A woman comes in irritable. The instinct in psychiatry is to reach for a diagnosis, maybe adjust a medication. Amanda Goldstein, MD, asks a different question first: when does it happen? If the irritability arrives like clockwork for one week every month, that points toward PMDD. If it started a year ago and has been slowly worsening, perimenopause may be the more accurate frame. The treatment that follows those two answers looks very different, and in Goldstein's practice, it often involves picking up the phone and calling a gynecologist.
"A psychiatric symptom is not always psychiatric in origin," she says. That single premise shapes how she approaches every patient. She reviews medical history, asks about recent labs, and coordinates directly with other providers before making any treatment decisions. The specialties are siloed, she acknowledges, but the body is not.
That same integrative logic guides how she handles one of psychiatry's most charged clinical conversations: whether to continue a psychiatric medication during pregnancy. She is direct about the stakes. Untreated depression and anxiety in pregnancy are associated with higher rates of preterm birth and low birth weight. The decision to taper off medication, stay on it, or adjust the regimen depends on the severity and history of the condition, and Goldstein describes her role as helping patients work through that calculus rather than delivering a verdict. "The goal is not a medication-free pregnancy," she says. "It's a healthy mother and child."
Some patients, she explains, can safely taper before pregnancy with close monitoring for any return of symptoms. Others, particularly those with recurrent or severe disorders, may continue their medication throughout. What she pushes back against is the reflexive assumption that stopping medication is automatically the safer choice.
The hormonal story doesn't end at birth, and it doesn't end when the postpartum period officially closes. One transition that Goldstein says deserves far more clinical attention is weaning. Breastfeeding alters several hormones that influence mood, including prolactin, oxytocin, estrogen, and progesterone. When a woman stops, those levels shift again. For some patients, it is only after weaning that symptoms of depression first surface, a pattern that can be easily missed or misattributed if a provider isn't specifically looking for it.
"Post-weaning depression (also called post-breastfeeding depression) deserves far more attention. Unfortunately, there is very little research on the subject, and it is often overlooked."
Goldstein says she now warns patients before they begin weaning, so the possibility is already on their radar if their mood changes. It is a small clinical adjustment, but it points toward something larger: a hormonal transition happening during an already vulnerable postpartum period, with almost no research behind it and no standard screening protocol to catch it. The gap between what patients experience and what medicine has chosen to study is, for now, wide open.
