Round 2: Is postpartum depression (PPD) preventable?

In round 2 of this debate, our participants share their opinions on whether PPD is preventable.

Dr Gisele Apter:  And welcome back to our Great Debates in this Psychiatry series, brought to you by Psych Congress Network. We are now in round two of this debate, and we'll be discussing whether postpartum depression, PPD, is preventable with Dr Payne and Dr Hoffman. Dr Payne, your opening argument on this topic.

Dr Jennifer L. Payne: This is actually a question that's near and dear to my heart. I'm very hopeful that as we get better at identifying who is at elevated risk for postpartum depression, that we can eventually begin to prevent and minimize the amount of time women experience postpartum depression. My research has identified biomarkers of postpartum depression that are predictive, with about 80% accuracy, of who is biologically at elevated risk. I think that in my lifetime, we'll be able to get the number of women experiencing postpartum depression down to a small number. There's evidence that a number of psychotherapeutic programs can prevent postpartum depression and that restarting psychiatric medications postpartum can also prevent recurrence. The new GABAergic-positive allosteric modulator antidepressants also work very quickly, which will minimize the time a woman is depressed in the postpartum time period. I think we will be able to, eventually, prevent postpartum depression or at least minimize it in the future.

Dr Apter: Wow. Thank you so much, Dr Payne, for this opening. Now, Dr Hoffman, what about your opening argument?

Dr Camille Hoffman: So, there were two evidence-based programs cited by the recent USPS Task Force and our recent ACOG clinical practice guidelines that were, actually, just released in June 2023 as interventions having the potential to prevent perinatal depression. One is called the ROSE program, or Reach Out Stay Strong Essentials from Mothers of Newborns, and it's an interpersonal therapy program. And then there's one called Mothers and Babies, which is a cognitive behavioral therapy program. And these programs are both part of ongoing broad, large investigations and perinatal populations in a couple of sites around the US. Also, our research group, or one of my research collaborators here in Colorado, recently published results from a trial where we investigated an eight-session, perinatally adapted brief interpersonal therapy intervention compared with enhanced usual care in pregnant women enrolling in prenatal care. So at their first prenatal visit, who either had a known major depressive disorder diagnosis in her past, or actively, or had a positive Edinburgh postnatal depression score, EPDS score, and we found that this brief intervention reduced depressive symptoms significantly, as well as rates of MDD from 26% in the control population to 6% in the intervention group.

Dr Hoffman: So, all of these are efforts that are evidence-based that reduce the risk of this. And I think in an ideal state, using a combination of biological markers and widespread access to these interventions, we can likely significantly reduce the risk of PPD. On the other hand, and this is speaking as a perinatal care clinician, not a psychiatrist, perinatal patients are broader and, sometimes, more psychosocially complex population compared to someone who is able to make her way to an outpatient psychiatry clinic. Just the distance traveled between those two groups and the ability to access those two different types of care are quite different. And so I think that some of this will be the main challenge in preventing all of PPD because it is a broader population with different and more broad risk factors that increase the risk. So, I think some PPD may certainly be preventable, but I also don't believe that any condition is 100%; 100% preventable or avoidable. So we have to be vigilant.

Dr Apter: Thank you. Those are, in a way, really two aspects of prevention. You're talking about biological markers or about wide risk, a bigger group. So, Dr. Payne, what would you, how would you respond?

Dr Payne: I agree with Dr. Hoffman that nothing is 100% preventable, but I really, strongly believe that we can work towards it with the help of science and technology and the future. I'm hopeful that we can use a blood test to predict who is at biological elevated risk; and then, along with clinical and social factors for individual risk factors, identify high-risk patients and put plans in place to support them and get them into treatment when it's needed. There are studies, for example, being done using the electronic health record that can automatically identify people who are at high risk of postpartum depression based on clinical and social factors that are noted in their record. So I'm hoping that a combination of approaches will allow us to catch most cases of postpartum depression before they start.

Dr Apter: Great. Dr Hoffman, your response?

Dr Hoffman: I agree with Dr Payne. I think compared to some of the things we try to predict risk for in obstetrics—preterm birth is an excellent example—and there are some biomarkers trying to be developed and offered commercially, preeclampsia risk prediction is similar. Those are two conditions that affect far fewer patients than postpartum depression. So, on the one hand, compared to our ability to pre-predict and prevent these other common but less common than this condition issues that arise in pregnancy, we should be able to make a much bigger impact and have much more rapid progress. We also know that PPD has a high recurrence rate and a higher risk of major depression later on in the in that person's life. And many of these risk factors can be ascertained during standard prenatal care. I guess the struggle on the obstetrics side is that there's also virtually no patient that we might see who has no risk factors, or at least not, you know, or who does not at least have one risk factor for this. So while that makes it seemingly easier to prevent because you can identify risk factors more easily, it also kind of makes it more overwhelming because some of these risk factors we can actually take on and move in a positive direction, and some are more of a challenge.

Dr Apter: Thank you. Fantastic. So, before we have our two closing statements, you are both underlining not only risks but also feasibility of what we can be doing in the future. And I think I'd like both of you to have a closing statement on this second round, Dr. Payne.

Dr Payne: So I think Dr. Hoffman really raised great points about feasibility dealing with clinical risk factors. Clinical risk factors tell you someone's at elevated risk, but they're not strongly coordinated with, correlated with exactly if that woman is going to develop postpartum depression. I'm hopeful that with biomarkers, with the blood test, that we'll be able to screen women universally in the way that we screen 99% of pregnancies for gestational diabetes, which is a far less common complication pregnancy than postpartum depression is. I think if we're able to move into the realm of using science and biological biomarkers, we'll do better at catching this illness before it begins in the future. If we're able to prevent postpartum depression, we will reduce the risk not only to the moms but to the children as well. Postpartum depression is an adverse childhood event. The more of those we can prevent and minimize, the better the health and mental health outcomes for the children. Good.

Dr Apter: Thank you so much, Dr Payne. Dr Hoffman, your closing statement on this second debate.

Dr Hoffman: So, I wholeheartedly agree with Dr Payne's comments about preventing an adverse childhood event or experience. And I think that we can, even if we are unable to identify 100% or prevent 100% of postpartum depression cases, identification is also preventive for the child. So we can, we think often in terms of the developmental origins of health and disease hypothesis where for the mother we're risk-reducing or treating, but that is preventive care for the fetus who will become a child. And in this way, maybe we do prevent 100% of transmission, even if we don't prevent a hundred per percent of postpartum depression diagnosis in that mom. And really, the notion that we prevent it is less important to me than addressing all aspects of health and wellness that contribute to this condition with all pregnant patients. This will make their overall health and wellness better and, hopefully, reduce some of the other things that arise during pregnancy that can have lifetime, lifelong consequences. In addition, I don't want my obstetric colleagues to think, okay, well, we have this biomarker check the risk is negative. We've addressed as many risk factors as we can and then become complacent about, well then, we've done all that we can to prevent this and overlook just identification, with screening and initiation of treatment that way.

Dr Apter: Thank you both. So, perhaps summarizing, we have here a really a pitch for working and, hopefully, very soon seeing some biomarkers and actually, a sort of public health approach where we need biomarkers, and we need all of the rest. So this concludes our round 2. And you will need to tell us who you think won this round 2 by answering the poll questions and that you will see on your screen. And sort of remember everything that Dr Hoffman and Dr Payne have been debating and, more or less agreeing, and completing one with the other. So don't forget to join us next time because we'll soon be coming round for round 3 where we will discuss whether PPD is the same as or almost the same as MDD. Is postpartum depression similar to major depressive disorder.