Margaret Howard

Patient choice of treatment for postpartum depression: a pilot study.

SummaryObjective: The lack of systematic efficacy research makes the selection of optimal treatment for postpartum depression (PPD) difficult. Moreover, the treatment decisions for women with PPD who are breastfeeding are heavily influenced by their concerns about infant exposure to antidepressant medication. The objective of this pilot trial was to examine the clinical characteristics of women with PPD associated with treatment selection.Method: This open pilot trial offered 23 women with PPD one of 3 treatment options: sertraline, interpersonal psychotherapy (IPT), or their combination administered in an outpatient mental health setting over 12 weeks. Baseline and treatment outcome measures included the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory (BDI) and the Edinburgh Postnatal Depression Scale (EPDS).Results: Completers across all 3 treatment groups (n = 18) experienced significant clinical improvement with each of the 3 treatment modalities on the HRSD (p < 0.001), BDI (p < 0.001) and EPDS (p < 0.001). There were trends for women with a prior depression to more frequently choose sertraline as a treatment (alone or with IPT, p = 0.07), and for women who were breastfeeding to choose sertraline (alone or with IPT, p = 0.10) less frequently.Conclusion: In this small sample of women with PPD, most women chose IPT with or without sertraline. A larger randomized study could further confirm the suggested predictors of treatment selection identified in this study: previous depression and breastfeeding status.

A psychiatric mother-baby day hospital for pregnant and postpartum women

SummaryMajor depression and other psychiatric disorders are common during pregnancy and the postpartum period, yet these disorders remain largely under-diagnosed and under-treated. Developing programs that are uniquely tailored to meet the needs of perinatal psychiatric patients can improve both the quality and acceptability of care. In this report, we describe the development and implementation of a novel mother-baby day hospital service designed to meet the mental health needs of this special population, and present preliminary data regarding treatment acceptability and effectiveness. Our experience using this model of care for the past five years has suggested that specialized units such as this one represent an acceptable, effective, fiscally viable approach to the care of pregnant and postpartum psychiatric patients. Further research is needed to more thoroughly assess the effectiveness of this type of specialized perinatal service.

Clinical characteristics of perinatal psychiatric patients : A chart review study

Although postpartum depression and other perinatal disorders have been the subject of increased research attention, important questions remain regarding women who actively seek psychiatric treatment during pregnancy and the postpartum period. In this study, we examined clinical records of 500 perinatal psychiatric patients who received treatment in a psychiatric day hospital (N = 398) or outpatient behavioral health clinic (N = 102). Patients’ presenting diagnoses, psychiatric history, treatment course, and depressive symptoms were recorded. The majority of women had major depression as their primary diagnosis, with an average Edinburgh Postnatal Depression Scale score of over 20. Many depressed patients were diagnosed with comorbid anxiety and substance abuse disorders. Although most women were willing to take psychotropic medications, a sizable minority were not, particularly those who were breast-feeding. For more than a third of the sample, the treatment sought while pregnant or postpartum represented their first contact with the mental health system. Treatment implications are discussed.

Symptoms of the anxiety disorders in a perinatal psychiatric sample: a chart review.

Abstract Symptoms of anxiety are a central feature of perinatal mental health, yet the anxiety disorders have received considerably less attention than depression in both perinatal research and practice. The present investigation involved a retrospective review of the clinical records of 334 patients seen at a psychiatric day hospital program serving pregnant and postpartum women. We examined the frequency with which the patients in this setting reported symptoms of anxiety, clinical correlates of elevated anxiety, and patterns of diagnosis in the clinical record. The results suggest that anxiety symptoms are very common in this population and that the presence of anxiety is associated with a more severe clinical profile, including higher rates of suicidality and increased use of psychotropic medications during pregnancy and postpartum. Although anxiety symptom levels were markedly elevated in this sample, anxiety disorders were diagnosed at relatively low rates. Implications for clinical practice, including discharge and treatment planning, are discussed.

Correlates of impaired mother-infant bonding in a partial hospital program for perinatal women

Maternal psychopathology is a risk factor for impaired mother-infant bonding, but not all women with this illness experience impaired bonding. This study investigated correlates of mother-infant bonding among 180 postpartum women treated in a psychiatric partial hospitalization program. Women completed self-report measures of depressive symptoms and mother-infant bonding, and a retrospective chart review assessed demographic characteristics, clinician-rated diagnoses, and obstetric factors. Symptoms of depression, self-reported suicidality, demographic characteristics, and mode of delivery were significantly associated with impaired bonding.

Clinical correlates of perinatal bipolar disorder in an interdisciplinary obstetrical hospital setting

BACKGROUND Pregnancy and the postpartum period can be destabilizing for women with bipolar disorder (BD), and treatment decisions particularly complex. Yet, to date, relatively little research has focused on perinatal BD. METHOD Following IRB approval, trained raters reviewed clinical records of 334 women who had sought treatment at a specialized partial hospitalization program serving perinatal women, including demographic, clinical, and treatment history information as noted in each patient׳s chart by treating providers. RESULTS Slightly over 10% of the perinatal sample was diagnosed with Bipolar I, Bipolar II, or Bipolar NOS Disorder. In addition, 26% of the sample, regardless of diagnostic status, reported recent, abnormally elevated mood persisting 4 or more days. Compared to women with other Axis I disorders, women with a BD diagnosis were more likely to report a substance abuse history, prior suicide attempts, and more extensive psychiatric histories, including greater use of pharmacotherapy. Pregnant women with BD were more likely to take psychotropic medications prenatally, and postpartum women with BD reported higher rates of birth complications and difficulty breastfeeding. LIMITATIONS This research is limited by use of retrospective data, and utilization of self-report and clinician diagnosis, rather than structured interviews. CONCLUSION Even in the context of a partial hospital sample with high levels of symptoms and impairment, the clinical features of perinatal women with BD stand out as markedly more severe in comparison to those of women seeking care for other perinatal psychiatric conditions. Risk for suicide, substance abuse, and difficulties in the mother-child relationship are concerns.

A mother–baby psychiatric day hospital: History, rationale, and why perinatal mental health is important for obstetric medicine

Background Women frequently experience depression, anxiety, or other mental health concerns during pregnancy and postpartum, impacting her and her infant’s health. Patients who require management of medical conditions during the perinatal period are even more likely to experience depression and anxiety compared to those without comorbid medical issues. Despite the availability of effective treatments, perinatal mental health utilization rates are strikingly low. Methods To address common treatment barriers, we developed a specialized mother–baby day hospital for women with psychiatric distress during the peripartum. In this report, we summarize findings from 800 patient satisfaction surveys collected from women treated at the program between 2007 and 2012. Results Findings suggest that women are highly satisfied with the treatment received, often noting that the inclusion of the baby in their treatment is a highly valued feature of care. Conclusion The relevance of perinatal mental health services for patients who are followed by obstetrical medicine specialists is discussed.

Psychological/verbal abuse and utilization of mental health care in perinatal women seeking treatment for depression

Research on psychological violence has suggested it is common among perinatal women and is predictive of later physical violence. Psychological violence is also a strong correlate of negative mental and physical health outcomes and may influence engagement in health services. Both physical and mental health care are of critical importance for perinatal women who may be especially vulnerable to psychological violence and its deleterious effects. This study examined the clinical records of 299 perinatal patients who received treatment in a psychiatric partial hospital program to determine whether there were differences in utilization of care between those women with and without current interpersonal psychological abuse. More women than expected who reported current psychological abuse left treatment early compared to those without such reports.

Advanced training in reproductive psychiatry: The case for standardization in training and a path to sub-specialty recognition

Reproductive psychiatry involves the study, evaluation, and treatment of psychiatric disorders throughout the reproductive cycle, including menarche, premenstrual periods, perinatal, and the perimenopausal transition. Published literature suggests that fluctuations in reproductive hormones, including estrogen and progesterone, can have profound impact on the development and exacerbation of a variety of psychiatric illnesses in women vulnerable to these transitions (MeltzerBrody and Steube 2014). Further, reproductive transitions represent times of profound psychological and socialenvironmental change, often with increased stress. The perinatal period is arguably the most critical of these transitions, in that psychiatric illness impacts not only the mother but can influence pregnancy and infant outcomes. In May 2015, the American College of Obstetrics and Gynecology (ACOG) issued a recommendation that perinatal women be screened at least once during this period for depression and anxiety using standardized tools (ACOG 2015). In January 2016, the United States Preventive Services Task Force issued a similar recommendation for screening for depression in pregnant and postpartum women but noted that screening should only be undertaken in systems where adequate diagnosis, treatment, and follow-up is available (U.S. Preventive Services Task Force 2016). The collective weight of these recommendations urges the field to intensify its focus on reproductive psychiatry training and concomitant establishment of specialty clinical programs, so appropriate specialists can be readily accessed. Historically, general psychiatrists have felt unprepared to manage the intricacies of treatment around reproductive transitions. In addition, there is a dramatic lack of standardization in training during residency programs, a gap currently addressed in the United States by members of the National Task Force on Women’s Reproductive Mental Health (Osborne et al. 2015). A recent survey of US psychiatry residency program directors by this Task Force found that only 59% of training programs required any formal education in reproductive psychiatry (Osborne et al. 2015). Fellowship training in reproductive psychiatry, often subsumed in the broader specialty area of women’s mental health (WMH), has grown considerably in the past 15 years (see Fig. 1). Such growth highlights the demand among graduating or junior psychiatrists for this specialized training. In 2015, the North American Society of Psychosocial Obstetrics & Gynecology detailed a list of clinical and research-oriented training programs on their website, and these programs were further detailed in a recent report by Nagle-Yang et al. (2017). Currently, neither reproductive psychiatry nor the broader field of women’s mental health are accredited subspecialties in psychiatry and do not have American Board of Psychiatry and Neurology (ABPN) recognition. As such, no known governing board exists to standardize the curriculum or training objectives, resulting in inter-program variability. Although reproductive psychiatry specialty training is in its relative infancy compared to other, more established Accreditation Council for Graduate Medical Education (ACGME)* Cynthia L. Battle Cynthia_Battle@brown.edu