Dr. Turck:
Welcome to Advances in Women's Health on ReachMD. I'm Dr. Charles Turk. And joining me to talk about how we can better manage patients with perinatal mental health conditions is Dr. Tiffany Moore Simas, who's the Chair of the Department of Obstetrics and Gynecology at UMass Chan Medical School. She was also a key presenter for a few sessions focusing on this exact topic at the 2023 American College of Obstetrics and Gynecology Annual Clinical and Scientific Meeting. Dr. Moore Simas, welcome to the program.
Dr. Moore Simas:
Thank you. Happy to be here.
Dr. Turck:
So to start with some background, would you tell us about the prevalence of perinatal mental health conditions?
Dr. Moore Simas:
Yeah, perinatal mental health conditions are one of the most common complications of pregnancy; they affect upwards of one in five perinatal individuals. And when I say perinatal mental health complications or conditions, what I'm referring to is really any mental health condition affecting individuals in pregnancy and postpartum. Most commonly, that's depression and anxiety. So when we talk about that “one in five,” those are averages across the depressive and mood disorders, and there are some populations that are at significantly higher risk. So for example, those who are marginalized by socioeconomic disadvantage, adolescents, and veterans, their rates tend to be as high as one in three and one in two, in some cases, especially over the course of the COVID pandemic and as it relates to anxiety.
Dr. Turck:
And how are we currently doing when it comes to identifying these patients?
Dr. Moore Simas:
There's still much work to be done here. We do have recommendations around universal screening using a validated screening tool for all perinatal individuals in pregnancy and postpartum. However, the reality of the implementation of those recommendations and what perinatal individuals experience is different, so perinatal mental health conditions do still remain underdiagnosed and undertreated.
Dr. Turck:
Now if we zero in on one of your presentations that focused on the new clinical guidance from ACOG, would you share its recommendations for screening and diagnosing perinatal mental health disorders?
Dr. Moore Simas:
Yeah, there's actually two clinical practice guidelines that have just been released. One is, as you say, regarding screening and diagnosis, and the second is related to treatment. With the one focused on screening and diagnosis, I think the major take-home points are that we should be screening all pregnant and postpartum persons using a validated screening tool for depression and anxiety. Twice in pregnancy, so at that initial obstetric visit, at about the 24- to 28-week glucola visit or somewhere later in pregnancy, and then in the postpartum period. The rationale for those three time points comes from the work of Katherine Wizner, where they screened 10,000 individuals for what we have historically called postpartum depression. But then they went back and said, “When was the likely onset?” And the likely onset is about a third, a third, a third. So about a third of people who experience a perinatal mental health condition have onset that predates pregnancy; they come into pregnancy with it, whether it was recognized or not, about a third develop it over the course of pregnancy, and about a third develop it in the postpartum period.
Another recommendation that I think people will find a change is that there is a recommendation to screen for bipolar disorder. Now bipolar disorder is a significant condition we want to pick up because persons with bipolar disorder are some of those that are at highest risk for postpartum psychosis, infanticide, and suicide, and we can precipitate mania and exacerbations if we're prescribing an unopposed antidepressant.
Dr. Turck:
And as you mentioned before, one set of guidelines broaches the topic of pharmacologic treatment. I was wondering if you would share some of the highlights from that set of guidelines.
Dr. Moore Simas:
I would say the overall highlights are there is an established care standard saying we as obstetric care clinicians should be screening for, assessing, and treating perinatal mental health conditions. Now to what extent we treat, psychotherapy we will refer out, right? This guideline specifically helps address when do you decide to initiate pharmacotherapy? How do you talk about it? How do you initiate it? How do you titrate it up? You know, when is it working? When is it not working, et cetera? And really, how do you have a risk-benefit conversation? Because one of the things we really need to change is how we talk about treating mental health conditions. Often perinatal individuals in the past have been faced with the decision of you know, medication or not medication, as if not treating it is without risk. But the fact of the matter is perinatal mental health conditions come with risks to the perinatal individual, to the pregnancy, to the outcomes, and to the offspring. And so really, the conversation needs to change from medication/no medication to untreated disease or treated disease.
Dr. Turck:
For those just tuning in, you're listening to Advances in Women's Health on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Tiffany Moore Simas about the management of perinatal mental health disorders.
So Dr. Moore Simas, if we switch gears and focus on another of your ACOG presentations, would you tell us about the new resources available that can help us integrate mental healthcare into obstetric practice?
Dr. Moore Simas:
ACOG has partnered with Lifeline for Moms Center at UMass Chien Medical School, which is where I'm from, and over the past couple of years, we have been working on a number of very functional resources that really were designed by psychiatrists and obstetricians for obstetricians, and we trialed them, beta tested them, et cetera. So the first is a toolkit. It's called the Lifeline for Moms Perinatal Mental Health Toolkit that's available on the ACOG website. We also created e-modules, so it’s an interactive learning series where you can get CME credits through ACOG to help bolster baseline knowledge about how to screen, assess, treat, follow up, and monitor persons with perinatal mental health conditions.
And then finally, we created an implementation guide. So how do you integrate mental health into obstetric care? A real step-by-step guide that includes actual algorithms and a baseline assessment to understand where your practice is at, where there are opportunities to do more, where there's opportunities to celebrate that you're really doing everything you need to do to meet the guidelines, and then concrete goals and steps to further augment the care that is already delivered.
Dr. Turck:
Now before we close, what key lessons do you hope learners took away from your presentations?
Dr. Moore Simas:
I hope they recognize how common perinatal mental health conditions are, being the most common complication of pregnancy. I hope they recognize that perinatal mental health conditions are the number one cause of maternal mortality. And based on the work of maternal mortality review committees, they're deemed wholly preventable. So this is really an issue that we as obstetric care clinicians really need to embrace with as within our scope of practice and really be able to address. I hope they take away concrete information around how to screen and diagnose mental health conditions and how to treat it, and most importantly, that there are resources out there to help them do it, that they're not on their own.
Dr. Turck:
Well, this has been a really insightful look at how we can better recognize and manage perinatal mental health conditions. And I'd like to thank my guest, Dr. Tiffany Moore Simas, for joining me to talk about her presentations at the 2023 ACOG Annual Clinical and Scientific Meeting. Dr. Moore Simas, it was a pleasure speaking with you today.
Dr. Moore Simas:
Thank you, I appreciate the opportunity to do so. Thank you so much.
Dr. Turck:
For ReachMD, I'm Dr. Charles Turk. To access this and other episodes in our series, visit ReachMD.com/AdvancesInWomensHealth, where you can Be Part of the Knowledge. Thanks for listening.
