Round 1: Who should be responsible for the postpartum depression (PPD) diagnosis?

In this round of the debate, listen to the experts’ compelling arguments on who should be responsible for PPD diagnosis.

Dr Gisele Apter: So, before we begin, I'd like to share how happy I am about this debate today and how great how our great speakers are going to be, that are going to be joining us. Dr Jennifer Payne, who's the perinatal and reproductive mental health specialist, and Dr Camille Hoffman, an OBGYN perinatal care and fetal medicine. Dr Payne will support the side of PPD as a mental health disorder, and Dr Hoffman will take the side of PPD as a maternal health disorder. So questions, such as postpartum disorder, is it a specific illness or is it depression during a specific time of life? These questions are constantly being discussed between physicians, and they're not just specialists’ issues because this has public health consequences such as who is screening, who will screen, who refers, who diagnoses?

Dr Gisele Apter: And obviously, this means women's health issues are at stake. How much pregnancy is at risk when does a woman have or not have a history of mental health issues? And how does that impact her health and her future offspring? And, of course, it is important for us to know how illness unfolds because this has a major impact on how we manage a disorder and how we treat it. So we will be trying to address these questions with three rounds of this major topic today, thanks to our wonderful renowned speakers. First debate will be who should be responsible for postpartum depression diagnosis? Second, is postpartum depression preventable? And third is postpartum depression similar to major depressive disorder. So, let's get started with round one and begin by addressing our first debate topic. Who should own the responsibility for the PPD diagnosis? We will start with Dr Payne. Please give us your opening argument.

Dr Jennifer L. Payne: Sure. Thank you so much for having me here today. I think there are a number of different ways to answer this question, but as a mental health professional, I think everybody should own the responsibility for making a postpartum depression diagnosis. Obviously, obstetricians and midwives are on the frontline, and they're often the first ones to suspect a postpartum depression diagnosis. But some patients will have psychiatrists who will be following them during this time period, and psychiatrists are also often available to primary care teams to advise them on treatment, even if they don't see the patient themselves. Psychiatrists can also provide education on best management practices for perinatal depression. Finally, pediatricians are increasingly involved in identifying women who are suffering from postpartum depression, as they now recognize the significant impact postpartum depression has on developing children.

Dr Apter: Excellent. Thank you, Dr Payne. Dr Hoffman, your opening argument.

Dr Camille Hoffman: Hi, and I also am really grateful to participate in this debate. So, my take as an OBGYN and high-risk perinatologist, or high-risk pregnancy care expert is that really, for a small fraction of patients who already have a psychiatrist or a mental health professional following them, those would, obviously and naturally, be managed and identified by a mental health professional or psychiatrist. But for many who enroll in prenatal care as their main interaction with the health care system, it's going to be the obstetricians, the midwives, family medicine physicians who do obstetric care who are the frontline responsible for identifying someone with a perinatal and/or postpartum depression diagnosis. And we know that even so, and with enhanced screening recommendations, still only about one-half of these disorders are even identified, which makes treatment in either an even smaller proportion.

Dr Hoffman: So, even in the context of standard prenatal care, which involves numerous interactions and visits over the course of a pregnancy and the postpartum period, we're missing this for a fair number of people. So, I don't know how we would expect these people who are missing from standard prenatal care, would suddenly find their way to the diagnosis by a psychiatrist or a psychologist. I want to emphasize, though, that because we have multiple interactions over a pregnancy and postpartum time course, we should own, as perinatal care clinicians, these opportunities to engage perinatal patients in the importance of this issue and how common it is. The little-known lifelong consequences that it has for not only the mother but also the infant who will become a child, adolescent, adult parent, him or herself. So, I really take the approach of emphasizing that during standard prenatal care. We naturally address other lifestyle factors, such as nutrition, sleep activity, stress reduction, that are both part of any healthy pregnancy and part of any mental illness to a pretty significant extent. So, if we are able to revisit these conditions and concerns as we're going to see these patients multiple times, we should take the opportunity to diagnose this, identify it, ease patients into treatment if they're not quite ready at their initial encounter or while we're building re rapport with them over their perinatal course. But we have more opportunities to identify and readdress it.

Dr Apter: Thank you so much, Dr Hoffman. Now, Dr Payne, perhaps a few words rebuttal.

Dr Payne: So I agree with Dr Hoffman that the opportunity for identification is greatest in the obstetrician's office. But we are still missing more than half of cases of postpartum depression despite the fact that women are seeing the obstetrician, you know, frequently and throughout the pregnancy, et cetera. That's why I really think it's everybody's problem. And I do a lot of educating families and in the general public, and I think it's important that everybody recognize that it's really important that if a woman is depressed in the postpartum time period, or during pregnancy, that she get identified and treated. And whether that’s with a mental health professional, her obstetrician, her family medicine doctor doesn't really matter. It's important that we identify these women and get them into treatment. So it's a team sport from my perspective.

Dr Hoffman: I can't disagree. Sorry.

Dr Apter: No, no. I was saying, yeah. Fantastic. Now, Dr Hoffman, your rebuttal, your answer to Dr Payne.

Dr Hoffman: So I absolutely agree with Dr Payne here. Helping all women with PPD will ultimately require all types of clinicians and other support people. It's a condition where it really should take a village, as others play a role in the spectrum of care, as well as in childcare, and just general family support in so many ways that are important and healthy for the mother and the child. And then, of course, patients who've previously been in psychiatric care need to stay in that care or reinitiate it. And I think part of the role of the obstetric care provider is also to help reinitiate or close that loop; continue it with mental health care professionals during the perinatal period because we know it's also not a state that's going to disappear once they're out of the perinatal period. So, continuing care and care coordination is also important.

Dr Apter: Thank you both. I think there's all really great points. So perhaps for this first round, Dr. Payne, your closing statement.

Dr Payne: Well, it's my hope that as people begin to recognize the devastating and long-term consequences of postpartum depression, that everyone will take an interest in making sure that women with postpartum depression get identified and treated. Psychiatrists can provide the education and guidance, but all providers and family members should be on the lookout for this very treatable disease.
Dr Apter: Thank you, Dr. Hoffman. Your closing statement.

Dr Hoffman: OBGYNs, midwives, and family medicine physicians who care for pregnant patients are the frontline providers responsible for screening diagnosis and initiation, or at least coordination of treatment and putting a mental health support system in place with our psychiatry and psychology colleagues, as well as social workers, care coordinators, and the PCP, who may ultimately see both the mother and the child. And so, all of these players ideally communicating on behalf of our patients is really critical in continuing treatment beyond the perinatal period.

Dr Apter: Well, thank you both. I do believe that this discussion makes meeting together as teams probably one of the main conclusions of our first round. But since this was round one of our great debate series, be sure to tell us how you think and who you think won this round by answering the poll questions you see on your screen.