Supporting the Peripartum Period Through Perinatal Psychiatry

Dr. Cheeley:
Perinatal mental health conditions are a leading cause of maternal mortality in the United States; yet these conditions are often undetected or undertreated during pregnancy and in the first year after childbirth. Welcome to NeuroFrontiers on ReachMD. I'm Dr. Mary Katherine Cheeley, and joining me today is perinatal psychiatrist and CEO of Reproductive Psychiatry and Counseling, Dr. Nichelle Haynes. Dr. Haynes will also be presenting a session on this topic at the upcoming 2023 Psych Congress. Dr. Haynes, welcome to the program.

Dr. Haynes:  
Thank you so much for having me. I'm really excited to talk to you.

Dr. Cheeley:
This is going to be so great. So as a mom of three, I really feel this deeply. So let's jump right in. I want to start with some background. Can you give us an overview of perinatal psychiatry as a specialty and how unique it is compared to just general psychiatry?

Dr. Haynes:
Sure. Definitely. So perinatal psychiatry encompasses the time pre-pregnancy, pre-pregnancy planning, infertility into pregnancy, also into the postpartum period, which we would include breastfeeding, and up to a year postpartum or maybe a little longer if breastfeeding is extended. So we really focus on the time in a person's life where they are dealing with reproductive hormones. And so we see how those hormones affect different people differently and really try to develop an individualized treatment plan for people, which I think is one of the beautiful things about perinatal psychiatry is we spend a lot of time talking with people about risk-benefit, getting to know them really well, and so it's very similar to general psychiatry. We just have a more narrow window of who we prefer to see. And our expertise, I think is a little bit elevated in some of those things to be able to have those risk-benefit discussions with people so that they can make informed decisions. And we really rely a lot on informed consent and navigating a lot of those really difficult situations and giving a lot of autonomy. So we really rely on some of those principles in a more in-depth way than you might in general psychiatry.

Dr. Cheeley:  
What are the common health conditions that women face during the perinatal period? And then which kind of healthcare providers are the right ones to be screening for these conditions?

Dr. Haynes:  
So I would say postpartum anxiety, postpartum depression, of course, are our bread and butter. And the other things that would be really important to screen for, of course, are postpartum psychosis, manic episodes in the postpartum period, and also, incorporating those same diagnoses in pregnancy as well because that's not a risk-free time either. And of course, as a perinatal psychiatrist, I'm going to say the ideal person that you're seeing is a perinatal or reproductive psychiatrist because we have the information to allow someone to have an informed discussion.

Dr. Cheeley:  
So my kids pediatricians actually screened me every time I came in, for I think it was obviously the initial visit after I had them, and then I want to say at the one month and the three-month mark, everyone was asking me about my mood and that was great for me as a new parent, trying to figure out what that looked like because you're exactly right, you are responsible for a whole other life. And so there's so many stressors that come with that. But I was really surprised, not only at my postpartum six-week checkup with my OB did I get asked, but also my pediatrician asked, which I thought was kind of cool.

Dr. Haynes:  
That standard of care that we are asked from multiple different people, the ideal situation is to be screened while you're pregnant. I think ACOG recommends once during the pregnancy, and then, of course, being screened in the hospital is actually evidence based. And then afterwards, OBGYN, pediatrician, midwife, whoever is caring for you can be doing screenings, which would be ideal.

Dr. Cheeley:  
Yeah, I think that the more times we ask and the more times we normalize the fact that new moms, it's not something you just have to white knuckle and get through is a positive step in the right direction. So we mentioned that these conditions are often underdiagnosed and definitely undertreated. Tell me a little bit more about the unmet needs of this patient population.

Dr. Haynes:  
I don't think I can understate it. The most common complication of childbirth are perinatal mood and anxiety disorders. Period.

So if we're worried about hemorrhage, if we're worried about preeclampsia or whatever, we should be worried about those things. We should be watching out for those things. But perinatal mood and anxiety disorders occur more commonly, so I can't understate the importance of having treatment, of getting screened, that it's so common for people to experience this. Like if you have a group of mom friends or if you know a group of moms, the likelihood is that one of them at least experience something along this.

It's a huge unmet need. I think the vast majority of people do not have treatment.

Dr. Cheeley:  
I think that's the key point that I try to change my perspective on is that it is something that needs to be treated. It's not something that for a lot of people, just go away after the fact. I think that that's a huge misconception, just because it's not a number on a screen, i.e. a blood pressure or a glucose, it doesn't mean that it's not there, and it doesn't mean that we can't treat it.

Dr. Haynes:  
Right. Exactly. It is difficult because it's everywhere and there's a lot of things that contribute. So it's not just hormones. It's not just societal expectations. It's not just that you're not sleeping. It's not just that everything in your life turned upside down all at once. It's not just that you're dealing with maybe potentially traumatic birth or that you had a huge medical procedure like a C-section. It's all of it comes together in a way to make this perfect storm. So you can't just point to one thing, and say, those are the people we need to screen. It's like we need to screen everyone.

Dr. Cheeley:
For those just tuning in, you're listening to NeuroFrontiers on Reachmd. I'm Dr. Mary Katherine Cheeley, and I'm speaking with Dr. Nichelle Haynes about perinatal psychiatry. I am loving this discussion, so let's jump back into it. We've identified that it's a problem, and it's a grossly underdiagnosed problem and definitely undertreated. So let's talk about solutions. What are the therapies that are available for this perinatal period.

Dr. Haynes:  
It really depends on the severity and the actual issue. A lot of people can have improvements in their symptoms by prioritizing their sleep. That's one of the most evidence-based things that we can do that if we are able to reach for the goal of five hours consecutive sleep and total of seven hours in a 24-hour period, that can provide a lot of benefit for a lot of people. So sometimes it's just that they need sleep. Therapy is an evidence-based way of approaching the problem for mild to moderate symptoms. Of course, we can have the discussion about feeding goals, how we can still reach those goals and incorporate. Of course, we also can use medications. And there are plenty of medications that when we look at the totality of the evidence that we do currently have, that we believe them to be not very risky, that we probably think that experiencing depression or anxiety in the postpartum period or during pregnancy is probably riskier than taking those medications. So the answer in psychiatry is the same—lifestyle modifications, therapy. or medications. And I think that those all can play a role here in different aspects, in different connected ways.

Dr. Cheeley:
Absolutely. I totally agree with you. How do you think we can work with our patients to manage these conditions more effectively? Is it linking them to other providers for care? What's that relationship look like with your patients?

Dr. Haynes:
I think validation and normalizing how difficult the situation is goes such a long way. Validating the experience, hearing our patients, asking them how they truly are, and creating that relationship where they feel safe to say, “I'm not okay. I'm so anxious. I'm so worried.” It really comes down to being warm and caring, and it does not take that much extra time. And that goes so far in creating a relationship where someone feels comfortable to tell you like, I'm struggling.

Dr. Cheeley:
I agree. And I know you're presenting on this at the psych conference, so I'm really excited to hear how that fleshes out. Is there anything else that you want to share with us today and with our listeners?

Dr. Haynes:
I think the most important thing is to create safety for your patients that they feel like they can talk about these things with us. And also, a clinical tip is please don't stop someone's medication just because they're pregnant. Have an informed consent discussion with them about what the risks are, and don't assume that you know what the risks are based on old information, old way of classifying medications, that that's outdated, that if you don't know, it's okay to say you don't know and just go look it up. There's apps that you can use to find the data that I've used myself. There's lots of resources out there to have the actual informed discussion consent with your patients because the vast majority of people who experience depression or anxiety or have bipolar disorder, stopping their medication is not going to make anything better, and in fact, could make things a lot worse.

Dr. Cheeley:
Very true. This has been such a great discussion, specifically, about the unique psychiatric needs of our patients in the perinatal period into motherhood. And then beyond that, thank you so much to my guest, Dr. Nichelle Haynes, for a great and insightful discussion. Dr. Haynes, it was awesome talking to you today.

Dr. Haynes:
Thank you so much for having me. This is the thing I could talk about all day, every day, and I'm just happy to continue the conversation and bring it to more people.

Dr. Cheeley:
For ReachMD, I'm Dr. Mary Katherine Cheeley. To access this and other episodes in our series, visit ReachMD.com/NeuroFrontiers where you can Be Part of the Knowledge. Thanks for listening.