Women face many barriers to treatment for postpartum depression, but obstetricians are well-positioned to help overcome them.
Postpartum depression (PPD) is the most common complication after pregnancy, affecting 1 in 7 new mothers or 400,000 births per year, according to the American Psychological Association. Yet less than 25% of the women who screen positive for the condition receive follow-up care, for reasons that range from stigma to their providers not knowing where to refer them.
Healthcare providers, most of them obstetricians, gathered early Saturday in Austin, Texas, for a product theater session sponsored by Sage Therapeutics to learn more about risk factors, screening, and current clinical approaches to PPD. Attendees heard from Tiffany A. Moore Simas, MD, associate professor of obstetrics and gynecology, and Nancy Byatt, DO, MBA, associate professor, both in the Department of Psychiatry at the University of Massachusetts Medical School in Worcester, Massachusetts.
Simas explained that professional guidelines differ on how often patients should be screened for depression; the American College of Obstetricians and Gynecologists (ACOG) recommends that clinicians screen women at least once during the perinatal period, using a standardized, validated tool. She surveyed the attendees, and the majority reported they screen their patients for depression once before they give birth and once postpartum, and nearly all said they would screen at least once.
PPD has the same features as major or minor depression—the emotional symptoms such as mood swings, the cognitive symptoms, as well as symptoms that relate to the ability to care for the baby. As Simas explained, “Although the criteria are the same, how it presents can often be different, or it can be masked by the fact that they are pregnant.”
There is much that can be dangerous for mother and baby: difficulty bonding, loss of appetite, fatigue, insomnia, and feelings of guilt. The other “critical component,” Simas said, which distinguishes PPD from the “baby blues,” is these symptoms persist for more than 2 weeks and continue to impair a mother’s ability to function.
PPD is “associated with significant negative consequences,” Simas said. It is linked to higher rates of substance abuse, including alcohol and tobacco; if the mother is depressed before she gives birth, the baby may have low birth weight. Depression may continue beyond the postpartum period; it can harm relationships with partners and affect a child’s development, both short term and long term. While rare, perinatal suicide is more common than postpartum hemorrhage, she said.
Treating more women with PPD is key, Simas said. “We have a real opportunity in addressing this issue, in the interest of saving lives.”
Barriers to Care
By themselves, lack of awareness and stigma can stop women from seeking help for PPD, Simas said, but there are many more barriers to care. Lack of time, lack of child care, and not knowing where to go for help also stop women from getting help. “There are additional barriers that we as providers experience,” including system-level barriers to diagnosing and treating PPD. “Postpartum depression is significantly underdiagnosed—greater than 50% of postpartum depression cases may go underdiagnosed without proper screening,” she said, and even when properly screened, fewer than 25% of cases are treated.
“The good news, despite all of that, is the OB/GYNs are really very well-positioned to address postpartum depression,” Simas said. Data show that patients prefer their obstetricians screen and treat them, and this is not so different from the way depression is treated elsewhere—outside of pregnancy and postpartum care, many mental health services are offered by primary care providers.
Until recently, it was unclear where professional societies stood on this issue, Simas said, but in 2015 ACOG issued a committee opinion that called for OB/GYN practices to screen for depression and be prepared to initiate medical therapy, refer to behavioral health resources, or both. While there are a host of reasons integrating behavioral health care into obstetric care makes sense, she said, “The biggest reason of all is that women want us to be doing this.”
In a poll of the audience, the most popular screening tool was the Edinburgh Postnatal Depression Scale, or EPDS; attendees had a copy of the questions at their seats. Simas said the final question on self-harm required special attention and immediate action if the patient indicated suicidal thoughts.
What Are the Risk Factors?
Byatt reviewed who is at risk for PPD and the basic steps of safely prescribing medication, typically selective serotonin reuptake inhibitors (SSRIs). The biggest risk factor for PPD, she said, is having a prior history—if a woman has suffered PPD in the past, her risk of having it again is 20 times higher. But there are other known risk factors: a stressful life, a traumatic birth, being poor or on public insurance, and not having social or family support. Byatt reiterated the difference between the very common occurrence of “baby blues,” which affect 50% to 60% of new mothers but pass in a few days, and PPD.
“Once you have determined it is depression, what are the options?” she asked.
Right now, she noted, there is not an FDA-approved therapy specifically for PPD. (Last week, Sage Therapeutics filed a new drug application for intravenous brexanolone, which has received breakthrough therapy designation for the treatment of PPD. Brexanolone was not part of Saturday’s presentation.) The key to treating PPD during pregnancy or the postpartum period is to minimize exposures, whether to illness or to multiple different drugs, Byatt said. Thus, while switching medications is generally not a good idea, not treating depression is not advised, because failing to treat depression can affect a mother’s ability to care for her baby. When prescribing, she said clinicians should start with half the recommended dose and closely monitor patients every 2 to 4 weeks, realizing they may have to increase the dose upward.
Byatt urged attendees to remind patients that SSRIs are well-studied, and that patients take other medications. “The best thing they can do is get the treatment they need,” she said.