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Unmet Needs in Postpartum Depression (PPD): Part 1

Unmet Needs in Postpartum Depression (PPD): Part 1

January 3, 2023

M. Camille Hoffman, MD, MSc; and Aviva Kristen Olsavsky, MD, discuss screening, diagnosis, and assembling an integrated for PPD.

Olsavsky and Hoffman
Remote video URL

This video is part of a 3-part series on “Unmet Needs in Postpartum Depression (PPD)." 
View part 2 here: 
https://www.clinicaltopicsdepression.com/video/unmet-needs-postpartum-depression-ppd-part-2
View part 3 here: https://www.clinicaltopicsdepression.com/video/unmet-needs-postpartum-depression-ppd-part-3

Camille Hoffman:
Hi, we're going to be talking about Clinical Topics in Depression at the Psych Congress, with a focus on postpartum depression, identification, treatment, new options in treatment, and what's on the horizon. I'm Camille Hoffman. I am a maternal fetal medicine physician. That means I am an OB-GYN with a focus on high-risk pregnancies. And I'm not a psychiatrist, but I do get to play with the psychiatrist at the University of Colorado.

Aviva Olsavsky:
My name is Aviva Olsavsky, and I'm a child and adolescent psychiatrist, as well as a perinatal psychiatrist, which means I work with people who are having babies, during the pregnancy, postpartum, and their children afterwards. And yeah, I'm really glad to sit down with you and talk about this Dr. Hoffman.

Camille Hoffman:
Yes. So, the first thing we want to think about and talk about is how do we screen, how do we diagnose? And I know from the OB world that there is a big shift and recommendation by our American College of Obstetricians and Gynecologist for anyone who provides prenatal care – so a physician, a midwife, a nurse practitioner – to screen for depression and anxiety three times during pregnancy: at the first prenatal visit, again in the third trimester, and at any postpartum visit. And that's because we know based on data that about a third of women will have preexisting depression, and so you're more likely to pick that up early if you screen for it, and ask about it, and then a lot of time  ̶  often 6, 7 months – to optimize treatment. In the third trimester, about another third will have developed depression or anxiety during their pregnancy. And then postpartum, the other third manifest symptomatology of depression or anxiety during that time, so multiple opportunities, really, to do something about this.

Aviva Olsavsky:
And I think it’s actually very fitting that we’re kind of having this talk together, and that we have this collegial relationship, because I think more of that needs to happen because some of the best ways I think to provide care, especially since there are not enough psychiatrists, particularly depending on where you're at in the country, it can be really helpful to have more integrated clinics where either, there can be a mental health part of that clinic. So, for instance, when you screen, then what do you do, right?

Camille Hoffman: Right.

Aviva Olsavsky:
You have to refer somewhere, especially if someone is really struggling. So having a clinic where you can kind of refer to within the clinic is really helpful.

Camille Hoffman:
Agreed, ideally, if you have integrated perinatal mental health coverage in your obstetric care setting—that’s magical and wonderful—and helps things flow in the best way with plenty of data to support that. It's not the reality for a lot of OB care providers, and so there are other ways to access input from a psychiatrist through perinatal psychiatry access programs. Some states have programs like that. An organization called Postpartum Support International has a program like that where I could call a number, talk to a perinatal psychiatrist, or a women's health reproductive health psychiatrist, and get advice and input on how to manage a patient that I'm seeing in obstetric care without that patient getting caught up in all of the barriers that would otherwise preclude her getting treatment.

Aviva Olsavsky:
Yeah, I think that makes a lot of sense. And then, I think a really important piece of it too is once someone does come in, and they're identified that they have these symptoms, then figuring out– what is it that is going on that's causing them? So sometimes, for instance, if you're thinking about the postpartum period, if someone had a traumatic delivery, they could look like they have postpartum depression, or they could have it, but they could also be suffering with postpartum PTSD or anxiety. And so I think it's really important that we identify what may be driving the symptoms, because...
And when I say that, I mean not just thinking about what is the DSM-5 diagnosis. That is important, and it's also important to understand the person in their social milieu, and what's going on for them. What are their social determinants of health? Because otherwise, if we don't understand those, we're actually not taking care of all the people that come to us, and we have to take care of everyone. And actually, one of the ways in which I really encounter this is because, when I work with somebody who is struggling with anxiety, depression, or PTSD in the postpartum period, I always talk about sleep first. Because poor sleep made nothing better, right?

Camille Hoffman: Right.

Aviva Olsavsky:
Never. Depression, anxiety¬, it makes nothing better. So, talking about how can we get the person sleeping, and often that ends up being kind of a social kind of network conversation where we're asking, "Who's on your support team?" And thinking out of the box, if the person doesn't have a partner that they're with, then thinking, "Who else can help?” “Do you have a friend?” “Do you have somebody in your church?” “Do you have a family member who can come and help a little bit?" Maybe even on the weekend you get a little nap, so thinking about that. Because I think as people who are having babies, we are very socialized to try and do it all. And women are amazing in the fact that they can do it all often, but I think sometimes, everyone needs help, so.

Camille Hoffman:
Yeah, it's so important. Not being a psychiatrist—I'm not sure if this is factual; but I've heard that there are really no psychiatric conditions where sleep is typically normal. That in most cases there is sleep disruption. And then you take a postpartum, a pregnant, a late pregnant patient or a postpartum patient, and inevitably their sleep is disrupted. It just goes with the territory. It's so often, especially in patients who are really vulnerable. Maybe they have a bipolar diagnosis, or maybe they've had very severe postpartum depression in a prior pregnancy; I do this aim, I target, "How are you sleeping?” first. Generally, they're not sleeping well, and then, "How do we improve your sleep?" With, for yourself, in the scenario of other children in the house, in the scenario of a newborn, with a partner or not, who else can help that patient.

Aviva Olsavsky:
Right. There's a reason why the US Preventative Task Force recommends a lot of IPT, interpersonal therapy-related and CBT-related therapies for this period; because the interpersonal aspect and the changes in role function are so important.
So, if you can actually empower the person who had the baby to solicit help from others, that's going to be something that will serve them—not just in the postpartum period—and help them to kind of overcome the kind of feeling like you need to do it all yourself.