Addressing Gaps in Postpartum Depression Screening and Care

Despite increased awareness, many patients with postpartum depression (PPD) continue to go undiagnosed. In this video, International Society of Reproductive Psychiatry (ISRP) Board Member and Psych Congress faculty Melanie Barrett, MD, discusses how mental health care providers can address gaps in PPD screening, diagnosis, and treatment in clinical practice. Barrett offers an overview of differential diagnosis considerations and treatment options that may best target depressive symptoms in this patient population. She also explores how clinicians may leverage universal screening and patient education to reduce stigma and improve patient access to treatment. 

• Universal screening, patient education, and established referral pathways may help address underdiagnosis, reduce healthcare inequities, and improve access to treatment.
• Clinicians should evaluate for bipolar spectrum disorders and postpartum psychosis, assess prior mood symptoms and family history, and consider that 28% of women with bipolar disorder experience their first mood episode postpartum.
• Psychotherapy, support groups, and pharmacotherapy are options based on symptom severity and treatment history, and zuranolone, a US Food and Drug Administration (FDA)-approved 14-day treatment specifically for PPD, may rapidly improve depressive symptoms.

Melanie Barrett, MD: Hi, I'm Melanie Barrett. I'm a psychiatrist. I practice in Edmond, Oklahoma in an outpatient practice. I'm also on the board of ISRP, which is the International Society of Reproductive Psychiatry.

Psych Congress Network: Despite increased awareness of postpartum depression, many women still go undiagnosed. What are the biggest reasons PPD continues to be missed in clinical practice?

Barrett: In addition to awareness of what postpartum depression is, I think we really need to be talking about and educating on, what's normal? When do you need to ask for help? How do you ask for help? How do you navigate the system and provide resources in the community to be able to follow up on that? 

It's very important to screen. We talk about doing universal screening to reduce healthcare inequities, and to have a system in place to know how to follow up on those screeners and how to facilitate care access points for our patients.

PCN: What key signs or symptoms may help clinicians differentiate PPD from bipolar disorder and postpartum psychosis during screening and diagnosis?Barrett: It's essential when patients come to us and they present with postpartum depression that we then take the next step to always rule out a bipolar spectrum illness and postpartum psychosis.

We know that 28% of women with bipolar disorder had their first onset of a mood episode in that postpartum period. While it's important to be asking our patients about previous diagnoses, about symptoms in the past that have been consistent with a bipolar disorder, we need to really have our eyes and ears open for that initial presentation and the postpartum period. So that starts with the screening tools that we're using and then the follow-up questions for our diagnostic evaluation. 

PCN: What role does a history of premenstrual mood symptoms play in assessing PPD risk?

Barrett: One thing that we can be looking for or asking about in our female patients is related to the menstrual cycle. Historically, prior to pregnancy, have they experienced mood worsening, anxiety worsening in that week before their menstrual period that then is alleviated with the onset of menses

That is kind of a red flag that we need to be listening for that would indicate they are at higher risk for a hormone-mediated mood disorder, family history of postpartum episodes, onset of postpartum episodes, to also clue us in.

PCN: What factors are most important to discuss with patients when weighing the risks and benefits of treatment during the postpartum period?

Barrett: When we're talking to our patients it's really important to communicate in a way that reduces shame, that reduces stigma, and that talks about how postpartum depression is a medical condition, not a reflection on one's ability to be a mom. It is not a sign of weakness and it is not something that you just power through. It's a medical condition, it's treatable, and we have treatment options.

We know that postpartum depression, if it's left untreated or undertreated, can persist for years and that can impact mom, it can impact baby, it can impact the whole family. It’s really important to not only identify but to discuss promptly and adequately treat postpartum depression for the individual and the whole family. 

PCN: What are some current options for PPD treatment and which new developments are you most excited about? 

Barrett: Postpartum depression is treatable. I think that's the main takeaway that I would want people to hear is that it is treatable. 

When we're thinking about treatment options, we're thinking about severity of presentation, history of prior episodes of depression, and how those have impacted the individual. Those are things that we're thinking about when we're formulating what options we might consider. 

But we're thinking about therapy as an option. We're thinking about support groups as an option. What medications have historically worked for this individual? Are those options to restart? 

Zuranolone has been really a breakthrough for postpartum depression. It is the only FDA approved option, specifically for pharmacotherapy, for postpartum depression. It's a 14-day treatment and it has the potential to rapidly improve postpartum depressive symptoms. 

And that is our goal, to, as quickly as possible, get moms feeling back to a state of euthymia and feeling back to themselves.

Melanie Barrett, MD, received her medical degree from the University of Oklahoma College of Medicine following undergraduate studies in Psychology at Texas A&M University in College Station, Texas. She completed her psychiatry residency at the University of North Carolina Hospitals, Chapel Hill, where she served as a Chief Resident. Dr Barrett specializes in the treatment of women’s mental health disorders and treatment resistant depression using an integrated approach and has obtained board certification from the American Board of Psychiatry & Neurology. She is currently serving on the Board of The International Society of Reproductive Psychiatry and is a Distinguished Fellow of the APA.

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