Transcript
Announcer:
Welcome to Advances in Women’s Health on ReachMD.
This medical industry feature, titled “Screening for Postpartum Depression: A Guidelines-Based Discussion,” is sponsored by Sage Therapeutics. This program is intended for healthcare providers who care for perinatal women. Here’s your host, Dr. Matt Birnholz.
Dr. Birnholz:
This is Advances in Women's Health on ReachMD, and I'm your host Dr. Matt Birnholz.
Here with me today are Dr. Jennifer Payne and Dr. Melissa Simon. With their expertise in obstetrics, gynecology, and psychiatry, our discussion on postpartum depression will explore screening strategies, health inequities, and the latest guidelines regarding the importance of early screening.
Dr. Payne is a Professor of Psychiatry and Neurobehavioral sciences, along with being a Professor of Obstetrics and Gynecology at the University of Virginia. Dr. Payne, it's great to have you with us.
Dr. Payne:
Thank you for having me.
Dr. Birnholz:
And Dr. Simon is a Professor of Obstetrics and Gynecology at the Northwestern University Feinberg School of Medicine. Dr. Simon, thanks for being here today.
Dr. Simon:
Thank you for having me.
Dr. Birnholz:
So, Dr. Payne, let's start by understanding the current landscape of postpartum depression screening. Can you give us a better sense and understanding of this condition and take us through some important tools and strategies?
Dr. Payne:
Absolutely. So, let's start with some definitions. First of all, what is postpartum depression? Postpartum depression is a depressive episode that can begin during pregnancy or in the immediate postpartum time period. A major depressive episode has a very specific definition. Psychiatrists use the Diagnostic and Statistical Manual to define various mental health conditions, including a major depressive episode, and according to the DSM we look for symptoms of low mood, poor energy, concentration, disturbances in sleep and appetite, negative feelings, feeling guilty, and even suicidal thoughts in women during the postpartum time period.
These symptoms have to be present every day for 2 weeks or longer, and it's a requirement according to the DSM that the symptoms are severe enough that they impact a woman's functioning.
Postpartum depression is different and separate from the postpartum baby blues. Symptoms of baby blues is really mood lability, feeling emotionally sensitive, maybe tearful, maybe extremely happy at times, and these symptoms really only last a few hours to a few days, and they do not impact functioning.
There are a number of ways to screen for postpartum depression, and really the best way is to use a standardized screening questionnaire. And there are two that I like to talk about. The first is the Patient Health Questionnaire 9. This is a 9-item scale that can be self-administered by the patient, and usually takes healthcare providers less than 3 minutes to complete. It's widely used to assess for depression in general, and can be used to screen for a postpartum depression. It's considered valid for use by the American College of Obstetrics and Gynecologists, or ACOG, in pregnancy and in the postpartum time period, and is also recommended for use by the American Academy of Family Physicians.
The Edinburgh Postnatal Depression Scale, or EPDS, is another scale that can be used to screen for depression, specifically during the perinatal time period. It's a 10-item scale, again, can be self-administered by the patient, and takes about 5 minutes to complete. It's used in both clinical practice and research as a screening tool specific to the perinatal time period, and it is considered valid for use by ACOG, as well.
Dr. Birnholz:
Well, thank you, Dr. Payne. That was an excellent review. Much appreciated.
Dr. Simon, turning to you now, can you elaborate on your goals of care for the patient when screening for postpartum depression?
Dr. Simon:
Thank you so much, Dr. Birnholz.
Based on my clinical experience, educating patients for postpartum depression can really help reduce stigma around mental health and depression as long as you are consistent with your practice and consistent with your patient in terms of saying that you do this, or you screen for all patients for depression every single time regardless of who the patient is, what they look like, or where they're from. Also just trying to frame why it's so important to screen, and screening, indeed, can help the patient, the baby, and loved ones. And it also allows opportunity to address any fears of repercussions from having postpartum depression because some patients, especially those who have felt like they've been abused by the medical care system or just not treated well in medical treatment or have family members or loved ones who hadn't been treated well by the healthcare system. It's really important to just address these fears up front, and really normalize the importance of screening for depression across the pregnancy and postpartum period. And also, this is about shared decision-making, that this is a partnership with all of my patients. I partner with them in their care journey regardless of how bumpy the road may be or if there's a positive screen for depression or other medical conditions, I'm in it with them, and so is the healthcare team who supports us in the journey of the patient through their healthcare needs.
Dr. Birnholz:
Thank you, Dr. Simon. Great insights there. And keeping those goals in mind, I'd like to take a closer look at health inequities that could contribute to the lack of screening and the underdiagnosis of postpartum depression.
So, Dr. Payne, coming back to you, what disparities exist in postpartum depression screening among historically underserved communities and what factors do you think contribute to these disparities?
Dr. Payne:
Absolutely. That's a great question. So, in the United States, postpartum depression is underdiagnosed and undertreated and it's important to note that perinatal individuals without a pre-pregnancy psychiatric history are less likely to be identified, referred, or managed for postpartum depression. And this is simply because they don't have a red flag alerting their physicians to the fact that they may be at risk for postpartum depression.
There are a number of factors that can contribute to the underdiagnosis and undertreatment of postpartum depression. So, women who lack certain social supports are at elevated risk for being missed in terms of being identified for postpartum depression. So, for example, women who experience intimate partner violence or are suffering from severe economic hardships are less likely to be identified, or to follow through with treatment, and this is because they are experiencing really hard social situations that limit their ability to follow through on referrals for mental healthcare and even filling a prescription or taking a prescription on a regular basis. And many of these patients are actually not screened because they don't follow-up for that 6-week postpartum visit with their obstetrician.
In addition, there's a lot of stigma surrounding mental health conditions and specific cultures may have certain beliefs about mental health diagnoses and treatments that may result in particular women not following through on treatment.
Finally, it's really important that mental health providers have a good fit with the patient. We talk about the therapeutic relationship is one of the key factors in terms of successful treatment of mental health conditions.
Dr. Birnholz:
Those are some really important contextual details surrounding these disparities, Dr. Payne. Thank you.
And Dr. Simon, I want to stay on this theme for a little bit longer and get your perspective on what strategies healthcare providers can implement to help reduce the stigma around postpartum depression and integrate screening into their practice. And I'm thinking particularly those in underserved communities. What can you tell us?
Dr. Simon:
Thank you so much, Dr. Birnholz, for that question. So important to always consider each patient's personal challenges, social determinants of health, or other social and environmental circumstances that make it harder to get to a clinic visit, to be able to get screened for depression and other health conditions. All those things are super important.
So, some of the key takeaways I would emphasize are that screening tools are available in languages besides English. And those screening tools that I want to emphasize that we all should be encouraged to use are the ones that are validated. So, the PHQ-9 is the one that I use and that we use in our practice consistently. And also, there is the EPDS, or the Edinburgh Postpartum Depression Screen, which is another tool that some practices use as well. And it is validated and in other languages as well. And the thing about these screening tools is that they can be used very frequently, and you adjust that screening cadence to the particular patient and their needs at that moment in their care. But, you know, before you even start screening, it is really important to engender trust. Trust is one of the most important foundations of good clinical care delivery and receipt of clinical care. If you have a patient that is more trustful of you and your healthcare team and your practice, then they're going to be more likely to be engaged in their care and to really feel that they're a partner with you on their care journey, throughout their entire perinatal care, postpartum care period. And they're going to feel valued and valuable and heard, and that's really critical to the foundation of engendering trust.
And then finally, making sure your clinical care practice has good referral processes in place for all patients regardless of their payer status, so regardless if they're privately insured or publicly insured or underinsured or uninsured, making sure there's all these different supports and referral processes in place because once a screen is positive in depression, you want to make sure that there is follow-up on that screen and not just screening for the sake of screening, but actually to get that patient the care that they need.
And so, we all, we as OB/GYNs, psychiatrists, and all the other myriad of healthcare providers that touch patients who are pregnant, birthing or postpartum, should become comfortable, or more comfortable, with – and certainly more proactive – about discussing depression, screening for it with validated tools, and making sure there's referral practices in place that are solid for every type of patient despite their ability to pay or their insurance type.
Dr. Birnholz:
For those just tuning in, you’re listening to Advances in Women’s Health on ReachMD.
I’m Dr. Matt Birnholz, and today I’m speaking with Drs. Melissa Simon and Jennifer Payne about the importance of screening patients with postpartum depression.
So, let's dive into the latest guidelines now, Dr. Payne.
Can you walk us through the recommendations from key medical professional societies for screening and diagnosing postpartum depression?
Dr. Payne:
Absolutely. So, there are a number of professional society recommendations. They're fairly similar, but they do differ on a few points so I'll go through them now. The American College of Obstetrics and Gynecology, or ACOG, recommends that every woman receiving a well-woman pre-pregnancy, prenatal, and postpartum care should be screened for depression and anxiety symptoms using a standardized, validated tool, and those include the PHQ-9 and the Edinburgh Postnatal Depression Scale. Screening should ensure timely access to assessment and diagnosis, and appropriate monitoring and follow-up.
The American Psychiatric Association, or APA, recommends that all perinatal patients should be screened for depression with a validated screening tool at least twice during pregnancy, once in early pregnancy for pre-existing psychiatric disorders, and once later in pregnancy. And then in addition to that, the APA recommends screening during pediatric appointments through the first 6 months postpartum.
And then the American Academy of Family Physicians, or AAFP, recommends that clinicians should screen for depression in pregnant and postpartum women, and that adequate systems should be in place to ensure accurate diagnosis and appropriate follow-up.
The American Academy of Pediatrics, or AAP, recommends screening for postpartum depression should be included in the prenatal visit, and that subsequent screenings of the mother can be performed at the child's 1-, 2-, 4- and 6-month wellness checkups.
And then finally, the United States Preventative Services Task Force, or USPSTF recommends that clinicians should screen for depression in pregnant and postpartum women and that adequate systems should be in place to ensure accurate diagnosis and appropriate follow-up.
These recommendations really complement each other with the take-home point that we should be screening everyone, and preferably, we should be screening at multiple timepoints, including during pregnancy as well as during the postpartum time period.
Dr. Birnholz:
Well, as I take in these perspectives from you both, it becomes automatically clear to me that both OB/GYNs and psychiatrists play a very vital role in postpartum depression screening.
So, before we wrap up our discussion today, I just want to get some final thoughts from each of you.
Dr. Simon, starting with you from an obstetrician gynecologist perspective, why is it so important for healthcare providers to take the lead in postpartum screening?
Dr. Simon:
Thank you for that question, Dr. Birnholz. You know, I want to emphasize that OB/GYNs, as the main healthcare providers to patients who are pregnant or birthing or postpartum along with midwives, nurse practitioners, family medicine providers, and others we're really positioned and importantly so, we should feel that strong ownness and responsibility to screen for depression. It's really critical because depression can have so many consequences, not just to the individual person who is experiencing depression, but to their offspring, to their family, to their loved ones, to their friends, to their community.
And so, it's really critical that we all team up together to screen for depression and use appropriate tools that are validated. Timeliness is really critical, and it's really important to ensure that you screen every single patient, so you destigmatize screening and the timing of that screening with clinical practice is really critical. So, the first or second post prenatal visit, the third trimester, and then postpartum.
And then, adjusting the timing and cadence of screening, if extra is needed, depending on an individual patient’s circumstances. And then, to encourage healthcare providers to screen for and provide support to patients with depression and experiencing depression. You know having systems in place where there's referral patterns, referral options. Having support such as social workers, case managers, those are all really critical, but more so, when you have a patient who faces access-to-care issues such as underinsurance, uninsurance, publicly covered individuals or privately covered individuals. Each type of insurance, or lack of insurance is a really important consideration in terms of administrative processes needed within a clinical care practice to be able to support a patient on their mental healthcare journey.
Dr. Birnholz:
Thank you, Dr. Simon. Much appreciated.
And from a psychiatrist’s perspective, Dr. Payne, what key takeaways would you like to share about postpartum depression screening to close our discussion today? You get the final word.
Dr. Payne:
Thank you. Well, I think that psychiatrists are really best-positioned to speak about the risk of postpartum depression with their established patients. I think it's important that psychiatrists not shy away, from treating patients with psychiatric conditions during pregnancy and postpartum, and it's important to warn patients that they may be at risk for postpartum depression, and to follow their patients carefully during the perinatal period. It's important to screen every patient, and it's also very important to collaborate with OB/GYNs on individualized care for patients during and after pregnancy in a timely fashion. I always like to say that psychiatrists are the quarterback in managing mental health conditions during the perinatal period, and it's important that they communicate with the rest of the team, including the OB/GYNs.
Dr. Birnholz:
Well, that's a great and memorable analogy to help take away from this conversation, Dr. Payne. And fantastic comments from both of you to think on as we come to a close.
Through our discussion, just to relay to our audience, it is clear that screening is a critical component of postpartum depression care provided by both OB/GYNs, psychiatrists, and other healthcare providers caring for women in the perinatal period, and that efforts to address health inequities in this area are absolutely essential. So, with that, I very much want to thank our guests, Dr. Melissa Simon and Dr. Jennifer Payne, for sharing their clinical expertise with us today.
Dr. Simon, Dr. Payne, it was wonderful speaking with you both today. Thanks so much.
Dr. Payne:
Thanks for having me. I really enjoyed the conversation.
Dr. Simon:
Thanks for having me.
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.
