While many doctors and patients are still surprised to learn that perinatal mood disorders are the most common complication of childbirth, their awareness is thankfully increasing. Given this, it’s an important time to review how both the diagnosis and treatment have made big strides in recent years so you can ensure your patients are getting optimal care before, during, and after their pregnancy.
Updated terminology that is more inclusive
While many doctors still refer to postpartum mood disorders as postpartum depression (PPD), it is more accurate to adopt the umbrella term of perinatal mood disorders. This latter name is important because it encompasses other mood issues that can be present such as postpartum anxiety (PPA), postpartum psychosis, and other mental health issues such as obsessive-compulsive disorder or preexisting mental health diagnoses. Postpartum anxiety is especially important not to miss, since the same percentage of women who are diagnosed with PPD are also diagnosed with PPA. If doctors are only asking about feeling sad or depressed, they will be missing the women who instead have symptoms of agitation, inability to sleep, or excessive worry. These women will go untreated, and they need it just as much as the mom with PPD.
Improved recognition of antenatal perinatal mood disorders
Historically, women have been screened for PPD at their postpartum visits. We now know that antenatal depression and anxiety are real, affecting about 7 to 20 percent of all pregnant women. What is worrisome is that untreated mental health disorders in pregnancy can lead to higher rates of PPD/A, missed prenatal appointments, poor diet and weight gain, use of illicit substances, and suicide. Their babies are also more likely to be born premature and be small for gestational age. Given that we have proven ways to treat these women that are safe and effective in pregnancy, it is crucial that we start screening for perinatal mood disorders well before they give birth.
Changes in the timing and frequency screening
Again, the norm used to be that a new mother was screened just once for PPD at her six week visit. As you’ll read in the next point, the American College of Obstetricians and Gynecologists (ACOG) has been hard at work reframing the postpartum period. Their goal is to change the mindset of postpartum care from a one-time six week appointment to a 12 week continuum of care model. With that, they call for earlier and increased screening for perinatal mood disorders. New mothers should be screened prior to hospital discharge for risk factors that may place her at higher risk of developing a perinatal mood disorder, and again at each of her postpartum visits. Additionally, many pediatrics offices are screening new mothers since they also come into frequent contact with them, which allows for increased screening and diagnosis opportunities.
Embracing the concept of the fourth trimester
As mentioned earlier, ACOG is working hard to change postpartum care from a single office visit and recovery clearance to an ongoing process that involves screening for multiple complications and tailoring referrals and support specific to each mother. This vision recognizes that recovering from birth is a life-changing process that takes time, and that with the birth of a baby also comes the birth of a new mother. In a perfect world this would be common sense, but we have yet to fully embrace it. Hopefully with ACOG lending its support, models of care and practice patterns will adapt to accommodate these and as part of it, increase not only the screening for perinatal mood disorders but also the coordination of appropriate referrals, treatment, and follow-up.
Realizing that dads need to be screened, too
Dads are often left out of the conversation when it comes to postpartum depression or perinatal mood disorders as a whole. However, newer evidence is showing that about 10 percent of new dads experience some depression or anxiety after their baby is born. Fathers are an integral part of their family, and just as untreated depression in new moms leads to poorer outcomes in babies, so goes the same for untreated dads. We can improve our screening and diagnosis of new fathers by incorporating them in office screening as well as providing patient education in the antepartum and postpartum time periods.
Increased patient awareness and education
Thankfully, the conversation regarding mental health seems to be flowing more easily in today’s society. We can continue to support this as physicians, whether by normalizing it in our patient visits, having office décor such as posters or pull-tab flyers in high-contact patient areas that promote mental health awareness, and providing educational handouts or videos. The Wellness Network’s prenatal and maternity solution addresses core issues, including pre- and postnatal mental health.
Breakthroughs in treatments
Many physicians by now have heard of the new drug recently approved by the FDA to treat postpartum depression. The new drug, brexanolone, is an IV infusion that needs to be administered in a hospital setting over 60 hours. While it has been shown to be effective in women with moderate to severe PPD, the price tag of $34,000 as well as the need for a hospital stay (which is not included in that price) certainly gives many physicians and new mothers pause. Despite these barriers, it is encouraging that more attention is being given to perinatal mood disorders, and increased research into effective treatments for this is a good thing.
The take-home message
Perinatal mood disorders are common, and we are now living in a time where discussing mental health disorders is becoming more mainstream. As physicians caring for pregnant and postpartum women, we need to continue to improve our screening well before these women give birth, and continue to do so frequently in the postpartum period. We need to make sure that with screening comes adequate referrals for therapy and ongoing support, and we must feel comfortable prescribing medications to pregnant and breastfeeding women. Lastly, we need to embrace the concept of the fourth trimester and whole-family care, because our patients expect and deserve this.
- The American College of Obstetricians and Gynecologists. Committee Opinion #736: Presidential task force on redefining the postpartum visit – Optimizing postpartum care. May 2018.
- ACOG Postpartum Toolkit.