particular month?" And kind of, and continue to do that during their pregnancy. And then we also come up with a plan kind of in this postpartum period of what they want that to look like. Because that can be driven by, you know, does she want to breastfeed? Does she not want to breastfeed? And what are the risks in terms of the medication into the breast milk as well into the baby?
Keith Sutton, Psy.D. (31:43):
Yeah, definitely. Well, and I'd be curious on your thoughts on, you know, and I know for a lot of moms, they experience mommy-brain after when their first children. And of course, you know, if they're breastfeeding and just in general right? Everybody's exhausted. In the more heterosexual gender normative families, the mom is staying home the father maybe has some time off, but is then oftentimes back to work. And so that can be a really difficult period of time. I was wondering if you can, I don't know if you have, can speak to any of that. It seems like it's almost a period where many people have the symptoms of ADHD. Short period of time, given the circumstances of the lack of sleep. And, and you know, of course our frontal lobe is the first thing to go when we're tired or sick or, you know, stressed or, or so on. Yeah.
Alecia Greenlee, MD, MPH: (32:39):
Yeah. So that first kind of couple of weeks after giving birth, we think of that time period, right, again, as that postpartum blues. So by definition not depression. And in that context, you might have low mood, low energy, you know, like you said, poor sleep concentrationdifficulties, you name it with the exception of, we always say if you have any suicidal ideation that is not postpartum blues, that is usually depression and you need additional support. And then after that time period, we then continue to monitor for things like postpartum depression or anxiety. But one of the things that I try to make sure I do when I'm working with patients is like, well, what does the social support look like for you? Because some, unfortunately, there's some of the expectations out there of like how motherhood or parenthood should look is just not reasonable for a lot of people.
Alecia Greenlee, MD, MPH: (33:32):
And then sometimes I see when people are trying to live towards that expectation, I'm like, "Wait, let's take a break." And so there are some little signs that I do use to help me even worry or gives me signs that I should be concerned that the person might be dealing with depression or anxiety that warrants treatment that sometimes appears to be normal to most people. And one of those is that you for say the woman who's breastfeeding is that she's stockpiling breast milk. So that can sometimes actually be a sign, that like the person is really anxious, they're really worried about feeding the baby and things of that nature. So I would say like, if you feel like you're in a space where you're not quite sure, I think it is reasonable to ask for help or support, at the very least, during those OBGYN follow-up appointments.
Alecia Greenlee, MD, MPH: (34:21):
They usually are screening for postpartum depression and anxiety. But then in terms of ADHD, I would say, again, it needs to be that you've had some symptoms like this even earlier on. So again, back before, you know, the age of 12, you should have had some symptoms. Yeah, of course, what they say, I think it's like about 60% of adults have like three to four symptoms of ADHD. When in reality, you know, to be considered to have ADHD, you have to have at least five symptoms plus having the symptoms prior to age of 12. So that's the conversation I will have with some of the people that come in and meet with me is that like, "I know it feels like you might have ADHD, but we really gotta teases the part and really put it together." Because, you know, not having the correct diagnosis can really result in, you know, not great outcomes.
Alecia Greenlee, MD, MPH: (35:12):
And I usually have to have a conversation with folks who come in and they have symptoms, say for anxiety or depression, but they thought they had ADHD. And sometimes they're disappointed that that is actually not the case. And I have to remind them like, you know, these other diagnoses are pretty serious too. Like, it's not as though like, "Oh, well, it's just depression or anxiety." It's like, no, no, this is something we need to do to support you with and something that you don't want to spend the rest of your life just suffering either.
Keith Sutton, Psy.D. (35:46):
Yeah. Well, and I think too that yeah, that's, I think that's a common thing because somebody will be high on ADHD scale. You know, when sometimes they're struggling with depression or anxiety, but yeah, if they don't have those childhood symptoms, then it's more depression or anxiety, which some people are, are oftentimes disappointed in. So we look at the meaning of it, but also, depression or anxiety is curable where ADHD is something that's, it's manageable and so, you know, we wouldn't want the person to be on medication lifelong if they had some--
Alecia Greenlee, MD, MPH: (36:20):
They don't need to be--
Keith Sutton, Psy.D. (36:21):
It could be addressed with medication and therapy and completely resolved. So I think that's, yeah, that's definitely an important part. And I've got a, I mean, this is just something I've thought about in thinking about women with ADHD, is that oftentimes I think for many women with ADHD, they were able to mask and get along well, especially with the inattentive, but sometimes when becoming a parent in that transition, or the gender-normative kind of heterosexual, cisgender couples where the woman is holding all of the mental load when they do have ADHD, it's like the cup runneth over. Not only are they doing all the things they were doing before, but now they're trying to juggle all the balls of all the, the whole family and the kids and so on. And so I've seen that a lot where people will come in at that point, and then we actually look in the history they did have ADHD, but it was not until they became a parent that it kind of pushed them over the edge in their functioning.
Alecia Greenlee, MD, MPH: (37:21):
Oh, yes. Substantially. And there was some article I was reading recently too, and looking at executive function differences between, you know, boys and girls, men and women. And it was saying that for women, executive function for women with ADHD specifically, that a lot of them are able to maintain their cognitive flexibility, where some of the males kind of struggle a bit more. And so sometimes that translates to that task switching that moms are doing a lot of, like, they can do that, but where there was similarities between men and women was that, the planning difficulties are still there. The inattention is still there. And so yeah, you may be able to go to the soccer game and then go pick up this kid from school and make the dinner, but they feel so overwhelmed by like the planning and the execution of all these different tasks that comes with parenthood.
Alecia Greenlee, MD, MPH: (38:17):
And then you add in, you know, disrupted sleep to the mix, and it feels just too, to be too much. And so then, yeah, again, you go back and look at that history and we see, "Oh, this was always something difficult for you." So I remember even recently, there was someone I was talking with, who was very bright, you know, and, and we were talking about their childhood, and I was asking like, different subjects that they liked in school, "Well, how'd you do in this, this one and this one?" And when we got to math, they, you know, they were like, “Oh, I did okay. You know, I, you know, I did pretty well on tests and things like that." And I'm was like, "Hmm, okay, well how did you do with showing your work on math?" They just, you know, started laughing.
Alecia Greenlee, MD, MPH: (39:00):
They were like, "Oh, no, I never showed my work. I just would put the answer down and, you know, my mom would talk to the teacher about like, well, does she got the answer right? So I don't know what the, you know, what's the problem? That kind of thing." And they were like, "I just didn't have the patience to kind of sit through this past of showing this person how I did specific things." And, and it kind of like highlighted to them, they're like, "Oh, wow, this is something that really has been here for most of my life. And it wasn't just that particular subject." They had that challenge. It was kind of happening throughout their lives, as well. And so a lot of times I'll hear or hear these stories of people jumping to different careers and things like that nature, which for some people that works out fine.
Alecia Greenlee, MD, MPH: (39:41):
You know, you're able to maintain a certain level of income, but for some folks that means they don't ever really get a promotion at work, or they don't have enough money for retirement and they're really struggling financially. So for me, I think that's why I care so much about like, kind of addressing this, especially in women who, you know, don't get paid as much as men, that's a whole other conversation. But, the implications of an untreated ADHD are huge. And I didn't really, you know, recognize that until after psychiatry residency, to be honest with you.
Keith Sutton, Psy.D. (40:17):
Well, and I think you're right, right? The deck stacked against women from the start, and also if the person becomes a mother, right, and progressing in the career, and then if you add on the ADHD too, that ends up really making things hard to move forward in the career, move up in the career. Now, yeah, can you talk about perimenopause and menopause and what that kind of is looking like for folks and women with ADHD?
Alecia Greenlee, MD, MPH: (40:49):
Yeah. I can talk about it too, like even in a broader context first. So what we see happen during this time period is, again, is that the ovaries begin to decrease in the amount of estrogen that is produced. But what also changes is the pattern of the production of estrogen during that timeframe. So going back to, you know, puberty and before perimenopause, regular cycle, you know, you kind of have a consistent kind of dip in estrogen, you know, that is predictable. But what happens during perimenopause is that you have more of this kind of unpredictable sawtooth pattern of estrogen going up and down. And so that's why we think that some women, you know, will have more cognitive kind of issues, depression or anxiety, and then you add in the additional layer of life changes during this particular time. It's also when a lot of people's parents are getting older, you know, might need more support.
Alecia Greenlee, MD, MPH: (41:44):
Your kids are older if you have them. Career might be more demanding. So there's all these other kind of social pieces layer on top of these hormonal changes. But when we look at women who have ADHD in perimenopause, a lot of them start to report pretty severe symptoms. And what they often will report to is that the medications that they were currently-- or previously prescribed don't feel like they're working quite as well anymore, and so maybe they need an adjustment there. But also oftentimes they might need the hormone replacement therapy in addition to psychiatric medications for all of those symptoms of ADHD, depression, or anxiety. And I know I'm talking a lot about ADHD, depression anxiety, but we also see other mood disorders get worse during this time as well. You know, bipolar disorder as well might be more challenging.
Alecia Greenlee, MD, MPH: (42:40):
But that's kind of what it looks like currently. And unfortunately, we're still in a space, we don't really have clinical guidelines around this. We don't have clinical guidelines around the young woman who might have changes in their ADHD symptoms that cycle, you know, throughout the month. For the most part, we have to just kind of prescribe the same kind of dosing, especially with the current kind of shortages and stimulants. So that makes things a bit more, more complicated. But yeah, that's where we are at right now with perimenopause and mood disorders.
Keith Sutton, Psy.D. (43:17):
And the estro-- the hormone replacement, can you talk a little bit about that? I'm embarrassed to say, what pops to mind is I think old information about estrogen being related to cancers or breast cancer or so on. But, yeah. Could you talk a little bit about hormone replacement?
Alecia Greenlee, MD, MPH: (43:37):
Yeah. Yeah. So I would say I don't prescribe that, but, I do work with a lot of people who, you know, they'll go see their OBGYN or their primary care doctor who will oversee that. But there is evidence showing that risk in terms of the hormone replacement therapy, the previous research showed that it was mostly the synthetic estrogens that increase a woman's risk, as well as starting estrogen later in life may not be a good idea. So a woman who is in menopause. So menopause by definition is, you have not had a menstrual cycle for at least one year. And so maybe women who are in late menopause, it doesn't make sense to start estrogen at that particular time. So what we're kind of learning now is that what we want to do is actually start it sooner, like during the perimenopausal phase and early menopause phase, to really reap the benefits of hormone replacement and reduce the risk. Because there are benefits beyond just mood symptoms and feeling better, and, you know, relief from the hot flashes, relief from issues around insomnia or night sweats.
Alecia Greenlee, MD, MPH: (44:57):
Not just those things, but also cardiovascular risk factors as well seem to be a sign that hormone replacement is actually more beneficial. But I would say still women should definitely talk with their provider to figure out what's the best plan for them based off, you know, family history and for themselves. Like if a woman has had a history of breast cancer, then you do really need to like, think it over, does it make sense to try to do hormone replacement therapy? But I would say this even outside of hormone replacement therapy, which is, when I say that, I mean estradiol or estrogen, and then progesterone. And then there are also some women who benefit from taking testosterone as well. But there are other medications for people who cannot take hormone replacement therapy for, you know, various reasons. There are non-psychiatric medications and psychiatric medications as well, because what we see is that estrogen actually impacts neurotransmitter production. So production of serotonin, dopamine, are impacted by the fluctuation in estrogen in the body. And so it's thought that some of the SSRIs or SNRIs with their antidepressant class of medications can actually help improve some of the physical symptoms that people experience through your perimenopause, as well as the mood or emotional symptoms as well.
Keith Sutton, Psy.D. (46:28):
Interesting. So helping to compensate for the deep-- increasing those neurotransmitters.
Keith Sutton, Psy.D. (46:37):
Now, again, as a cisgender guy, I was like, "Yeah, how do you--"I mean, I've worked with a number of clients who have experienced perimenopause and so on. But I was curious about how women are figuring out what-- that they are in perimenopause? I have worked with a number of people that were like, "Oh, it might be menopause starting," or so on. Yeah. How do women kind of identify that?
Alecia Greenlee, MD, MPH: (47:07):
Yeah. So there are a number of menopause scales out there now that people can like-- or screening tools that we use to help kind of look at the number of symptoms. But what we typically see is that there will be a change in the menstrual cycle. But here's the thing that's tricky with perimenopause or just menopause in general, is that that perimenopausal phase can last from anywhere from 4 to 10 years, you know? And so what sometimes is really useful is actually if you have a, you know, relationship with your mother, talking with her and saying, "Hey, when did you go through menopause?" And that can be pretty insightful. So a lot of women go through menopause by the, or by the age of like, kind of 52. So the range can be, you know, down into the forties. And then for some women who there is a family history of kind of early menopause, it can be even earlier.
Alecia Greenlee, MD, MPH: (47:59):
But what you usually see is a change in the length of the menstrual cycle. So maybe every month is when you had your period, and now it's every 21 days, or, and then it eventually starts to be you miss a period, or, and then you miss two and then, and kind of, and so on and so forth. This kind of, again, unpredictable start to be a pattern. It can be challenging sometimes to figure that out for women who have irregular cycles, which is a pretty good number of the population. But, what you generally see is it starts to kind of start--stop having it, but you can also have a number of symptoms, which on those screening to would tell you hot flashes, cognitive fogging, some women are having joint pain or muscle aches, increased fatigue, anxiety, depression. It is a really long list, but there are a few tools.
Alecia Greenlee, MD, MPH: (48:53):
And hopefully people's primary care doctors and providers are utilizing those tools. And there's some directories now too, I want to say the menopause.org has the directory list of people who are menopause, kind of certified, who have-- did additional training and have knowledge about it. And I will say it is hard to find people who feel comfortable with treating perimenopause, unfortunately. A lot of women I speak to, they're like, "Oh, I'm having all these symptoms, and I went to my doctor and they said it's too soon to do anything." And that can be really frustrating for a lot of people, but there is more and more knowledge coming out, and again, those research gaps just are really there and it unfortunately impacts the clinical guidelines that a lot of providers feel comfortable with.
Keith Sutton, Psy.D. (49:40):
Yeah. And I know there's such an overarching issue in research and gender, piece. And I imagine birth control also makes it even more confusing. For example, if you have ADHD and you're not having a period regularly or so on, as well, right? Some of the birth control helps regulate the menstrual cycle.
Alecia Greenlee, MD, MPH: (50:02):
Yeah. And some, and I would say this too, like some women who have like premenstrual dysphoric disorder, they may be on a birth control just to avoid, you know, having to deal with that or that choice to be the treatment modality that they use for that. And what's interesting is that if you have PMDD, you are more likely to have mood changes during perimenopause. And so again, though, some women will start to be like, "Oh, I'm just feeling like I don't remember things the way that I used to." And that hormone kind of replacement that they're getting from the contraception isn't sufficient anymore. So I encourage people to, again, try to talk to your providers as much as you can.
Keith Sutton, Psy.D. (50:43):
Definitely. Well, this has been wonderful. Thank you so much for the information. What do you want the therapist or psychiatrists who are listening to this podcast to really take away,
Alecia Greenlee, MD, MPH: (50:55):
Believe women, believe them about their stories. Be curious about their stories from early childhood and beyond. Bring their families into hear what they have to say as well. I think for me, I had family therapy training as well, so I like really believe in the system as well being a part of the picture. And a lot of times you will hear how people are suffering at home.
Keith Sutton, Psy.D. (51:20):
Yeah. Definitely. Well, thank you so much. I really appreciate this, and I think it's such an important issue that I don't think there's a lot of knowledge around. So it's great that you're putting this out there and we're lucky to have you as part of our practice.Thanks so much for this conversation today.
Alecia Greenlee, MD, MPH: (51:36):
Yeah, thank you, Keith. I appreciate it. Bye.
Keith Sutton, Psy.D. (51:40):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c):(3): nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those. four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c):(3): nonprofit, so all donations are tax deductible. Today we'll be speaking with Dr. Alecia Greenlee, who is a board certified psychiatrist, who brings both rigorous training and deep humanity to our work with women navigating ADHD and co-occurring mental health conditions.
Keith Sutton, Psy.D. (02:19):
Today we'll be speaking with Dr. Alecia Greenlee, who is a board certified psychiatrist, who brings both rigorous training and deep humanity to our work with women navigating ADHD and co-occurring mental health conditions. After earning her medical degree from UC San Francisco, she completed her psychiatric residency at Harvard Medical School, Cambridge Health Alliance, where she served as chief resident in consultation, liaison, psychiatry, and developed expertise in collaborative care and mental health services for vulnerable populations. She went on to fellowship training at the University of Chicago, first in consultation, liaison, psychiatry, and then in reproductive psychiatry, gaining specialized knowledge in how the body and mind interact throughout women's lives. Alecia specializes in comprehensive psychiatric evaluation and evidence-based treatment for adults with particular expertise in how hormonal changes throughout the female lifespan from menstrual cycles to pregnancy to perimenopause influence ADHD symptoms and overall mental health. Her commitment to health equity drew her to focus on women's and minorities mental health populations, often underserved by research and clinical resources. She approaches each patient with cultural attunement and warmth, creating collaborative safe spaces where people from all backgrounds feel genuinely heard. Her practice reflects a commitment to whole person care that considers not just psychiatric symptoms, but the complex interplay of biology, identity, life circumstances, and medical conditions that shape each individual's treatment needs. Let's listen to the interview.
Keith Sutton, Psy.D. (03:50):
Well, hi, Alecia. Welcome.
Alecia Greenlee, MD, MPH: (03:52):
Thank you. Thank you for having me, Keith. Appreciate it.
Keith Sutton, Psy.D. (03:54):
Yeah, thanks for joining me today. So I know of your work because you're part of our Bay Area center for ADHD, and I was really interested in interviewing you because of the work you do in psychiatry with the clients with ADHD that we work with, but one of your specialties is also with women and women's hormonal issues. And so I think that's really interesting piece that I think maybe a number of psychiatrists or even therapists are missing at times, or even not seeing kind of that connection between the two. I know that I've had a couple clients recently where, as I was doing couples therapy or whatever it might be, they were struggling with depression, and then actually the hormones got addressed and that really shifted a lot. So I've got a lot of interest in this area. But first, before we even jump into that, , I'd love to hear about how you got to doing what you're doing and your kind of evolution of your thinking.
Alecia Greenlee, MD, MPH: (04:49):
Yeah, sure. So, for me, whenI look back over my life, one of the things I think had a huge impact on me was just the community I grew up in. And it was a very ethically, racially diverse community in Sacramento, California. And I didn't even know it was, you know, underserved, all these type of, you know, housing and instability, you know, different things. But as I got older, I realized a lot of the people that I was close to were struggling with physical illness, but then also underneath that there was mental illness. And so, once I got to medical school, I continued my interest in health disparities work and really grew an interest in kind of health policy and how do we structure access to mental health services. Because I just found, like with doing my rotations that, you know, when people were physically well, that's one thing, but you know, if they still struggle with their mental health, it is hard to really live a full life, you know?
Alecia Greenlee, MD, MPH: (05:48):
And so this would impact their housing, their ability to be employed, relationships, so on and so forth. And so when I think about the trajectory of where I am today, where I am doing a lot of work with people who have like ADHD as you said, but also other comorbid diagnoses as well, to me it just really feels like a kind of public health calling. But being able to do that work on the individual level to make sure people can take care of themselves, can take care of them, their families, they can contribute to their community. So that's how I got into this work. So yeah, that's where I'm at.
Keith Sutton, Psy.D. (06:26):
And had you, was your direction going into medical school in psychiatry, or was it more in other health and then you switched, or did, were you going into psychiatry and then you brought in the women's mental health and hormonal work? Yeah, because I think you, you've got training in two different areas than most psychiatrists do.
Alecia Greenlee, MD, MPH: (06:45):
Yeah. Yeah. So my initial interest in medical school was actually in geriatric medicine. So I really loved going back to the Midwest and spending time with the elders in my family and hearing their stories and being there to help, like, take care of them. So I grew up again on the west coast. So I went into medical school thinking like, "Oh, I'll be a geriatrician who does a lot of work with making sure people take care of their physical health." But on that particular rotation, I did a geriatric, internal medicine rotation at the VA in Fresno, actually. I love talking to people and hearing their stories and doing really well with patients who were struggling with depression, anxiety, and just really enjoyed my psychiatry rotation. But I was one of those people that loved just about every clinical rotation, which makes sense later on in terms of my training.
Alecia Greenlee, MD, MPH: (07:42):
But that was the big kind of push towards mental health, which just seeing how many patients I had who had these physical ailments, and as I got to know them more, it was like, "Oh, actually there were other things going on that could not be seen." So there may have been a history of substance abuse, and prior to that they may have had kind of history of trauma and so on and so forth. So I just saw how much mental health impacted people's physical health and really learned about, oh, all of the ways and all the difficulties that come with being able to access care. And so I knew I wanted to do psychiatry after that third year of medical school. So then I decided to go to Cambridge Health Alliance, which is one of the Harvard training programs in Cambridge, Massachusetts, where they really spent a lot of time teaching us about not just medications, but therapy.
Alecia Greenlee, MD, MPH: (08:37):
It was like, therapy was a huge component of that particular program, which drew me there, but it was also the last public health hospital in the state of Massachusetts. So it was very diverse, in terms of ethnic background as well as social economic status because we're serving patients who were students at Harvard as well as people who were from the area and surrounding areas. and at that particular time, what was happening there was a large, you know, substance abuse crisis because this is during the opiate, ECA epidemic at its peak. And so when I went there, a lot of the focus was really on, you know, addressing issues of trauma, substance abuse, things of that nature. Whereas the issue around ADHD wasn't as clear for adults, in that particular training, which is kind of true throughout psychiatry.
Alecia Greenlee, MD, MPH: (09:32):
And then another area that also wasn't really well developed was women's psychiatry. And funny enough is that a lot of psychiatrists actually are not comfortable treating women during pregnancy or postpartum. And a lot of us haven't had additional training in the hormonal aspects of mental health. And to be honest, part of it is because the research is just not fair to support it fully. Right? And the funding for that research has been a huge issue. And I don't even know if you know this, but one thing to be aware of is that reproductive psychiatry, which is about a year long, fellowship at most places, is still not an accredited fellowship program through psychiatry. Yeah. And so despite, kind of this huge need, there still needs to really be funding for the training, funding for the research.
Alecia Greenlee, MD, MPH: (10:32):
And myself, I actually chose to do what's called consult liaison psychiatry, which is basically you're the psychiatrist working on the medical surgical floors of hospitals, outpatient. You see people who need a transplant. You see women who are pregnant or postpartum, a mix of medical needs as well as psychiatric needs, which for me, going back to the beginning makes perfectly good sense. But I then chose to go on and do some more training, after that fellowship in reproductive psychiatry to kind of just strengthen the knowledge that I already had, but also just to understand a little bit more of the nuances and what are the treatment options out there for those who are assigned female at birth in terms of, psychiatric needs.
Keith Sutton, Psy.D. (11:19):
Yeah. Well, that's great. So you kind of came full circle. You went in at the medical end, and then were really kind of interested in seeing a lot of the mental health piece and then went through the mental health, kind of, angle and then ended up with the mental health and its interplay with the medical. That's great. That's a lot of complexity. It's amazing training. And I think that that piece, especially for women and women that are dealing with hormonal issues or pregnancy, I mean, pregnancy is oftentimes an issue that comes up for so many. It's about whether to stay on their medication, whether to go off their medication, whether it's antidepressants or treatment for OCD or, you know, all these kind of things. Because oftentimes that's what's really helping. And-- but you also want to make sure that the baby is going to be as healthy as can be.
Keith Sutton, Psy.D. (12:08):
Yeah. So I wanted to maybe focus, there's so much that we could focus on, but let's focus on, , ADHD and through the lifespan, as well as the kind of integration with what that looks like hormonally. Although I know also depression anxiety is all mixed in there because particularly folks with ADHD also have a lot of comorbidities that are going on. So as a psychiatrist, sometimes it's very straightforward sometimes, right, there's, there's multiple things going on.
Alecia Greenlee, MD, MPH: (12:36):
Yeah. Yeah. There usually are multiple things going on for a lot of people. But I would say even before we see this hormonal influence in terms of people's mental health, specifically women in mental health, one issue with ADHD that we all are aware of is the misdiagnosis of young girls. And like, why is that happening? Like, why is it that the rate of boys to girls is three to one when that then eventually decreases, like over the lifespan? And I continue to think about this, you know, partially probably because I have my own kids. I'm always like, you know, “Is everyone going to be okay?” I have two little girls. But also it has huge implications for someone's overall wellbeing, right? Is that we know that when girls are missed in terms of a diagnosis of ADHD that increases their risk for early pregnancy or early motherhood. That increases their risk for sexual, risky behaviors. That increases their risk for lower self-esteem.
Alecia Greenlee, MD, MPH: (13:42):
All these things that really have a huge impact on your life long term. So, you know, I do think about that and one of the conversations I had with a colleague who is a child adolescent psychiatrist, she was talking about this in that, you know, a lot of girls may have more inattentive symptoms as opposed to boys where they have more hyperactive. And I mean, the reality is this: the inattentive symptoms, you know, you kind of struggle with, whereas the hyperactivity is usually disruptive to the rest of the environment, which then prompts teachers, parents, you know, folks to kind of say, "Hey, something is going on here." Where unfortunately with girls, what we're seeing happen is that they often get diagnosed with like, anxiety or depression as opposed to someone really considering ADHD. What I hear most of in the patient population I work with is a lot of women, they then get diagnosed and they're like, "Oh, shoot, I think that my daughter might have this. Like, let me, you know, kind of go and get her some support." So again, yeah, even before the hormonal kind of piece in puberty happens, we do see that there is this difference in the ratio.
Keith Sutton, Psy.D. (14:55):
Yeah, I did-- I was interviewed on the news about the increase in diagnosis in adult women, because it's doubled in the last few years, although it's still significantly less than what the-- if everybody that was actually diagnosed with diagnosed, I think it went from 2% to 4%. But really the prevalence is about 7%. And, yeah, I guess the male chromosome, the Y chromosome is a bit more fragile, and that's why I guess there's more hyperactivity, impulsivity, autism. So we'll just come straight out with the male fragility from the beginning. And then, I was also looking into some research and that, in giving teachers vignettes, when they changed the pronouns and they put 'she,' or when they put 'he,' they were oftentimes referred for ADHD, but if put, 'she' referred for anxiety diagnosis. So many young girls, women, those identified as a female at birth oftentimes go undiagnosed. And exactly like you're saying, because it's flying under the radar, it's not the kid that's bouncing outta the seat. And although women can also have ADHD, hyperactive, impulsive, but it's more tending to be the inattentive.
Alecia Greenlee, MD, MPH: (16:08):
That's dismissed. Yeah. Yeah. Yeah, definitely. I think those social cultural kind of norms or expectations definitely impacts the diagnosis or lack there of a diagnosis or the misdiagnosis, unfortunately. But I even was reading a study recently that was saying that girls who are diagnosed with ADHD, even during this time period right, are less likely to receive medications still despite having the diagnosis and are more likely to kind of be put into this category of doing behavioral therapies, which are really helpful and useful. And sometimes, you know, maybe there are concerns around kind of the side effects of the medication, but what I often think about is like, "Oh, well, what are the implications of putting this girl who's struggling so heavily into behavioral therapy where they're being asked to learn how to manage their time and do all these things effectively without this additional support?" And I'm not saying that they have to do medication, but just what is going on there that we kind of feel like "It's okay, like they don't really maybe need medication as much as some of the boys." So, yeah.
Keith Sutton, Psy.D. (17:17):
I imagine it goes back to that like not a behavioral problem or so on and in that aspect. And that I talk about with parents, our goal is to help the kids get through their childhood without a great deal of shame. And, you know, when the person knows, like, I should be able to do this, but they can't put it into action because the ADHD, oftentimes there's that effect on shame and self, self-worth and so on. So, which yeah, the therapy can help with, but still, if you're still stumbling and coaching could help the person actually get up to the, where other folks are.
Alecia Greenlee, MD, MPH: (17:51):
Yeah, it's tricky. Yeah. But yeah, but then we move into puberty. Okay. So now the brain is, you know, producing these, what we call gonadotropin hormones. Basically these are the hormones that will then act on, you know, the ovaries to produce estrogen, progesterone. And then in males it'll go on to act on the testes to produce testosterone, but focusing solely on girls, what's interesting is that this particular time in life, we also see an increase of ADHD diagnosis. The ratio then eventually goes from that 3:1 to 2:1. And we do think part of it is hormonal, part of it is probably psychosocial, right? Again, maybe finally those inattentive symptoms are kind of being, I guess, essentially taken more seriously. You know, it starts to affect their schoolwork and things like that as there's more demands.
Alecia Greenlee, MD, MPH: (18:46):
But in terms of the hormonal piece, what we think is happening is that, you know, every month -- well, we'll say for everyone who has a normal regular cycle -- there is a fluctuation in estrogen and progesterone. Okay. You know, why do we think that impacts our mental health? Well, estrogen is thought to be neuroprotective so good for the brain, essentially. And what happens in the menstrual cycle is early in the luteal phase, you know, or right after ovulation, the release of the egg is that you have an increase in progesterone, and at the same time you have a little dip in estrogen. And what we're seeing from the recent research is that girls who have ADHD at this particular time of the month might notice they have more hyperactivity and impulsivity. And then later on in this phase of the cycle, right before their period start, like about a week or two before it starts, we also have another dip in estrogen.
Alecia Greenlee, MD, MPH: (19:50):
This time the progesterone is coming down also. And at that particular phase, what we're seeing is people have more inattentive symptoms as well as like, things like depression or anxiety. Because even for women who don't have ADHD, a lot of women can have what we call premenstrual dysphoric disorder. So have sadness, anxiety, you know, it can be so severe that they have even suicidal ideation, that one to two weeks before their period starts. And what we find is that women who have ADHD, they are-- have a rate of about 60% of them having PMDD or this premenstrual dysphoric disorder compared to the general population where it's around 20% or so. So again, there clearly is some type of hormonal impact that is starting to happen during puberty. And we see similar kind of patterns in pregnancy and the postpartum period as well as perimenopause.
Alecia Greenlee, MD, MPH: (20:55):
I'll take a step back though and say with pregnancy, what tends to happen is, well, a number of things. One, about 98% of women who say they have a diagnosis of ADHD already often don't continue taking medications. It's not clear if it's the women making that choice, or is it their provider who's concerned about medications during that particular time. But then right after pregnancy, you have this huge drop off in estrogen. Okay. And this is another time where we see an increased number of diagnoses of ADHD. One probably because you now have this little human who requires a significant portion of your time, as well as the change in hormones that are happening. And then similar, again, same thing during perimenopause. Estrogen starts to kind of eventually taper down, but it's a little bit more erratic during that time. And that's actually a lot of the population that I'm seeing now because their symptoms get so severe during that time that they are, like, at their wits end, where maybe years past, they were able to kind of manage the best they could. So it's really interesting.
Keith Sutton, Psy.D. (22:11):
Well, and I know that one of the biggest differentials for ADHD is whether or not the symptoms were they're in childhood and particularly prior to age 12. And I usually, when I'm doing an evaluation, I'm looking for those elementary school years, essentially pubescent years because once puberty hits, oftentimes there's a lot of, a lot of different things that are going on for the person. Is that something that, or-- I'm just curious about how you think about it. But maybe, you know, I'm relying too heavily on the pre-puberty time and that there's more onset, but typically the symptoms in the original diagnosis was seven years old or younger. But typically we're going to see, even if they're maybe not causing a problem, those--
Alecia Greenlee, MD, MPH: (22:54):
Are they present
Keith Sutton, Psy.D. (22:55):
--Inattentive or the hyperactive, impulsive, of course is more obvious. But, yeah. I was curious about your thinking about that.
Alecia Greenlee, MD, MPH: (23:03):
Yeah, yeah. Yeah. No, very much similar to you. I think about what was their life like prior to puberty. I definitely ask about that. And so for me, you know, one of the things that I make sure I spend a lot of time doing is really getting that narrative history from someone, is really understanding "Okay, school was okay, you know." And it's, "A lot of the people I see, you know, they've made it to graduate school in their life and they have pretty, you know, I mean, what some people might say high functioning kind of roles and, and things of that nature now." But when we take a look back early on, we see all these ways there were all these inefficiencies of doing things or making shortcuts to complete their homework in time and kind of masking behaviors and things of that nature.
Alecia Greenlee, MD, MPH: (23:50):
And I'd similar probably to you, is I still do a lot of collateral history gathering. So, you know, access to their parent or someone who knew them at that particular time can often comment on things, as well. And then similarly marching through middle school into high school, you know, and if they go to college and so on, it's very sim-- But yes, you'd still, I still expect that you would have symptoms prior to the age of 12 in order to have a diagnosis of ADHD in adulthood. And so that's a key differentiator. So I do see a lot of women who do have mood changes or cognitive changes during perimenopause, and we do have to spend some time kind of distinguishing, "Okay, this is ADHD, and then this could just be related to the hormonal changes." And so what I usually recommend actually in both camps is like, Hey, have you talked with your OBGYN or your primary care doctor about getting on hormone replacement therapy, making sure it's appropriate for you, you know.
Alecia Greenlee, MD, MPH: (24:50):
You know, in terms of risk factors and things of that nature. And then oftentimes we'll work together to figure out, "Okay, now does it make sense to make adjustments in terms of psychiatric medications?" And I find that to be like, pretty helpful. So I would say there's a percentage of folks that go on and get that hormone replacement therapy, and they're fine. They don't really, you know, need any, you know, psychiatric medication, the anxiety or depression improves. Or if they have ADHD already and they go and, and get that treatment and their symptoms have worsened, sometimes it does get better. But I would say there is still a good percentage of folks who I do see who are on hormone replacement therapy and have been say, three, four months or so before I see them. And they are really struggling.
Alecia Greenlee, MD, MPH: (25:38):
And for a lot of these women, what we often gather in their history is say, "Oh yeah, I have a, I have a kid with ADHD. But like, I thought maybe they got it from my spouse." You know, that type of thing. And then we talk about it and we really take a look. They're like, "Oh yeah. Been dealing with for a while." And what's the most kind of prevalent symptom that I see is that people actually are more coming in because they feel kind of depressed or demoralized because they haven't been able to kind of achieve the things that they feel is just like within their grasp. And so that for them is often what leads to them getting additional support from me.
Keith Sutton, Psy.D. (26:16):
Yeah. And as you were saying about the, doing the, you know, talking to the parent of a-- adult I think is so significant to really get that, you know, childhood symptomatology, you know, to kind of differentiate. And the piece that I'm curious about with the pregnancy as you're mentioning, I realize I haven't even quite dug into it, but the safety around being on a stimulant medication while pregnant if you have ADHD.
Alecia Greenlee, MD, MPH: (26:48):
Yeah. So, what we have kind of so far is that it's pretty safe, but I would say this, and most reproductive psychiatrists will tell you the same thing. It really depends on the individual, in terms of their severity of symptoms, in terms of the ADHD symptoms. Like, is the severity so bad that like you are someone who might more likely be to get into a car accident, you know, if you're off your medication or you keep forgetting your other child in the car. You know, all these like kinda little things that, yeah, it's a big deal, right, on the day to day, or you might lose your job without it. So we end up having a really like, robust conversation around kind of, the risk and benefits of treatment as well as not treatment. And for those who elect to go forward with treatment, we're often monitoring for kind of their blood pressure during the pregnancy, making sure, you know, they don't develop preeclampsia and things of that nature.
Alecia Greenlee, MD, MPH: (27:47):
And then also the growth of the fetus is what the OBGYN is monitoring. because one thing you have to kind of watch out for someone who is on stimulants is if they have signs of an intrauterine growth restriction, so the baby appears to be too small. But yeah, that's kind of the information that we have. And so some, what some women elect to do is they might be on, continue on a stimulant, but they may take it kind of more on an as-needed basis. They might lower the dose. And unfortunately a lot of the non-stimulants haven't really been studied in women during pregnancy for ADHD. But like I said, yeah, about 90%, 98% of women end up not taking a medication. But I will say this, I have heard stories from patients who have said, "Oh, I was told I needed to stop this medication during pregnancy. Like, I can't safely take it." And so then there's this huge fear that like, "Oh, if I do this, I'm going to do something to hurt my baby or hurt myself." But what we find, oh, go ahead.
Keith Sutton, Psy.D. (28:47):
I was going to say too, I know a lot of the research is kind of confounded because, you know, oftentimes they don't control for whether the parent had ADHD, so you know, when they're kind of looking at effects of different things on, you know, related to ADHD and, because the high edibility sometimes, you know, there's a correlation between something else and, and in utero and ADHD. But a lot of that is oftentimes accounted for by the parents' genetics of the ADHD. But I don't know how much the research has been done on the stimulant medication during that time. Yeah, yeah. Definitely.
Alecia Greenlee, MD, MPH: (29:23):
Yeah. I think there was a study that came out Sweden recently. Yeah, there was a Swedish study that came out that shows that they're likely safe. But again, there's just not a lot of additional supporting data to just say, "Yes, definitely continue." But I will say this, what we know for sure is that if you have a mental health disorder and you are pregnant, what the goal should often be is to, for it to be stable. Because what we know is when it's not, people don't do well no matter what the diagnosis is. And so we are often weighing, just like with every other psychiatric diagnosis, do you continue medication during pregnancy or not? And oftentimes for most of the other diagnoses, with the exception of ADHD, I would say most of the time we're recommending, like, you probably should continue treatment during this particular vulnerable period because the negative outcomes associated with poor mental health are so grand that we really do recommend it.
Alecia Greenlee, MD, MPH: (30:20):
And that can be just as simple as like, the mother's own physical wellbeing. Right? Like preeclampsia, again, is associated with mental health disorders that are not well treated during that time. You're at higher risk for developing that. And I've unfortunately seen pretty negative outcomes for women and their children when they haven't had their psychiatric diagnosis addressed during that time period. And so what we often are trying to do, is making sure, you know, if you're not going to continue medication, do you have other forms of mental health support? Like, are you able to see a therapist during that particular time? And is someone checking in with you regularly to make sure, like, "Hey, this may be a time where we might need to reintroduce the idea of talking-- of trying a medication." So there are times where I will have some female patients who will decide that they don't want to continue medications during that time, but we'll still check in to see, "Hey, how are your symptoms doing this particular month?" And kind of, and continue to do that during their pregnancy. And then we also come up with a plan kind of in this postpartum period of what they want that to look like. Because that can be driven by, you know, does she want to breastfeed? Does she not want to breastfeed? And what are the risks in terms of the medication into the breast milk as well into the baby?
Keith Sutton, Psy.D. (31:43):
Yeah, definitely. Well, and I'd be curious on your thoughts on, you know, and I know for a lot of moms, they experience mommy-brain after when their first children. And of course, you know, if they're breastfeeding and just in general right? Everybody's exhausted. In the more heterosexual gender normative families, the mom is staying home the father maybe has some time off, but is then oftentimes back to work. And so that can be a really difficult period of time. I was wondering if you can, I don't know if you have, can speak to any of that. It seems like it's almost a period where many people have the symptoms of ADHD. Short period of time, given the circumstances of the lack of sleep. And, and you know, of course our frontal lobe is the first thing to go when we're tired or sick or, you know, stressed or, or so on. Yeah.
Alecia Greenlee, MD, MPH: (32:39):
Yeah. So that first kind of couple of weeks after giving birth, we think of that time period, right, again, as that postpartum blues. So by definition not depression. And in that context, you might have low mood, low energy, you know, like you said, poor sleep concentrationdifficulties, you name it with the exception of, we always say if you have any suicidal ideation that is not postpartum blues, that is usually depression and you need additional support. And then after that time period, we then continue to monitor for things like postpartum depression or anxiety. But one of the things that I try to make sure I do when I'm working with patients is like, well, what does the social support look like for you? Because some, unfortunately, there's some of the expectations out there of like how motherhood or parenthood should look is just not reasonable for a lot of people.
Alecia Greenlee, MD, MPH: (33:32):
And then sometimes I see when people are trying to live towards that expectation, I'm like, "Wait, let's take a break." And so there are some little signs that I do use to help me even worry or gives me signs that I should be concerned that the person might be dealing with depression or anxiety that warrants treatment that sometimes appears to be normal to most people. And one of those is that you for say the woman who's breastfeeding is that she's stockpiling breast milk. So that can sometimes actually be a sign, that like the person is really anxious, they're really worried about feeding the baby and things of that nature. So I would say like, if you feel like you're in a space where you're not quite sure, I think it is reasonable to ask for help or support, at the very least, during those OBGYN follow-up appointments.
Alecia Greenlee, MD, MPH: (34:21):
They usually are screening for postpartum depression and anxiety. But then in terms of ADHD, I would say, again, it needs to be that you've had some symptoms like this even earlier on. So again, back before, you know, the age of 12, you should have had some symptoms. Yeah, of course, what they say, I think it's like about 60% of adults have like three to four symptoms of ADHD. When in reality, you know, to be considered to have ADHD, you have to have at least five symptoms plus having the symptoms prior to age of 12. So that's the conversation I will have with some of the people that come in and meet with me is that like, "I know it feels like you might have ADHD, but we really gotta teases the part and really put it together." Because, you know, not having the correct diagnosis can really result in, you know, not great outcomes.
Alecia Greenlee, MD, MPH: (35:12):
And I usually have to have a conversation with folks who come in and they have symptoms, say for anxiety or depression, but they thought they had ADHD. And sometimes they're disappointed that that is actually not the case. And I have to remind them like, you know, these other diagnoses are pretty serious too. Like, it's not as though like, "Oh, well, it's just depression or anxiety." It's like, no, no, this is something we need to do to support you with and something that you don't want to spend the rest of your life just suffering either.
Keith Sutton, Psy.D. (35:46):
Yeah. Well, and I think too that yeah, that's, I think that's a common thing because somebody will be high on ADHD scale. You know, when sometimes they're struggling with depression or anxiety, but yeah, if they don't have those childhood symptoms, then it's more depression or anxiety, which some people are, are oftentimes disappointed in. So we look at the meaning of it, but also, depression or anxiety is curable where ADHD is something that's, it's manageable and so, you know, we wouldn't want the person to be on medication lifelong if they had some--
Alecia Greenlee, MD, MPH: (36:20):
They don't need to be--
Keith Sutton, Psy.D. (36:21):
It could be addressed with medication and therapy and completely resolved. So I think that's, yeah, that's definitely an important part. And I've got a, I mean, this is just something I've thought about in thinking about women with ADHD, is that oftentimes I think for many women with ADHD, they were able to mask and get along well, especially with the inattentive, but sometimes when becoming a parent in that transition, or the gender-normative kind of heterosexual, cisgender couples where the woman is holding all of the mental load when they do have ADHD, it's like the cup runneth over. Not only are they doing all the things they were doing before, but now they're trying to juggle all the balls of all the, the whole family and the kids and so on. And so I've seen that a lot where people will come in at that point, and then we actually look in the history they did have ADHD, but it was not until they became a parent that it kind of pushed them over the edge in their functioning.
Alecia Greenlee, MD, MPH: (37:21):
Oh, yes. Substantially. And there was some article I was reading recently too, and looking at executive function differences between, you know, boys and girls, men and women. And it was saying that for women, executive function for women with ADHD specifically, that a lot of them are able to maintain their cognitive flexibility, where some of the males kind of struggle a bit more. And so sometimes that translates to that task switching that moms are doing a lot of, like, they can do that, but where there was similarities between men and women was that, the planning difficulties are still there. The inattention is still there. And so yeah, you may be able to go to the soccer game and then go pick up this kid from school and make the dinner, but they feel so overwhelmed by like the planning and the execution of all these different tasks that comes with parenthood.
Alecia Greenlee, MD, MPH: (38:17):
And then you add in, you know, disrupted sleep to the mix, and it feels just too, to be too much. And so then, yeah, again, you go back and look at that history and we see, "Oh, this was always something difficult for you." So I remember even recently, there was someone I was talking with, who was very bright, you know, and, and we were talking about their childhood, and I was asking like, different subjects that they liked in school, "Well, how'd you do in this, this one and this one?" And when we got to math, they, you know, they were like, “Oh, I did okay. You know, I, you know, I did pretty well on tests and things like that." And I'm was like, "Hmm, okay, well how did you do with showing your work on math?" They just, you know, started laughing.
Alecia Greenlee, MD, MPH: (39:00):
They were like, "Oh, no, I never showed my work. I just would put the answer down and, you know, my mom would talk to the teacher about like, well, does she got the answer right? So I don't know what the, you know, what's the problem? That kind of thing." And they were like, "I just didn't have the patience to kind of sit through this past of showing this person how I did specific things." And, and it kind of like highlighted to them, they're like, "Oh, wow, this is something that really has been here for most of my life. And it wasn't just that particular subject." They had that challenge. It was kind of happening throughout their lives, as well. And so a lot of times I'll hear or hear these stories of people jumping to different careers and things like that nature, which for some people that works out fine.
Alecia Greenlee, MD, MPH: (39:41):
You know, you're able to maintain a certain level of income, but for some folks that means they don't ever really get a promotion at work, or they don't have enough money for retirement and they're really struggling financially. So for me, I think that's why I care so much about like, kind of addressing this, especially in women who, you know, don't get paid as much as men, that's a whole other conversation. But, the implications of an untreated ADHD are huge. And I didn't really, you know, recognize that until after psychiatry residency, to be honest with you.
Keith Sutton, Psy.D. (40:17):
Well, and I think you're right, right? The deck stacked against women from the start, and also if the person becomes a mother, right, and progressing in the career, and then if you add on the ADHD too, that ends up really making things hard to move forward in the career, move up in the career. Now, yeah, can you talk about perimenopause and menopause and what that kind of is looking like for folks and women with ADHD?
Alecia Greenlee, MD, MPH: (40:49):
Yeah. I can talk about it too, like even in a broader context first. So what we see happen during this time period is, again, is that the ovaries begin to decrease in the amount of estrogen that is produced. But what also changes is the pattern of the production of estrogen during that timeframe. So going back to, you know, puberty and before perimenopause, regular cycle, you know, you kind of have a consistent kind of dip in estrogen, you know, that is predictable. But what happens during perimenopause is that you have more of this kind of unpredictable sawtooth pattern of estrogen going up and down. And so that's why we think that some women, you know, will have more cognitive kind of issues, depression or anxiety, and then you add in the additional layer of life changes during this particular time. It's also when a lot of people's parents are getting older, you know, might need more support.
Alecia Greenlee, MD, MPH: (41:44):
Your kids are older if you have them. Career might be more demanding. So there's all these other kind of social pieces layer on top of these hormonal changes. But when we look at women who have ADHD in perimenopause, a lot of them start to report pretty severe symptoms. And what they often will report to is that the medications that they were currently-- or previously prescribed don't feel like they're working quite as well anymore, and so maybe they need an adjustment there. But also oftentimes they might need the hormone replacement therapy in addition to psychiatric medications for all of those symptoms of ADHD, depression, or anxiety. And I know I'm talking a lot about ADHD, depression anxiety, but we also see other mood disorders get worse during this time as well. You know, bipolar disorder as well might be more challenging.
Alecia Greenlee, MD, MPH: (42:40):
But that's kind of what it looks like currently. And unfortunately, we're still in a space, we don't really have clinical guidelines around this. We don't have clinical guidelines around the young woman who might have changes in their ADHD symptoms that cycle, you know, throughout the month. For the most part, we have to just kind of prescribe the same kind of dosing, especially with the current kind of shortages and stimulants. So that makes things a bit more, more complicated. But yeah, that's where we are at right now with perimenopause and mood disorders.
Keith Sutton, Psy.D. (43:17):
And the estro-- the hormone replacement, can you talk a little bit about that? I'm embarrassed to say, what pops to mind is I think old information about estrogen being related to cancers or breast cancer or so on. But, yeah. Could you talk a little bit about hormone replacement?
Alecia Greenlee, MD, MPH: (43:37):
Yeah. Yeah. So I would say I don't prescribe that, but, I do work with a lot of people who, you know, they'll go see their OBGYN or their primary care doctor who will oversee that. But there is evidence showing that risk in terms of the hormone replacement therapy, the previous research showed that it was mostly the synthetic estrogens that increase a woman's risk, as well as starting estrogen later in life may not be a good idea. So a woman who is in menopause. So menopause by definition is, you have not had a menstrual cycle for at least one year. And so maybe women who are in late menopause, it doesn't make sense to start estrogen at that particular time. So what we're kind of learning now is that what we want to do is actually start it sooner, like during the perimenopausal phase and early menopause phase, to really reap the benefits of hormone replacement and reduce the risk. Because there are benefits beyond just mood symptoms and feeling better, and, you know, relief from the hot flashes, relief from issues around insomnia or night sweats.
Alecia Greenlee, MD, MPH: (44:57):
Not just those things, but also cardiovascular risk factors as well seem to be a sign that hormone replacement is actually more beneficial. But I would say still women should definitely talk with their provider to figure out what's the best plan for them based off, you know, family history and for themselves. Like if a woman has had a history of breast cancer, then you do really need to like, think it over, does it make sense to try to do hormone replacement therapy? But I would say this even outside of hormone replacement therapy, which is, when I say that, I mean estradiol or estrogen, and then progesterone. And then there are also some women who benefit from taking testosterone as well. But there are other medications for people who cannot take hormone replacement therapy for, you know, various reasons. There are non-psychiatric medications and psychiatric medications as well, because what we see is that estrogen actually impacts neurotransmitter production. So production of serotonin, dopamine, are impacted by the fluctuation in estrogen in the body. And so it's thought that some of the SSRIs or SNRIs with their antidepressant class of medications can actually help improve some of the physical symptoms that people experience through your perimenopause, as well as the mood or emotional symptoms as well.
Keith Sutton, Psy.D. (46:28):
Interesting. So helping to compensate for the deep-- increasing those neurotransmitters.
Keith Sutton, Psy.D. (46:37):
Now, again, as a cisgender guy, I was like, "Yeah, how do you--"I mean, I've worked with a number of clients who have experienced perimenopause and so on. But I was curious about how women are figuring out what-- that they are in perimenopause? I have worked with a number of people that were like, "Oh, it might be menopause starting," or so on. Yeah. How do women kind of identify that?
Alecia Greenlee, MD, MPH: (47:07):
Yeah. So there are a number of menopause scales out there now that people can like-- or screening tools that we use to help kind of look at the number of symptoms. But what we typically see is that there will be a change in the menstrual cycle. But here's the thing that's tricky with perimenopause or just menopause in general, is that that perimenopausal phase can last from anywhere from 4 to 10 years, you know? And so what sometimes is really useful is actually if you have a, you know, relationship with your mother, talking with her and saying, "Hey, when did you go through menopause?" And that can be pretty insightful. So a lot of women go through menopause by the, or by the age of like, kind of 52. So the range can be, you know, down into the forties. And then for some women who there is a family history of kind of early menopause, it can be even earlier.
Alecia Greenlee, MD, MPH: (47:59):
But what you usually see is a change in the length of the menstrual cycle. So maybe every month is when you had your period, and now it's every 21 days, or, and then it eventually starts to be you miss a period, or, and then you miss two and then, and kind of, and so on and so forth. This kind of, again, unpredictable start to be a pattern. It can be challenging sometimes to figure that out for women who have irregular cycles, which is a pretty good number of the population. But, what you generally see is it starts to kind of start--stop having it, but you can also have a number of symptoms, which on those screening to would tell you hot flashes, cognitive fogging, some women are having joint pain or muscle aches, increased fatigue, anxiety, depression. It is a really long list, but there are a few tools.
Alecia Greenlee, MD, MPH: (48:53):
And hopefully people's primary care doctors and providers are utilizing those tools. And there's some directories now too, I want to say the menopause.org has the directory list of people who are menopause, kind of certified, who have-- did additional training and have knowledge about it. And I will say it is hard to find people who feel comfortable with treating perimenopause, unfortunately. A lot of women I speak to, they're like, "Oh, I'm having all these symptoms, and I went to my doctor and they said it's too soon to do anything." And that can be really frustrating for a lot of people, but there is more and more knowledge coming out, and again, those research gaps just are really there and it unfortunately impacts the clinical guidelines that a lot of providers feel comfortable with.
Keith Sutton, Psy.D. (49:40):
Yeah. And I know there's such an overarching issue in research and gender, piece. And I imagine birth control also makes it even more confusing. For example, if you have ADHD and you're not having a period regularly or so on, as well, right? Some of the birth control helps regulate the menstrual cycle.
Alecia Greenlee, MD, MPH: (50:02):
Yeah. And some, and I would say this too, like some women who have like premenstrual dysphoric disorder, they may be on a birth control just to avoid, you know, having to deal with that or that choice to be the treatment modality that they use for that. And what's interesting is that if you have PMDD, you are more likely to have mood changes during perimenopause. And so again, though, some women will start to be like, "Oh, I'm just feeling like I don't remember things the way that I used to." And that hormone kind of replacement that they're getting from the contraception isn't sufficient anymore. So I encourage people to, again, try to talk to your providers as much as you can.
Keith Sutton, Psy.D. (50:43):
Definitely. Well, this has been wonderful. Thank you so much for the information. What do you want the therapist or psychiatrists who are listening to this podcast to really take away,
Alecia Greenlee, MD, MPH: (50:55):
Believe women, believe them about their stories. Be curious about their stories from early childhood and beyond. Bring their families into hear what they have to say as well. I think for me, I had family therapy training as well, so I like really believe in the system as well being a part of the picture. And a lot of times you will hear how people are suffering at home.
Keith Sutton, Psy.D. (51:20):
Yeah. Definitely. Well, thank you so much. I really appreciate this, and I think it's such an important issue that I don't think there's a lot of knowledge around. So it's great that you're putting this out there and we're lucky to have you as part of our practice.Thanks so much for this conversation today.
Alecia Greenlee, MD, MPH: (51:36):
Yeah, thank you, Keith. I appreciate it. Bye.
Keith Sutton, Psy.D. (51:40):
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