In this week’s episode, Dr. Jason James & Dr. Ewurama Sackey share how physicians can improve postpartum depression screening and management.

Dr. Sackey: My name is Ewurama Sackey. I am a child and adolescent psychiatrist, a reproductive psychiatrist, and the director of Women’s Behavioral Health at Allegheny Health Network.

Dr. James: Hi, my name is Dr. Jason James. I’m an obstetrician gynecologist in Miami, Florida. I’m in private practice and I’m the medical director of FemCare Ob-Gyn. I’m also the president of the medical staff at Baptist Hospital of Miami.

Dr. Sackey: I think a lot of people don’t do screenings for postpartum depression because they don’t know which things to use to screen. We use the EPDS, which is the Edinburgh Postnatal Depression Scale, or we can even use a PHQ-9.

Then, on the other side, there aren’t always places to send people when you have positive screenings. Where did they go, what do they do? Additionally, I’ve had a lot of patients say, “When I fill these things out, I don’t always answer honestly because I am scared that someone is going to call child services and take my children away.” I think there’s stigma, it’s a resource issue, and it’s also a structural issue in terms of where do we send patients and what resources do we have for them?

Dr. James: I would agree completely that those are all significant factors. As someone who’s an OB/GYN, performing those prenatal and postpartum visits, I’ll tell you that historically, we get very little training on the mental health aspects of caring for pregnant women. Nevertheless, we’re the ones that are responsible for evaluating, screening, and then, if not treating, referring. I believe that number one is just a lack of training.

Number two: lack of reimbursement. Our time is very, very finite. There are so many things we’re supposed to be screening for in terms of domestic violence, substance abuse, teratogenic medication exposure, seat belts, and so many other things. While PPD is certainly extraordinarily important, sometimes it may get lost in the shuffle.

I also very much agree with Dr. Sackey that many healthcare providers are worried about screening because they’re worried about the results. Because if those results show a patient who needs to be referred or treated, the availability of resources and the insurance coverage of that treatment are often in question. As a result, I think many healthcare providers are concerned that if they find an abnormality that requires follow up, they may not have the resources needed. So they’d sometimes rather just stick their head in the sand and not address the issue unless it becomes readily apparent.

Dr. Sackey: About 60% to 85% of people who give birth experience baby blues. It is a normal thing that people go through because it’s an adjustment period. Not only are you adjusting hormonally—there’s been a huge drop in your reproductive hormones, but also changes in other hormones. Cortisol increases, your TSH is fluctuating, your oxytocin, your prolactin—but there are also environmental changes. There is a new person potentially added to your family, and there’s a role change as well.

People go through a normal adjustment period, so they might be more tearful. They might feel as though they’re not completely adequate, but they’re still functioning. They’re not getting a lot of sleep. They might feel a little irritable and they might not be eating as well as before, but that’s normal and should regulate within two to four weeks. The worst of it with the baby blues is about three to four days postpartum.

With postpartum depression, this is something that’s lasting longer and is functionally impairing. Someone can’t care for themselves or their baby. They’re feeling a huge disconnect. They’re feeling like, “Someone would be better doing this job than me. I can’t care for this child. I’m not feeling a connection to this child.” There might be thoughts of harming themselves or the baby. There’s a lot of social isolation and not sleeping. When I think of postpartum depression, it’s functionally impairing, lasts a lot longer, and is a lot more severe than baby blues.

Dr. James: Yeah, I don’t think I could say it any better. I would also contribute that while I’m a huge proponent of advocating on the behalf of breastfeeding, that it is often a source of significant stress and difficulty because even though it’s natural, it’s not necessarily easy or as straightforward as people would hope. I think that many moms feel extraordinarily anxious and concerned when that process doesn’t go as they would hope it would, and I think it can contribute to the baby blues quite a bit.

The main difference with postpartum depression, of course, is it persists. It can also occur in the third trimester, whereas postpartum blues are necessarily right after the birth. Postpartum depression can be third trimester depression. And like Dr. Sackey said, it’s functionally impairing. For me, the most vital question is, “If your baby is having difficulty, do you feel motivated to address those issues?” A lot of times, moms feel that they’re just not able to tend to their child. That, to me, is the red flag that says that it’s become functionally impairing.

Dr. Sackey: I completely agree. Also, with breastfeeding, I think a lot of people feel the pressure, but we always say that what’s best for mom is what’s best for baby. Someone recently said something to me and I thought, that’s so spot on: If you go to a kindergarten, can you pick out which kids were breastfed versus which kids were formula fed?

I think a lot of moms feel pressure, but when you’re getting up to feed, you’re decreasing your sleep. That contributes to postpartum depression. Also, when you’re getting up to feed, it might be difficult to feed because your oxytocin and prolactin are decreased when you’re depressed, so it is very difficult to produce milk then. So it creates this cycle where people are blaming themselves. We really want people to be in a space where they’re feeling, “I’m in a confident space to parent.” What’s best for you mentally is what’s best for your baby.

Dr. Sackey: When I see patients at the beginning of the pregnancy, I’ll often, almost jokingly, say to them, “Look, during your pregnancy, I basically become your obstetrician, your gynecologist, your primary care physician, and your psychologist,” because a huge component of what we do is mental health—talking about what’s normal and not normal.

I start, at the beginning of the pregnancy, letting them know that discussions about mental health or psychological issues are the norm in prenatal care. I try to make it so that they’re comfortable opening up about those issues, understanding that unless they already have a psychologist or psychiatrist that they’re dealing with, it’s a huge hurdle to get them into a mental health therapist. So that’s where I start. I start off with a very open-ended question: “How are you feeling? Are you doing well? Are you happy? What are your concerns?” That’s not necessarily about physical complaints or pregnancy-related complaints, but also giving patients the permission to talk about their mental health concerns as well.

Dr. Sackey: Yeah, that’s a really great point because perinatal mood and anxiety disorders are the number one complication of pregnancy, and, in the postpartum period, suicide. Postnatal suicide and substance use are the top causes of death after a pregnancy. I think it’s really important for not just behavioral health professionals but also OB/GYNs to have that conversation.

We try to have our team talk to patients about their birth preferences. Often, we like to say, “This is the plan,” and we sometimes think we have to stick to it, but things change. So, “What are your preferences in the postpartum period? And if these things are to happen, how are we going to address them?” We often bring in partners to discuss that as well.

Dr. James: I just want to touch one more thing on that. We talk about birth plans all the time, and even the best plans often are not accomplished the way we hope. It’s important to let parents understand that pregnancies and childbirth are marked by significant degrees of unexpected outcomes. I find that with patients who have the most difficult issues with mental health, it’s because they have a situation they weren’t expecting. It can be an unplanned cesarean section, premature labor, or a baby that ends up in the NICU. Those parents are going to be the most likely to have postpartum depression because it’s a combination of the hormonal changes, the reaction to the situation, and those combined to exacerbate the potential for depression.

Dr. Sackey: We know that Black and Brown women are more likely to experience trauma throughout their lives, whether that’s racial trauma, sexual trauma, or trauma from being of different socioeconomic statuses. When you have risk factors for perinatal mood anxiety disorders, you are more likely going to experience them. As providers, we have to start looking at people’s risk factors being a woman, a woman of color, experiencing trauma, and then also potentially having depression or anxiety before giving birth.

Also, you are more likely as a Black or Brown woman to experience medical issues due to medical racism, like gestational diabetes, gestational hypertension, pre-eclampsia, C-sections, birth trauma. Even knowing those things can increase your risk for anxiety and depression in the postpartum period. Also, if you have a child in the NICU or your child was born pre-term, that also is a huge risk factor.

We must talk about those risk factors, making sure that we’re doing screenings on all of our patients. Some studies have even said that we should have lower EPDS cutoff scores for women of color. Look at people’s scores, not just their scores, but how they answered questions. Talk to them, give them referrals, and let them know we’re not going to call child services unless there’s something egregious going on in terms of child abuse or neglect, but there are services on the other side that are going to help you with your mood and your anxiety. That can be therapy, medications, or both.

Dr. James: I practice in Miami, Florida, so my patient population is about 75% to 80% Hispanic. We have a checklist of risk factors on the hospital chart for every patient so that we can address and look for those risk factors.

The other big issue is just recognizing cultural differences within specific ethnic groups. Hispanic patients have different ways of dealing with mental health issues than non-Hispanic patients. Patients have certain specific characteristics. Sometimes you may have a family member who is able to communicate their issues better than the patient. There may be concern or embarrassment about discussing their mental health issues. I think these are all factors, and we just have to make sure that we are implementing that cultural sensitivity component into the training of the healthcare providers so that they can recognize differences in different groups.

Dr. Sackey: Absolutely, and to tack onto that, sometimes our patients say, “I would go to this service or this group, but I don’t know if I feel comfortable being the only person who looks like me.” Having providers that are similar to patients, in addition to services that are specifically for patients of certain cultural groups, can often eliminate some of the barriers that we have in reaching those patients.

Dr. James: Whether it’s a physician or a midwife or nurse practitioner, it’s important that we all take ownership of this situation. It is our job to screen. If we don’t screen, no one else is going to do it. And if no one does it, then these patients will fall through the cracks, and the morbidity becomes so much more significant. We’re the frontline, and we need to make sure that we are being proactive in screening our patients and screening frequently. It costs nothing. It takes a very, very brief amount of time. But the differences that we can make in our patient population are immense.

Even aside from postpartum depression, the other things that we can catch are social issues, homelessness, food scarcity, domestic violence, all sorts of things. The amazing things that we can find out when we screen patients for postpartum depression are just innumerable.

Dr. Sackey: I agree. And we must think outside of the box and offer patients many different things, like getting in touch with family members or having patients bring their family in. For a lot of patients who are trying to take care of their children in the postpartum period, or unfortunately, for some patients who’ve experienced a pregnancy loss but are still going through similar symptoms because they’ve had these hormonal changes, having family members who know the symptoms can help. We can educate them on postpartum depression and anxiety so that they can identify symptoms to help the patient get care when they need to get it.

Also, talk to patients very early even before they may exhibit some of the symptoms. Let them know that it is possible to take medications during pregnancy and while breastfeeding, talking to them about the risk of being on meds versus not. For a lot of patients, there’s a greater risk for being off of meds. We can let them know that there is this great medication called zuranolone, which has been effective for many patients for postpartum depression. It allows you to stay at home with your baby while you are being treated for postpartum depression; it’s a medication that is 14 days and can be taken in the evening. It helps you to sleep. We know that sleep is a huge thing that we need to protect during the postpartum period as well.

In order to prevent and treat postpartum depression by bringing in a lot of people’s networks and communities, we can help to treat postpartum depression, but also identify it, which is the first step.

Dr. James: I want to circle back on what we talked about before, which is, what are some of the barriers? We talked about the fact that healthcare providers are worried because they don’t know how to manage it if they uncover postpartum depression.

We now have FDA-approved treatments specifically for this disease state, like zuranolone. We can be reassured that we can treat the patients, that we have high efficacy and rapid onset of efficacy. Whereas historically, we were using medications off-label that took quite a while to demonstrate any improvement, and patients would be quite frustrated, as would healthcare providers. The landscape has markedly changed and has given us as providers more confidence in screening because we know that we can treat with high efficacy.

Thanks for listening. Stay tuned for next week’s episode. To hear more, follow PeerPOV: The Pulse on Medicine on Apple Podcasts, Spotify, or Amazon Music.

This transcript has been edited for readability.