Transcript
Announcer:
Welcome to Advances in Women’s Health on ReachMD.
This medical industry feature, titled “Expert Insights and Clinical Strategies for Postpartum Depression Screening,” is sponsored by Sage Therapeutics. This program is intended for healthcare providers who care for perinatal women. And now, here’s Dr. Melissa Simon and Dr. Jennifer Payne.
Dr. Simon:
Hi, I'm Dr. Melissa Simon, a Professor of Obstetrics and Gynecology at the Northwestern University Feinberg School of Medicine.
And I'm joined by my colleague, Dr. Jennifer Payne. Together, we'll share our experiences screening patients for postpartum depression, explore strategies to overcome common challenges in screening, and identify best practices among healthcare providers to collaborate in the care of both pregnant and birthing persons with postpartum depression. I look forward to our discussion today, Dr. Payne.
Dr. Payne:
Likewise, Dr. Simon. Hi everyone. My name is Dr. Jennifer Payne, and I'm a Professor of Psychiatry and Neurobehavioral Sciences, as well as Obstetrics and Gynecology at the University of Virginia.
Postpartum depression can significantly impact mothers, infants, and partners, so identifying its symptoms in a timely manner is key. And that's why I'm glad to have this opportunity to discuss this important topic with you today, Dr. Simon.
Dr. Simon:
Great. So, let's jump right in, Dr. Payne. Can you describe postpartum depression and why it's so important to identify in a timely manner?
Dr. Payne:
So, in the United States, 13.2% of mothers with a recent live birth have reported experiencing postpartum depression symptoms every year. Onset during pregnancy can occur, so about 50% of cases of postpartum depression actually begin during pregnancy, and according to the DSM-5-TR, onset can also occur in the immediate postpartum time-period. Clinically, however we see onset of depression in the postpartum time-period, up to 12 months postpartum, and various expert opinion and guideline definitions are used.
Symptoms include depressed mood, changes in weight, appetite and sleep. There can be suicidal thoughts and feelings of worthlessness, hopelessness and negative thoughts. There's a significant impact on the patient in that her functioning is impaired, and there's also the stigma, fear and shame of having postpartum depression in what is usually viewed as a happy time-period.
So, with that background in mind, I think this would be a good time to discuss our experiences from clinical practice when screening patients for postpartum depression. Dr. Simon, based on your own clinical experience, can you share some insights into how healthcare providers can integrate postpartum depression screening into their routine clinical practice?
Dr. Simon:
Thank you. So, in my practice, I tend to follow the American College of Obstetricians and Gynecologists, or ACOG, guidelines, and the United States Preventive Services Task Force, or USPSTF, recommendations for screening.
Generally, what we do is administer the Patient Health Questionnaire, or PHQ-9, to patients at the first or second perinatal care visit. This is repeated in the third trimester, closer to childbirth, and as frequently as needed based on the patient circumstances and need. The PHQ-9 is also administered at around 1 or 2 weeks postpartum and during the full postpartum visit occurring approximately 4 to 8 weeks after birth. I think it's important to note that ACOG guidelines and the USPSTF recommendations on postpartum depression screening encourage all care providers that see patients that are postpartum to screen for postpartum depression.
Also, I want to discuss that patients should be screened at several points during their pregnancy and postpartum, and those points are not necessarily prescribed other than it is highly recommended to do this in the first and second, or first or second visit that you see the patient, and also, postpartum. And then, at least in the third trimester, prior to birth. And then you can gauge based on the patient themselves and their circumstances as to the frequency of screening, specifically with the PHQ-9.
So, that's been my approach in general, when screening patients for postpartum depression. How about you, Dr. Payne? Can you tell us about your best practices for screening in your experience?
Dr. Payne:
So, when providing psychiatric healthcare, my focus is on providing individualized, patient-centered care when following a woman closely through pregnancy and postpartum. I think it's important to ask questions about the pregnancy and their care goals and how they want their pregnancy to progress, and what their goals are for psychiatric care during pregnancy. I also use a screening tool, such as the PHQ-9 or the Edinburgh Post Natal Depression Scale, or the EPDS, to monitor a patient’s symptoms during pregnancy and the postpartum time-period. At my university, we collaborate very closely with the OB/GYN clinic where our electronic health records system flags patients who are at elevated risk of postpartum depression. And the OB/GYN clinic can reach a mental health provider on an acute basis and refer them to my perinatal mental health clinic.
And now, Dr. Simon, let's turn to some of the challenges in postpartum depression screenings, such as stigma and health inequities. I'm interested to know, what are your thoughts here?
Dr. Simon:
Thank you so much for that question, Dr. Payne. This is a really important topic. This issue of stigma around mental health is a huge one, especially since we've emerged from the pandemic.
It’s just really important to acknowledge that right up front and to work really hard with each of your patients to build that trust, especially since perinatal care requires a series of visits over the entire pregnancy and postpartum. And so, starting at a point of honesty, humility with your patients and saying you screen every single individual for depression and to explain why it's so important to talk about depression and mental health issues during and after pregnancy is really important.
The other issue has to deal with intimate partner violence or the experience of family violence at home. It’s important to screen for that as well throughout pregnancy and postpartum. There’s also fear of Child Protective Services being contacted, especially in some minoritized or marginalized communities, because that has been used against such communities in the past.
Finally, I want to acknowledge that there are a lot of other access-to-care issues especially with respect to those who are covered or not covered, or not adequately covered by insurance because that can make referrals to psychiatry or to counseling or other mental healthcare services, whether in person or telehealth really challenging. And so, acknowledging that and having people in your clinic or on your clinical care team who can help you with the referral process with your patients is really critical.
So, Dr. Payne, with all those challenges in mind, what are some things we can do to address them?
Dr. Payne:
So, it's important that we educate and train frontline providers and teach them about the importance of screening, teach them how to screen, and to know what to do when a screen is positive.
I think your approach to screening both during pregnancy and during the postpartum time-period is really important. And I think screening also includes asking about a history of mental health problems and mental health treatment. I think using validated screening tools, like the PHQ-9 or the EPDS really has a lot of benefits. You can implement those screening tools across all patients and make it a standard part of clinical care in your clinic.
It also facilitates using the same language between the provider and the patient about symptoms and severity, because you can look at the screen together and talk in more depth about the symptoms that they mark as they are experiencing them. In addition, a patient can actually fill out those screening questionnaires in the waiting room or have electronic screening prior to the appointment and that will allow the provider to have time to review the screen and then talk in more depth with the patient.
And now that I've mentioned some ways that could help address challenges around postpartum depression, I'd like to get your take on this, Dr. Simon. From your vantage point, what are some recommendations you would make to support these patients?
Dr. Simon:
It is super, super important, again, to hopefully have established really good rapport with your patients before the screened positive happens and that really is foundational. It’s foundational to trust, to engagement of your patient in their care with you as a partner in their health journey during pregnancy and postpartum. It’s just really important then to just be non-judgmental and to operate under an important mantra of cultural humility. Like understanding you can't be competent in everyone's culture, but you're seeking to understand and you're seeking to understand not just the person themselves, but their circumstances, the challenges that they individually face their fears, their hopes and dreams.
Always keep the conversations going at every visit. Also, like I said earlier, normalizing mental health issues, that they happen with actually quite frequency in the perinatal journey both prenatal and postnatal. And that there are ways to manage mental health concerns or depression. And actually, also, to reassure the patient that part of being a good parent is to be honest about symptoms and feelings that you could be feeling. And to be honest about the need for seeking care or referral or other support because no one person can do it alone.
The other thing that's important in this screening process and this finding a positive result process and communicating it to your patients, is to examine and the value of support systems - social factors such as social determinants of health. And so it's really important that all of those factors be taken into consideration when you as a provider are speaking with a patient and that all of these factors may affect seeking help, diagnosis, and creating care plans for patients themselves. So, bottom line is, listen, support, and be there for the patient.
And journey with the patient, in terms of co-partnership and open, clear communication, because it's critical moving forward to get through that diagnosis. And being collaborative at every stage along the way is really important.
Announcer:
For those just tuning in, you’re listening to Advances in Women’s Health on ReachMD.
Today, Dr. Jennifer Payne and Dr. Melissa Simon share a conversation about best practices in postpartum depression screening.
Dr. Simon:
So now, I'd like to hear from your perspective, Dr. Payne, on collaborative care strategies to improve postpartum depression screening and diagnosis. How can OB/GYN, psychiatrists, and other healthcare providers work together to provide the best support for our patients?
Dr. Payne:
Well, I think that the keyword here is communication and as the psychiatrist, I really view it as my responsibility to make sure that I'm communicating with other care providers on the team. I often teach my residents that the psychiatrist should be the quarterback and should be reaching out to other members of a patient's care team to make sure that they understand the care plan from your perspective. Communication is key to understanding one another's point-of-view on recommendations regarding care approaches including screening efforts. I also think it's important to establish communication with other members of the team, like the OB/GYN, like the pediatrician so that they feel comfortable reaching out to me and telling me what they're observing about a patient of mine so that I can get on top of a recurrence or relapse as soon and as quickly as possible.
It's important to really function as a team, and I think that the team also includes outside of other care providers, but the patient’s family members as well. I often ask patients to bring their family members in for consultation in my clinic where we can discuss the pregnancy everybody's feelings about it and discuss what the care plan is going to be during pregnancy and during the postpartum time-period. This really allows shared responsibility to guide the patient’s hopes, both for the baby and the individual and will also have a positive impact on the baby and the family as a whole.
There are a number of integrated care models where OB/GYN's and psychiatrists collaborate closely to provide comprehensive care and one of those is to have a psychiatrist that is specifically available to a clinic, or works at a clinic. Sometimes we have a clinical social worker, or a nurse, who screens all the patients in an OB/GYN clinic, and then can refer at-risk patients who are complex to a particular psychiatric provider. But it doesn't matter if an OB/GYN doesn't have a particular psychiatrist with whom they work closely. There are actually state and national referral and consultation services that are available.
For example, I volunteer on a weekly basis to provide consults to OB/GYN's and other providers on the Postpartum Support International Hotline. And there are a number of state initiatives that are being put into place as we speak. So, there are a number of other types of referrals and consultation services available to frontline providers.
Now, we're just about out of time for today, but before we close, let's give some final thoughts from our discussions. And why don't you lead us off, Dr. Simon?
Dr. Simon:
Thank you, Dr. Payne. So, final thoughts, I want to emphasize, it's important to engender trust throughout the entire care journey perinatal care, both antepartum or antenatal and postpartum at every visit, at every point or touch-point of care, as well, that the patient feels surrounded by love and care and that patient feels valued and valuable, and most important, heard.
And then ensure that clinical practice operations are administering timely screenings, consistent for every single patient, and using validated screening tools, such as the PHQ-9 or the Edinburgh Postpartum Depression Screen. And then finally, to have that good referral and resource patterns with warm handoffs as much as possible throughout the perinatal both prenatal and postpartum period.
So, those are some of my key takeaways, but I'll give you the final word, Dr. Payne. What key points would you like everyone listening today to take back to their practice?
Dr. Payne:
Sure. So, first is screening, screening, screening. And so, screen during pregnancy, screen prenatally, screen postpartum. And everybody and their brother should be screening, whether they're a psychiatrist, an OB/GYN, a nurse practitioner, midwife, emergency room physician, or primary care doctor. And then, I think the second big point is communication is key. Ongoing conversation with the patients, as well as with other multidisciplinary team partners, is really key to making sure that everybody is fully aware of what's happening with this particular perinatal patient, what the plan is and what the plan is for the postpartum time-period.
I think it's important to highlight the importance of collaboration and communication between patients and their families, as well as healthcare providers in supporting patients with postpartum depression. So, making sure that family members and significant others also understand what the plan is, and the importance of screening and identifying perinatal depression early. Together, we can ensure that patients get identified early and don't fall through the cracks and get the care that they need. It also allows the patient to have the best experience possible of becoming a parent.
Dr. Simon:
Wonderful. And with those thoughts in mind, I'd like to thank Dr. Jennifer Payne for sharing her expertise and insights on implementing postpartum depression screening in our practices. Dr. Payne, it was a great experience speaking with you today. Thank you.
Dr. Payne:
With you as well. And I'd also like to thank Dr. Melissa Simon for sharing her clinical insights and expertise on screening for postpartum depression. Dr. Simon, it's been a real pleasure.
Announcer:
This medical industry feature was sponsored by Sage Therapeutics. If you missed any part of this discussion or to find others in this series, visit Advances in Women’s Health on ReachMD.com, where you can Be Part of the Knowledge.
