Transcript:

Moderator: Hello, and welcome to today's podcast, Navigating Postpartum Depression Through Care Coordination. Today, we will be discussing postpartum depression and the implementation of multidisciplinary care models to improve patient care. We are thrilled to have two special guests with us to participate in the discussion, Dr Nicole Cirino and Dr Julie Carbray. Welcome; we're so happy to have you both with us. We'd love to have you introduce yourselves. Dr Cirino?

Dr Cirino: Thank you. I am excited to be here. So, my name is Nicole Cirino. I am a reproductive psychiatrist who has been practicing now for almost 25 years. I am the division chief of reproductive psychiatry and a professor in both the Department of OB/GYN and Psychiatry at Baylor College of Medicine, which is within Texas Children's Hospital Pavilion for Women. I'm also the chair of the executive board of Postpartum Support International and the education chair of the Board of the International Society of Reproductive Psychiatrists.

Moderator: Over to you, Dr Carbray.

Dr Carbray: Thank you for having me. Thank you, Dr Cirino. My name is Julie Carbray, and I'm a psychiatric mental health nurse practitioner and a clinical professor of psychiatry and nursing at the University of Illinois Chicago's Department of Psychiatry and College of Nursing. There I direct a large mood disorder clinic for children, and I oversee a mood disorder program, along with nurse practitioner training across the College of Nursing. So, working with children, families, and mothers has been a part of my wheelhouse there for the last 32 years.

Moderator: Fantastic. So, let's start with a question for Dr Carbray. What is postpartum depression?

Dr Carbray: Great question. Postpartum depression is a significant mental health condition that affects approximately 15% to 25% of women within the first year after childbirth. And this is estimated to be even higher in women of color. Postpartum depression usually manifests within a few weeks following delivery, but it can develop up to 1 year later, distinguishing it from those not more mild transient baby blues to being a real cluster of symptoms that form a diagnosis of postpartum depression.

Those symptoms include typical characteristic features of major depressive symptoms, things like losing interest in activities or things that a woman used to do prior to the depression episode, changes in sleep and appetite, excessive guilt, having low energy, and even being tearful, and these symptoms can persist for months on end. So, essentially, what you see is a shift in mood from the baseline of the woman as they're going through their pregnancy and postpartum.

Moderator: Thank you, Dr Carbray. Dr Cirino, what are the known impacts of postpartum depression?

Dr Cirino: Yeah, so we have learned, you know, kind of following the data of the last 15 to 20 years that postpartum depression not only impacts the mother but also can impact their families and the child. It can reduce maternal bonding, which can negatively affect infant development. It can further exacerbate maternal physical health, and it can worsen and cause impairment in family dynamics. Untreated postpartum depression can also result in long-term negative consequences for the child's development. So, despite our awareness of these negative impacts, only about 50% of postpartum depression cases are actually detected.

Moderator: Wow, it sounds like many individuals are not receiving the mental health care that they really need. Dr Cirino, why do you think that might be?

Dr Cirino: There really are a lot of barriers to seeking help that prevent women from receiving the appropriate mental health care during the postpartum period. New mothers may be reluctant to ask for help or report their symptoms due to social stigma. They may fear they're being judged or misunderstood by their health care provider; they may be concerned about being reported to social services.

Another barrier is access to health care in the United States, especially for women who are uninsured or underinsured; women, for instance, who receive state-funded medical coverage during pregnancy, often lose access to that coverage shortly after. This coincides with the time that the symptoms of postpartum depression develop, and we cry for our treatment. Also, there is a shortage of perinatal mental health clinicians nationwide. Thus, we are moving towards a health care system where all obstetric clinicians will be able to be informed about maternal mental health conditions and, in many cases, even initiate treatment.

Dr Carbray: Exactly right, Dr Cirino. This access issue and some of the impediments to getting women the care that they need are going to make a huge difference. Another known barrier to seeking help includes a lack of standardized screening tools. Typically, across different clinical areas, different tools might be used to detect those depressive symptoms in pregnant women and women of childbearing age. And so, we're missing cases because of a lack of guidelines and standardization across different centers of care.

Then, also, inadequate assumptions about who's coordinating care can often get in the way. It may be that the mother has been seen with their infant in the pediatric office, but they believe that, perhaps, OB/GYN has already gotten the ball going with some of the concerns about the mom. Perhaps, maybe the lactation consultant isn't sure whether or not somebody has detected some of these concerns in the woman. So, those types of inadequate coordination among health care services can often be a barrier to timely diagnosis and treatment. And that's directly related to our conversation today.

Moderator: Fantastic, thank you both for that important background information. So, in our discussion today, as you mentioned, we'd like to talk about how care coordination may help address these barriers. Dr Cirino, what is care coordination in the context of postpartum depression and what purpose does it serve?

Dr Cirino: Care coordination and postpartum depression are essential for ensuring that mothers receive comprehensive care, mental health education, and access to resources and services. It involves collaboration across specialties. They can include primary care, obstetricians, gynecologists, nurses, midwives, pediatricians, mental health specialists, lactation consultants, and others. Research does demonstrate that multidisciplinary care approaches enhance the quality of care for new mothers, which ultimately improves outcomes for mothers and their infants. In addition, multidisciplinary care has been shown to reduce the burden on individual health care professionals.

Moderator: Dr Carbray, what are some potential challenges with implementing multidisciplinary care models?

Dr Carbray: Yeah, that's a great question. Probably the largest is time. We're all very busy clinicians in our clinical settings. And so, not only time but also communication barriers. Establishing those contexts between different clinical services, as well as some comprehensive training that can occur all the way across those multidisciplinary professionals that Dr Cirino mentioned earlier. Then, in addition, engaging mothers and learning and finding some culturally specific ways to be able to tap into their needs to get that education and to connect with others around their care. So, to overcome these difficulties, all of us as providers should establish clear communication protocols, build this culture of collaboration, and identify resources to begin with.

So, we're having guidelines and those established resources then, also discussing effective ways to educate our patients and to establish outreach so that we're getting the care that's appropriate care for our population in a timely basis. We're not reinventing the wheel each time we have a mom encountering depression.

Moderator: Fantastic. So now that we've set the stage, let's talk practically. Dr Cirino, can you share a real-life example of how care coordination and multidisciplinary care have helped mothers navigate postpartum depression?

Dr Cirino: Yes, I'd love to. One approach that we find incredibly helpful is to have mental health specialists embedded in the obstetrics and gynecology clinic setting. So, where I work now at Baylor College of Medicine, our psychiatry group called the Women's Place is one clinic within the large obstetrics and gynecology outpatient setting. So, literally, a patient can come over to our clinic without having to leave the building. Not to mention, we share notes, schedulers, etc. So, it makes it very easy for care to be transferred over to mental health services and also reduces the stigma. We also support our OB /GYN clinicians and partners and implement universal screening.

So, we help them set it up. We provide both urgent and non-urgent care for women suffering from postpartum depression who screen positive, and we're available for consultation and questions. They don't feel kind of left out in the lurch and not know what to do when a patient presents with symptoms. That really helps! We found an increased universal screening when there is support from the mental health team. We also provide perinatal mental health education to all obstetric clinicians in our hospital, including nurses and social workers.

So those who work in the hospital are aware of the perinatal gluten anxiety disorders, they're comfortable recognizing depression, they know where to refer out, and many of them often initiate treatment themselves. Another thing that we found state by state is we have a perinatal psychiatry access program in Texas called PeriPAN. This is a part of the perinatal psychiatry access program network in which any clinician can call to receive an immediate consult from a perinatal mental health expert and help them manage the patient that's sitting in their office in their postpartum visit. And so, we will kind of advise on treatment, management, referrals, etc. There is also a national perinatal mental health access program through Postpartum Support International. So that's something to look for in your state.

Moderator: That's great information! Thank you. Dr Carbray, can you share some practical tips for health care providers who would like to implement or improve care coordination and multidisciplinary care models?

Dr Carbray: Yes. You know, it's great to hear about the great work that Dr Cirino is doing. Here in Illinois, we have similar models of consultation around cases. The need for building more practitioners specializing in this field has been overwhelming—as she also noted. So, it comes down to resources. It comes down to being able to have direct consultation relationships across your medical center.

In our center, we have very similar services to Dr Cirino's in that we've had established relationships that go across pediatrics, OB/GYN, and our women's health service in our psychiatric department have these relationships on an ongoing basis. So, referrals inwardly and to the outward community are effectively reached because everybody is getting to know one another. Education is robust in terms of continuing to share new findings for how to best help moms. There are also some active research projects within our state of Illinois.

We have a state senator who's been very active in looking at how do we best support women of color. We have several projects that have been established to try to reach those women and connect them with equal treatment teams to their culture and to accommodate some of their distinct needs. So, we have some community groups that are linking moms with similarly cultured nurse midwives within our group of many nurse midwives within our health system. We also have something called the Sunnyside app that a couple of my colleagues in the department of psychiatry are using across OB/GYN to embed some cognitive behavioral therapies on an app-based service to provide support to moms when that warm handoff can't happen.

They're studying the efficacy of that, along with linking to other mothers who may be within the community experiencing similar symptoms. Like Dr Cirino, there's also a consultative service across the state of Illinois, where if a practitioner is having a woman who is encountering postpartum depression, there can be direct access to a psychiatrist who can provide some advice on managing that case—that's called their Illinois DocAssist Program. Then, there are multiple online sites, including several perinatal mental health resources for clinicians that offer new disorder screeners, up-to-date research on helping women, and some of these online CBT interventions that clinicians might be able to supplement across their visits with patients with postpartum depression.

I think there's knowing your resources and knowing the community and those individuals invested in the same care for women encountering postpartum depression really is the key.

Moderator: Wow, thank you! Sounds like a lot of amazing programs. Finally, I'd like to ask you both to offer some advice. How can mothers and their families seek out and advocate for comprehensive mental health care in the postpartum period? Dr Cirino, I'll ask you to start.

Dr Cirino: Yes. I think that's a great question. I think there are—actually, it depends on the state—but there are potentially many resources available, but you have to know where to look. Often, that can be the difficult part. I would start by having a woman go to her obstetric clinician, most of whom are trained to assess and provide referrals and often initiate treatment. Hopefully, the obstetric clinician is part of one of these communities that has started to gather resources and have resources available.

Many resources we have, for instance, are hyper-local, and some are national. There is research, for instance, at Texas Children's Hospital called Uplift, where there are actually trained social workers who can visit the home and provide mental health treatment for new mothers. That's something that's hard to find if you're not aware it is something that's available, especially for women who prefer to have the treatment that comes to the home or have barriers to accessing care. On a national level, Postpartum Support International, which is nicknamed the Red Cross of Perinatal Mental Health Disorders, provides a number of free services such as education, individual one-on-one peer support, up to 30 support groups a week virtually, and a provider directory.

This website is postpartum.net. They also offer a free helpline and support, which we now have for the first time in the last 2 years: a national 24-hour maternal mental health hotline that is in both English and Spanish. These are resources that are available to everybody throughout the United States and can help guide you to local resources.

Another resource I wanted to mention is Massachusetts General Hospital, which has the website womenshealth.gov. It offers high-quality education about perinatal mental health conditions and specifically really focuses on treatment options and their safety for use during pregnancy and lactation, which is something that many mothers and clinicians are concerned about a lot more education on.

What do you think, Dr Carbrey? There are some. What else do you think?

Dr Carbray: Yeah, you took some of those words out of my mouth. That national maternal mental health hotline. I love the number. It's 833-TLC-MAMA, M -A -M -A. This, of course, is not only a helpline, but I can also steer women towards resources in their community. The only other resource I might add is the nationalmothersandbabiesprogram.org, which does list evidence-based interventions for moms and can provide tools for you as a therapist, as well as for moms themselves in trying to envision a comprehensive approach toward their care, including some of their own strategies for managing depressive symptoms and can also provide a resource for home visits depending upon where those moms live.

Yeah, I think a lot of it does depend on where mom lives in terms of their state resources, but we do have some national resources now that moms can tap into.

Moderator: Wow! Thank you so much for such an informative discussion. Can you each share a few closing thoughts? Dr Cirino, let's start with you.

Dr Cirino: Well, I'd just like to close with it. The good news is that postpartum depression is a treatable condition. We have many trainees who come through our clinic. I'm sure as Dr Carbary does as well. They always come back to me after someone has been successfully treated. I cannot believe how much better she got. I cannot believe how well she looks. So, this is a treatable condition. However, one single treating clinician, one single modality, and one single medication are often never the answer for recovery for these women. Women do better with the support of their entire health care provider team: their lactation consultant, postpartum doula, their obstetrician, and their child's pediatrician. During each visit, we talked about other touch points that she could make with her obstetric team and her community. Have you reached out to postpartum support international? What about lactation? Have you talked to your child's pediatrician about your concerns about the fact child's not sleeping? We really try to get mothers engaged in multiple kinds of points of care throughout. So, the family, the community, and the local and national organizations all play a role in recovery.

We really tell women, you know, if you're not feeling well, please speak up so those around you can help you. There are likely resources available that you're not aware of. There are likely other women and clinicians who want to help. I'm always so surprised that when women say they really were afraid to bring it up to their peers or their friends, and then when they did, the established connection where often their peer or their friends says, ‘I had that too. It was terrible. Let me help you with that.’ Women are just so surprised at how receptive their partners, their colleagues, and their community are to a woman bringing this up to them. So don't let the woman be isolated; speak up if you're feeling unwell.

Dr Carbray: Dr Cirino, those are great points. I'd like to echo that it really is that sense of isolation that sometimes gets in the way of a woman asking for the help that they need. So, how do we help women, especially, I would add, women of color who may be feeling very disenfranchised and may not have a community that they can easily tap into? How do we help them access those resources to seek support from that community? How do we build connections not only with women in need of our assistance to be able to help them through these depressive symptoms and to navigate their treatment? How do we best collaborate? Really not assuming that it's somebody else's house that's caring for this child, having those effective ways of communicating with each other, having a list of resources and establishing relationships with this common concern of caring for women during this time, and continuing to challenge ourselves, both in our training environments and across our clinics. How do we best overcome stigma and address some of the cultural issues that get in the way of women asking for what they need when they're going through this experience that can have a huge impact on their entire family?

Moderator: Absolutely. Thank you so much, Dr Cirino and Dr. Carbray. For our listeners, if you want to dig deeper into the topics covered in today's discussion or learn more about postpartum depression, please visit spotlightppd.com. Please consider sharing this podcast with your peers and engaging in your own conversations.