While postpartum patients with depression are in danger of not getting the care they need, obstetric providers continue to face obstacles from a health system with too few resources to treat these patients.
To start with, recognizing women who need to be treated for postpartum depression "has not historically been part of an ob/gyn's professional identity," Tiffany Moore Simas, MD, co-chair of the American College of Obstetricians and Gynecologists (ACOG) Maternal Mental Health Work Group, told ľֱ.
Sheryl Kingsberg, PhD, of University Hospitals Cleveland Medical Center in Ohio, told ľֱ that postpartum depression is best understood from a biopsychosocial perspective, and that a variety of factors ranging from past history of depression, history of anxiety disorders, as well as sociocultural and interpersonal factors, can all contribute to the problem.
"A good clinician should make sure they are addressing all ... components," she said.
Screening
But only in the last 4 to 5 years has there been a "universal agreement" ACOG and the U.S. Preventive Services Task Force (USPSTF) to screen all pregnant women for perinatal depression.
In February 2019, the USPSTF updated their recommendations, stating that women at high risk of perinatal depression, including high-risk pregnant women (such as those with current depressive symptoms, a history of depression, or a survivor of domestic violence) and those less than a year postpartum without an existing diagnosis of depression, should be referred to counseling.
ACOG updated its on screening for perinatal depression in October 2018. They said that all women should be screened at least once for depression and anxiety in the postpartum period. Moreover, they stated that if a woman is screened for depression in pregnancy, she should be screened again postpartum.
"There is evidence that screening alone can have clinical benefits, although initiation of treatment or referral to mental health care providers offers maximum benefit," ACOG wrote.
The Council on Patient Safety in Women's Healthcare, a consortium of women's health organizations, even goes a step further, said Moore Simas, who is a professor at the University of Massachusetts in Worcester. Their support screening at the beginning of pregnancy, at 24-28 weeks gestation, and postpartum to identify the onset of depression in each woman.
Types of Postpartum Depression and Treatments
Once women are identified as having postpartum depression, appropriate therapy is essential. Kingsberg said that cognitive behavioral therapy is the most evidence-based type of therapy, but there is not a one-size-fits-all type of therapy for all women. She added that postpartum depression generally manifests as either more anxious depression or a flat depression.
Anxious depression has a flavor of obsessional worrying and rumination -- obsessive compulsive disorder (OCD) features without actually being OCD, said Kingsberg. She described it as "what if?" thinking: "What if I go crazy, what if I forget to do something, what if I pull off the road into oncoming traffic?"
Cognitive behavioral therapy can help women recognize these "irrational and catastrophic" thoughts as "uninvited guests," she added.
On the other hand, there is flat depression -- when a woman has no range of emotion, is disconnected, and has trouble bonding with her infant, Kingsberg noted.
"Their system is shut down, they cannot have any dopamine response [even though] oxytocin should be providing an affirmative bond," Kingsberg said. "Cognitive behavioral therapy can shift those neurotransmitters, but sometimes women need a boost of antidepressant in combination with cognitive behavioral therapy."
In terms of pharmacotherapy, the FDA recently approved brexanolone (Zulresso), the first drug approved specifically to treat postpartum depression, after an overwhelming recommendation from an FDA advisory committee.
Overcoming Staffing Shortages
Despite these available therapies, many clinicians are unaware of how to proceed when they have a patient in need of treatment or worse yet, encounter barriers at the systems level, such as a lack of resources where they can refer women.
"There are not enough psychiatrists, let alone perinatal psychiatrists," Moore Simas said. "In some parts of the country, the providers just aren't there. If you pick up the phone to try and find a provider ... it's a tremendous long wait for women to get care."
Kingsberg said that while some ob/gyns may be comfortable to prescribe selective serotonin reuptake inhibitors (SSRIs) for patients with mild to moderate conditions, for example, she noted that ob/gyn clinicians always need "one or two psychologists that they can refer patients to."
"Women don't self-refer, they don't know where to go," Kingsberg said. "Somebody needs to be talking to them about why they're having these thoughts and what's to be expected."
She added that while the ob/gyns see women at the 6-week postpartum visit, pediatricians should also get involved with referrals, since they see women more often at well-child visits with their babies.
But even if clinicians can find a provider to see their patients, there is still a tremendous amount of stigma associated with seeking care for postpartum depression.
"Even if a woman is aware of it, she might not want to reveal it. Pregnancy and postpartum [is supposed to be] the happiest time," Moore Simas said.
She said that getting help "shouldn't be reliant on a woman who's suffering" -- that providers need to be educated and systems need to be created to support these patients.
Fortunately, resources are starting to be made available to providers in some states through perinatal psychiatry access programs. In Massachusetts, Moore Simas helped to develop " which launched in July 2014.
MCPAP (Massachusetts Child Psychiatry Access Program) for Moms is a three-pronged intervention consisting of training, education, and tool kits for obstetric providers, she said. During weekday business hours, providers "can pick up the phone, talk to a referral specialist, get guidance" or even have a face-to-face consult.
Other states have started to adopt similar programs. Wisconsin has the , which is also designed to connect providers to perinatal psychiatric specialists. They list a toll-free number, and offer consultation services during the week.
Representative Katherine Clark (D-Mass.) put forward legislation to fold these types of programs into the , Moore Simas said. (In 2016, Congress passed the ".")
Currently, there are 15-17 perinatal psychiatry access programs with phone lines around the U.S., with some states either receiving funding from the Health Resources and Services Administration, or through foundation or state funding.
On a national level, is a hotline available to anybody in the country, Moore Simas noted.