Science & Sensibility

By, Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take.  The first post in the series is here  Part III will appear on Dec 13th, 2012.– Sharon Muza, Community Manager.

________________________

We have the opportunity to hear another expert perspective regarding the use of antidepressants, stigma, and the role childbirth education might play in the prevention of perinatal mood and anxiety disorders (PMAD). This installment features Nancy Byatt, D.O., MBA. Dr. Byatt is a perinatal psychiatrist and Assistant Professor of Psychiatry and Obstetrics & Gynecology at University of Massachusetts Medical School/UMass Memorial Medical Center.  Dr. Byatt’s research focuses on understanding and evaluating ways to improve depression outcomes for perinatal women and their children through health care system improvement.  Her current research aims to improve the uptake of evidence-based treatments for perinatal depression in obstetric settings.  I know I speak for Lamaze International in thanking Dr. Byatt for participating.

WK: What can we do to increase the understanding that a woman’s mental health is part of maternal health?  

Dr. Byatt: Providing psychoeducation to women and their partners about the importance of perinatal mental health is a good first step.   Psychoeducation should aim to destigmatize depression and other perinatal mental health concerns and encourage women to engage in treatment.  Providing psychiatric resource and referral source guides may also empower women to seek treatment.  Childbirth educators could also be trained in motivational enhancement interventions that may inspire women to address their mental health concerns.  For example, providing information about health risks, wellness interventions, support groups, psychotherapy, medication options, and other mental health resources can encourage women to engage in treatment.

WK: How might childbirth professionals integrate perinatal mood disorders in classes? 

Dr. Byatt: Childbirth education classes are an excellent opportunity to prepare women and their partner or primary support for the emotional transition to the postpartum period.  Ideally, women should be taught how to take care of themselves both physically and emotionally during this vulnerable time period.  Women and their partners or primary support could be given information about the signs and symptoms of depression so they can recognize depression if it occurs.  It would also be helpful to destigmatize depression and review mental health resources.  Psychoeducation could also be provided about what factors may put women at higher risk for a perinatal mood disorder.

WK: How would you describe the stigma of perinatal mental health disorders and its impact?

Dr. Byatt: Many studies have demonstrated that many women feel very ashamed of perinatal depression and as a result may be less likely to seek help.  More specifically, women may be afraid that they will lose parental or personal rights if they disclose psychiatric symptoms.  They may also fear feeling judged by perinatal health care professionals and/or friends and family.   Acknowledging depression symptoms can also negatively impact women’s view of themselves as a mother.   Unfortunately, these concerns may result is avoidance of mental health discussions.

WK: What do you see as the most significant barriers to treatment for women with PMADs?

Dr. Byatt: Women face many barriers to accessing and seeking help for perinatal depression. Stigma and shame have been consistently reported in numerous studies.  Studies also suggest that interactions with perinatal health care professionals may discourage help-seeking. Some women also report that their emotional needs are not addressed by perinatal health care professionals, perceiving them as unresponsive or unsupportive.  Women also perceive that perinatal health care professionals lack training in regards to perinatal mental health.  Available treatment resources are often limited for both perinatal women and obstetric providers and staff, creating both patient and provider barriers, respectively.

Some typical (but not all inclusive) symptoms of Postpartum Mood and Anxiety Disorders Are you feeling sad or depressed? Do you feel more irritable or angry with those around you? Are you having difficulty bonding with your baby? Do you feel anxious or panicky? Are you having problems with eating or sleeping? Are you having upsetting thoughts that you can’t get out of your mind? Do you feel as if you are “out of control” or “going crazy”? Do you feel like you never should have become a mother? Are you worried that you might hurt your baby or yourself? list courtesy of Postpartum Support International

Women note numerous factors that impede their ability access mental health treatment, including disconnected pathways to depression care.  Women’s interactions with mental health providers can also be perceived as a barrier to treatment. Women may find it hard to access mental health care due to long wait times or lack of available providers. Women may not know who to call or how to get help or have difficulty finding a mental health provider willing to see perinatal women.  

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy? 

Dr.  Byatt: It is imperative to consider risk of untreated depression when considering medication or non-medication treatment during pregnancy.  Multiple studies have demonstrated that perinatal depression can negatively impact mother, infant, child and family.   Maternal depression has been associated with emotional and functional disability in children of depressed mothers.  Although risks have been reported with SSRI use in pregnancy, the preponderance of data is reassuring.

The risks and benefits of treatment with antidepressants should be weighed against the risks of untreated illness.  Does exposure to the antidepressant or untreated illness pose a greater risk?    If treatment with an antidepressant is indicated, then a discussion of the risks and benefits should take place before medication is prescribed.  Pharmacotherapy should be used judiciously and treatment should aim to maximize evidence-based non-medication treatments, such as psychotherapy, in order to maintain or reach remission of the maternal symptoms.

WK: What are your thoughts regarding discontinuation of medication in pregnancy?

Dr. Byatt: Clinical decisions should be based on the risks, benefits and alternatives to medication treatment.  Untreated maternal illness and the potential risks of psychotropic medication must be considered.  It is vital to consider women’s treatment preferences, illness severity, and the risks of no treatment and under-treatment.  Discontinuation of an effective medication often poses more risk than continuation because it carries the risk of relapse and/or in utero exposure to a second antidepressant.

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice?

Dr. Byatt: A combination of staff training, structured screening programs, and community resource guides may help childbirth education organizations encompass perinatal mental health training into their curriculum and practice.  Training childbirth educators in mental health can allow them to feel more confident discussing perinatal mental health, which in turn may mitigate women’s fears and concerns and activate them to seek treatment.

Conclusion:

I wonder about the perception of lack of training in childbirth education courses as a part of the barrier to treatment noted by Dr. Byatt. Disconnected pathways to care seem a call to action for childbirth professionals. Where women and families find lack of education, empathy, and acceptance –childbirth professionals could provide pathways to better treatment merely through community resource lists.  Training, structured screening programs and community resource guides are good suggestions to not only optimize care for women, but to optimize practices for educators.

If you took inventory of the training and resources you have been given regarding perinatal mental health—what would you find? Do you know what resources are available from your certifying organization for you to use in your classes? Have you read Kathy McGrath’s article on the Lamaze.org website on Baby Blues? What are some of your favorite resources and activities that you use in class to cover these topics? How do you envision your childbirth organization creating or growing pathways in the future to support continued education on this topic?

Check

About Nancy Byatt, DO, MBA

Nancy Byatt, DO, MBA:  Dr. Byatt’s clinical, educational and research efforts have been led her numerous publications and awards including the Briscoli Award for Resident-Faculty Academic Collaboration and APA/APIRE Junior Investigators Award.   She recently submitted a Career Development Award Proposal to the NIH/NIMH (National Institute of Health/National Institute of Mental Health) in order to develop and evaluate a new low-cost program that aims to improve the delivery of depression care in outpatient obstetric settings.  Her recent publications include:

1. Byatt N, Biebel K, Lundquist R, Moore Simas T, Debourdes-Jackson G, Ziedonis D.  Patient, Provider and System-level Barriers and Facilitators to Addressing Perinatal Depression:  Perspective of Obstetric Providers and Support Staff. Journal of Reproductive and Infant Psychology.  Link to article:  http://dx.doi.org/10.1080/02646838.2012.743000

2. Byatt N, Biebel K, Debourdes-Jackson G, Lundquist R, Moore Simas T, Weinreb L, Ziedonis D.  Community Mental Health Provider Reluctance to Provide Pharmacotherapy May Be a Barrier to Addressing Perinatal Depression: A Preliminary Study. Psychiatric Quarterly, 2012; ePub ahead of print DOI: 10.1007/s11126-012-9236-0.

3.  Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012 Dec;33(4):143-61. doi: http://www.ncbi.nlm.nih.gov/pubmed/23194018

4. Byatt N, Deligiannidis K, Freeman M.  Antidepressant Use in Pregnancy:  A Critical Review Focusing on Controversies and Risks. Acta Psychiatrica Scandinavica. In Press.

 

Walker Karraa Babies, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Perinatal Mood Disorders, Postpartum Depression depression in pregnancy, guest post, maternal mental health, mental illness, Nancy Byatt, PMAD, postpartum depression, postpartum mood and anxiety disorders, Postpartum Support International, PPD, treatment for PPD, Walker Karraa

This is a post by Science & Sensibility’s regular contributor, Walker Karraa, MFA, MA, CD(DONA)

The recently published study, “Reducing Postpartum Depressive Symptoms Among Black and Latina Mothers: A Randomized Controlled Trial” (Howell et al., 2012) has garnered attention among birth and perinatal mental health professionals.  The intention of this post is to (a) present the evidence given in the study; and (b) encourage community discussion, exploration, and solution-driven strategies for childbirth education practices that address postpartum depressive symptoms in communities of color.

Study Breakdown: Objectives and Rationale

The objective of the randomized controlled study was to “estimate the effectiveness of a behavioral educational intervention to reduce postpartum depressive symptoms among minority mothers” (p. 942).

The rationale for the study itself included the current quantitative data demonstrating the public health problems presented by the high prevalence of postpartum depressive symptoms in American women, and the subsequent negative effects of depressive symptoms on maternal quality of life, mother-infant attachment, and the impact of those symptoms on the social, cognitive, and emotional development of children (cited studies: Gaynes et al., 2005; Howell, Mora, Horowitz, & Leventhal, 2005; Martin et al., 2006; Zayas, Cunningham, McKee, & Jankowski, 2002). Most relevantly, rationale for a study examining African American and Latina mothers specifically was based in evidence of three previous studies that have demonstrated “the burden of postpartum depressive symptoms is especially high in low-income black and Latina women” (p. 942; cited studies: Das, Olfson, McCurtis, & Weissman, 2006; Howell et al., 2005; Lewis-Fernandez, Das, Alfonso, Weisman, & Olfson, 2005).

In this study, Howell, et al., (2012) offered that the rationale for generating a behavioral educational intervention was also rooted in previous research findings that “situational factors such as postpartum physical symptoms, overload from daily demands, and poor social support play a major role in the generation of depressive symptoms” (p. 942, cited studies: Howell et al., 2005; Howell, Mora, DiBonaventura, & Levanthal, 2009; Howell, Mora, & Levanthal, 2006).

 Methods: How Did They Do the Study?

• Recruitment: 540 self-identified black and Latina mothers recruited to participate during their postpartum hospital stay at a “large tertiary inner-city hospital located in East Harlem in New York City” (p. 943). Inclusion criteria included participants who self-identified as black or Latina, 18 years or older, with neonates weighing 2,500g or higher, with 5-minute Apgar score of >7.
• Randomization: Randomization of groups occurred through approved procedure of computerized randomization of participant number. Research coordinators were blinded to the assignment of the study arm of those who would receive the intervention and the control arm that received enhanced usual protocol.

 Intervention: What did they do?

For the group assigned to the intervention, the following 2 steps were taken:

Step 1:

“The in-hospital component of the intervention involved a 15-minute review of an educational pamphlet and partner summary sheet by the mother with a Masters-trained bilingual social worker” (Howell, et al., 2012, p. 943)

 What was in the pamphlet?

“The pamphlet represented each potential trigger of depressive symptoms as a “normal” aspect of the postpartum experience and provided specific suggestions for management. For example, the prevalence of moderate or heavy vaginal bleeding immediately postpartum was depicted by eight of 10 female silhouettes colored red; only one of 10 was red 3 months postdelivery. Simple “to do” statements (rest; use pads) were listed between the two rows of figures.  A separate page was dedicated to social support and ‘helpful organizations’ were listed” (Howell, et al., 2012, p. 943).

 What was the “partner summary sheet”?

The partner summary sheet spelled out the typical pattern of experience for mothers postpartum, i.e., it was designed to “normalize” the feelings and behaviors experienced and enacted by most mothers postpartum and stressed the importance of social support for the patient. The social worker reviewed the patient education pamphlet and partner summary sheet with the patient during her postpartum hospital stay and answered questions (Howell, et al., 2012, p. 943).

 Step 2:

A phone call 2 weeks post-delivery by a social worker was placed to each mother in the intervention group to assess symptoms, symptom management skills, and to review the “to-do” lists in the pamphlets.

 Results: What Did They Find?

The authors compared the group of mothers who did not receive the intervention to the intervention group and published the following results:

• Positive depression screens were less common among the intervention group compared with the non-intervention group at 3 weeks (8.8% compared with 15.3%, P=.03), 3 months (8.4% compared with 13.24%, P=.09), and 6 months (8.9% compared with 13.7%, P=.11).
• Analysis for up to 6 months follow-up demonstrated that:

“Mothers in the intervention group were less likely to screen positive for depression compared with enhanced usual care (odds ratio 0.67, 95% confidence interval 0.47-0.97)” (Howell, et al., 2012, p. 948).

Implications

Here the authors noted that implications were that behavioral education could address and modify risk factors that have been shown to correlate with postpartum depressive symptoms. Increasing mothers’ knowledge about triggers, and the “to-do” list of management of those triggers, followed by the phone contact with trained social worker provided an intervention that demonstrated significance in reduced postpartum symptomatology for this study.  Authors noted that implementing visual modalities in educational materials assisted mothers’ understanding of the triggers, and the range of “normal” symptoms that could be addressed with behavioral strategies, and re-examined in a timeframe of normalcy.

 Limitations

The authors noted that limitations included potential lack of generalizability, as the study took place in one site; they suggested future research in multiple settings would be indicated.

Food for Thought

How does the study inspire ways in which you might most effectively address postpartum symptoms, their triggers, and education with your clients? What are some ways you might use this information in your childbirth education classes?

And lastly, perhaps deeper still, can we truly engage this topic without discussing the role of racism plays in creating barriers to treatment, stigma, and lack of access to care for women of color? What are the steps childbirth and doula organizations can take toward addressing this issue? I would suggest position papers on perinatal mental health and racial disparities would be first line action items for organizations to implement publicly. Outreach to public health and mental health professionals from the organizational level, would further support birth professionals to gain the knowledge and tools needed to acknowledge and address these issues, and become active participants in substantive social change for the future of childbearing women. How many of our organizations are listed in educational pamphlets on postpartum depression as “helpful organizations”?

Walker Karraa, MFA, MA, CD(DONA)

Walker is currently the President of PATTCh, a not for profit founded by Penny Simkin and Phyllis Klaus–dedicated to the Prevention and Treatment of Traumatic Childbirth. Walker is a doctoral candidate at Institute of Transpersonal Psychology, a certified birth doula, writer, and maternal mental health advocate.  She holds an MA degree in Clinical Psychology from Antioch University Seattle, and a BA and MFA degree in dance from UCLA.  Walker is a contributor to the Lamaze sites, www.givingbirthwithconfidence.org and www.scienceandsensibility.org.  She lives in Sherman Oaks, California with her husband, and two children.

References

Das, A., Olfson, M., McCurtis, H., & Weissman, M. (2006). Depression in African Americans: Breaking barriers to detection and treatment. Journal of Family Practice, 55, 30-39.

Gaynes, B., Gavin, N., Meltzer-Brody, S., Swinson, T., Gartlehner, G., Brody, S., & Miller, W. (Ed.). (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes (Summary, evidence report/technology assessment No. 119). Rockville, MD: Agency for Healthcare Research and Quality.

Howell, E. A., Balbierz, A., Wang, J., Parides, M., Zlotnick, C., & Leventhal, H. (2012). Reducing postpartum depressive symptoms among Black and Latina mothers: a randomized controlled trial. Obstetrics & Gynecology, 119(5), 942-949. doi:10.1097/AOG.0b013e318250ba48

Howell, E. A., Mora, P. A., Horowitz, C. R., & Leventhal, H. (2005). Racial and ethnic differences in factors associated with early postpartum depressive symptoms. Obstetrics & Gynecology, 105, 1442-1450.

Howell, E., Mora, P., Chassin, M., & Levanthal, H. (2010). Lack of preparation, physical health after childbirth, and early postpartum depressive symptoms. Journal of Women’s Health (Larchmont), 19, 703-708.

Howell, E., Mora, P., DiBonaventura, M., & Levanthal, H. (2009). Modifiable factors associated with changes in postpartum depressive symptoms. Archives of Women’s Mental Health, 12, 113-120.

Howell, E., Mora, P., & Levanthal, H. (2006). Correlates of early postpartum depressive symptoms. J Maternal Child Health, 10, 149-157.

Lewis-Fernandez, R., Das, A., Alfonso, C., Weisman, M., & Olfson, M. (2005). Depression in US Hispanics: Diagnostic and management considerations in family practice. Journal of American Board of Family Practice, 18, 282-296.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: final data for 2004. National Vital Statistical Report, 55, 1-101.

Zayas, L., Cunningham, M., McKee, M., & Jankowski, K. (2002). Depression and negative life events among pregnant African-American and Hispanic women. Women’s Health Issues, 12, 16-22.

 

Walker Karraa Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Walker Karraa Childbirth Education, postpartum, postpartum depression, postpartum mood disorders, PPD, PPMD, Walker Karraa, women of color

Later this month, Science & Sensibility contributors will share their hopes for the year 2012: what we would like to see accomplished in the ensuing months on behalf of mothers, babies and families, and the maternity care industry as a whole.  One of my hopes for the coming year(s) is that childbirth education organizations like Lamaze will increase their attention to issues revolving around maternal mental health; training birth professionals to screen, recognize, support and appropriately refer women with whom they work who may be suffering from one of the myriad perinatal mood disorders (PMDs)we now understand exists.

To that end, I’d like to share with you a study that recently crossed my desk (thank you, Walker Karraa) which assessed online resources pertaining to PMDs.  Donna Moore and Susan Ayers published their findings from A Review of Postnatal Mental Health Websites: Help for Healthcare Professionals and Patients in the Archives of Women’s Mental Health in November of last year.  The aim of the study was to conduct a systematic review on any and all current websites that maintain a primary purpose of discussing postnatal health with particular interest in the depth, breadth, quality and technological excellence of sites that specifically discuss postnatal mental health. 

 

Studies show that 10–15% of new mothers are diagnosed with postnatal mental illnesses, and potentially one in four women may have significant distress without meeting criteria for a disorder.” (Baker et al. 2009a, b;Czarnoka and Slade 2000)… However, there is now increasing evidence that anxiety disorders are also prevalent in between 3% and 43% of women in the postpartum period (Glasheen et al. 2009).”

The four major search engines were employed (Google, Bing, Ask Jeeves and Yahoo) and the top 25 results for each key word entered were then analyzed.

Disappointingly, the publication of results does not list all sites scrutinized (I would like to see what their search results generated) but the authors did list the top five websites, according to their criteria for excellence which included accuracy of information, available resources for mothers, and website (technical) quality:

Table 1
*_{Table 1 re-purposed directly from publication}

 

The websites were examined for their quality of information and navigability based on the basic criteria list above, as well as by the following sub-categories:

1. Accuracy of Information
a. symptoms (of postnatal mood disorders…not only PPD but anxiety, psychosis and PTSD

b. risk factors (psychosocial, medical history and additional factors)
c. impact (of postnatal mood disorders upon the mother, infant and her partner/family)

2. Available Resources
a. self-help
b. tools for mothers
c.  support for mothers
d.  additional resources.

3. Website Quality
a. authority
b. contact ability
c. up-to-date
d. navigation
e. presentation
f. advertisements (appropriateness or lack there-of, distracting, misleading…)
g. accessibility

 

As concluded by the authors:

 

Information was often incomplete and tended to be about symptoms, predominantly depressive symptoms, such as tearfulness. Coverage of other symptoms of anxiety, puerperal psychosis or PTSD was minimal. This could reinforce the misconception that postnatal mental illness is solely depression or simply an extension of the ‘baby blues’.”

What type of information, as certifying organizations, are we providing our educators?  What kind of information are we, as childbirth educators, providing our clients?  Are we providing information that is accessible (understandable), readily available (are we not shying away from difficult-to-discuss topics) and high quality (evidence-based)?  Are we acknowledging that somewhere between ten and forty-three percent of the women we teach will end up suffering a postnatal mood disorder?  Are we discussing risk factors and approaches to late pregnancy and birth that might help them avoid this outcome?

 

Invitation for reader feedback:  How are YOU implementing postnatal (or perinatal) mood disorders into your curriculum?

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Kimmelin Hull Childbirth Education, Perinatal Mood Disorders, PTSD Archives of Women's Health, baby blues, PMD, postnatal mood disorders, postpartum depression, postpartum psychosis, postpartum websites, postpartym anxiety, PPD, SEO, women's mental health