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.

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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?

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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.

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