Dr. Lee S. Lee S. Cohen, director of the Women’s Mental Health Center at Massachusetts General Hospital. .Gyn News 20.01.2023
Postpartum/perinatal depression (PPD) remains the most common complication in modern obstetrics, with a prevalence of 10%–15% based on multiple studies over the past 2 decades. During those same 2 decades, there has been growing interest and motivation across the country, from small community hospitals to large academic centers, to promote screening. Such screening is integrated into midwifery practice, usually using the Edinburgh Postpartum Depression Scale (EPDS), which is the most widely used validated screen for PPD globally.
As mentioned previous columnsUS Preventive Services Task Force recommended PPD screening in 2016, which includes screening women at highest risk and both acute treatment and prevention of PPD.
Since then, screening women for such a common clinical problem as PPD has been widely adopted by clinicians representing a broad spectrum of interdisciplinary care. Included are providers who care for postpartum women: midwives, psychiatrists, doulas, lactation consultants, postpartum support group facilitators, and other advocacy groups.
An open question that has been of great concern recently our group and others have been what happens after the show. It is clear that identifying PPD in itself is not necessarily a challenge, and we have many effective treatments available, from antidepressants to mindfulness-based cognitive therapy and cognitive-behavioral interventions. There is also a growing number of digital apps aimed at alleviating depressive symptoms in women with postpartum major depressive disorder. An unanswered question is how to engage women once PPD is diagnosed and how to facilitate access to care in a way that maximizes the likelihood that women with PPD will receive adequate treatment.
The “perinatal treatment cascade” refers to the majority of women who, on the other side of the PPD diagnosis, fail to receive adequate treatment and continue to have persistent depression. This is perhaps the biggest challenge for the industry and clinicians; How do we, on the other side of screening, see that these women have access to care and recover?
Against that background, it is surprising that the Canadian Task Force on Preventive Health Care recently advised against screening with systematic questionnaires, noting that the benefits were not clear and there was no distinct advantage over standard practice. The proposal contains an assumption that standard practice includes mental health enquiries. Although the task force continues to recommend screening for PPD, their recommendation against screening with a standardized questionnaire represents a bold, comprehensive, if not myopic, view.
While the Canadian Task Force on Preventive Health Care made its recommendation based on one randomized controlled trial, assuming that women receive mental health counseling and that women like mental health engagement around their depression, this is not a uniform part of practice. . So it’s puzzling why the task force is making a recommendation based on such scant data.
The way to optimize access to care and referral systems for women with PPD is not to remove a part of the system that is already in place. Well-validated questionnaires such as the EPDS are easy to administer and are routinely integrated into the electronic health records of both small and large centers. These questionnaires are an inexpensive way to increase the likelihood that women will be identified and referred for a range of potentially beneficial interventions.
PPD is also easy to treat with medication and a wide range of non-drug interventions. New interventions are also being explored to maximize access to women with postpartum mood and anxiety disorders, such as peer-delivered behavioral activation and cognitive-behavioral therapy, which can be community-based and implemented from urban to rural areas of the United States.
The greatest research need may be the pathways to effective treatment and access to resources for these women, and this issue has prompted our group to investigate these issues in our more recent investigations. A better understanding of the factors that limit the access of mental health providers with expertise in perinatal mental health to the logistical challenges of navigating the health care system for sleep-deprived new mothers and their families requires greater attention and clearer answers.
The entire field has a responsibility for postpartum women to figure out the mix of practitioners, resources, and platforms that need to be used to engage women so that they receive effective treatment because we have effective treatment. But the solution to improving perinatal mental health outcomes, unlike the approach of our Canadian counterparts, is not to be found in abandoning questionnaire-based screening, but in identifying the best ways to maximize PPD prevention and access to care.
Dr. Cohen is director of the Ammon-Pinizzoto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides informational resources and conducts reproductive mental health clinical care and research. He has been a consultant to manufacturers of psychiatric drugs. Send him an email firstname.lastname@example.org.