Clinicians and Researchers Team up for Better Postpartum Depression Diagnostics, Care.
Identifying when a patient is suffering from postpartum depression and taking a quick course of action is often much harder than taking care of any other urgent medical concerns that patients may have.
When one of Dr. Sukanya Srinivasan’s patients suffers stroke-like symptoms, she has a plan of care in mind. As a family medicine physician for 20 years, she is familiar with the resources in the medical community to handle this patient safely and effectively.
However, if a young mother is exhibiting signs of emotional distress, lines begin to blur.
“I’ve got her in; she clearly needs help. Now what’s next?” Dr. Srinivasan says. “There isn’t as direct a connection with behavioral health providers like there is with physical health providers because of access, privacy, stigma, and cost.”
Historically minimized and often misunderstood, postpartum depression — including anxiety and other mood disorders — is one of the four biggest killers of women in the first year after they give birth, according to Dr. Hyagriv Simhan, Vice Chair of obstetrical services at UPMC Magee-Womens Hospital. In each of those disease states, knowledge and care gaps prevent providers from optimizing treatment.
Part of the problem is the difficulty of identifying risks for postpartum depression. Women may not be willing to share what they’re feeling, or may not even understand that they are at risk, thinking they’re just tired from the rigors of new motherhood.
“You’re sleep deprived, especially if you’re nursing. You can see how that would become extremely socially isolating,” explains Dr. Richard Beigi, President of Magee Hospital.
Layered on top of those barriers are issues that plague many facets of health care, from a lack of transportation to a lack of insurance or time for appointments. And the stakes couldn’t be higher.
“It can kill people,” Simhan says bluntly. “But even if it’s not lethal, it’s costly, morbid, and I think just looking at death related to depression is just the tip of the iceberg.”
While some women may only experience depression around childbirth, for others, it might be a window to an underlying chronic condition. Identifying and treating it is an opportunity to reduce cost, consequences, and preserve quality of life, while also reducing the likelihood of its secondary effects, including diabetes and hypertension.
According to the National Institute of Mental Health, postpartum depression — defined as feelings of sadness and anxiety that interfere with a woman’s ability to care for herself and her family — occurs in up to 15 percent of all births. While it can begin shortly before or anytime after childbirth, it most commonly begins between a week and a month after delivery.
Yet while the condition is common and potentially lethal, during the last decade, only one new drug — brexanolone —has been approved by the U.S. Food and Drug Administration to treat postpartum depression, according to Dr. Simhan. The drug does present barriers: it requires continuous IV infusion in a hospital setting for 60 hours. Other postpartum treatments include psychotherapy, selective serotonin reuptake inhibitors, or other medications.
To create better care, researchers and clinicians are developing an array of strategies designed to both better diagnose risk and connect women to treatment.
Magee Hospital held a January symposium called Focus on the Fourth – referring to the 12- week postpartum period after birth of a child, which is now being called the “fourth trimester” by numerous national organizations, including the American College of Obstetricians and Gynecologists.
During the symposium, leading experts offered current knowledge and guidance on the medical and psychological issues that women face during this difficult transition time, including direct access to postpartum depression counseling to which Dr. Srinivasan has since referred some of her patients.
“The good thing for us is over the years we have really developed what I see as a spectrum of services to meet people both where they are and with what they need,” says Dr. Priya Gopalan, chief of psychiatry at Magee Hospital. “We have a robust integrated care program.”
Three OB/GYN practices have added behavioral health specialists, and UPMC plans to expand this integration of care, which allows a woman to visit a therapist at the same time she is at the practice for prenatal or postpartum care.
“We are under the belief that sometimes coming to a place labeled as ‘behavioral health’ may be stigmatizing, so we are trying to put more behavioral health scientists in the offices where patients are being seen,” Dr. Richard Beigi explains, adding, “There’s a lot of stigma around these problems: there’s real stigma, and then there’s perceived stigma.”
In order to increase access and identification of women at risk, Dr. Srinivasan has also adapted her own practice to reach out to women who come in with their children for well-baby visits, based on a model developed by the IMPLICIT (Interventions to Minimize Preterm and Low birth weight Infants using Continuous quality Improvement Techniques) Network. Knowing that some women don’t always seek care for themselves but reliably bring their children, the network developed and implemented a system of maternal health screenings, including postpartum depression, taking full advantage of this window of opportunity.
“Women go where their children go,” Dr. Srinivasan says. “It’s a useful entry point to having mothers talk about their needs. Patients are grateful for this inquiry into their health.”
Seeing the immediate need in his practice helped inform Dr. Simhan when he and two collaborators — Tamar Krishnamurti and Alex Davis of Carnegie Mellon University — developed the new My Healthy Pregnancy app, which has been in the design phase for seven years and debuted for expectant mothers to use in November 2019.
Using a combination of medicine, machine learning, and decision science research, the three created a tool that gathers risk data from users while communicating personalized health information on a variety of topics, including mood disorders.
The app asks each woman slightly different questions based on her unique situation, says Krishnamurti, who is an assistant professor of medicine at the University of Pittsburgh as well as an adjunct assistant professor of engineering and public policy at Carnegie Mellon. It then helps the patient connect with resources to help her.
“Every individual has a different risk trajectory that changes depending on events that occur. We developed these algorithms, and as a result, ask questions throughout their pregnancy,” she says. “We wanted to build a tool that wasn’t just usable for clinical risk predication, but was also useful for the person to connect in a way that routine prenatal care wouldn’t allow for.”
Having a data-driven tool may also help women who aren’t necessarily aware that they are approaching a tipping point into postpartum depression.
“We tend to normalize what we go through. There is a lot of denial, and there is a lack of awareness of depression and anxiety generally in society,” Dr. Gopalan points out. “I think that’s slowly changing.”
In addition to providing care, My Healthy Pregnancy also collects data that will be helpful in refining the tool and developing other interventions.
“It’s a product of clinical care, but also an important clinical tool for research,” explains Dr. Simhan. “That’s a really nice platform to do things like biomarker discovery within those populations.”
In another collaboration, Dr. Simhan is working with Dr. David Peters, an expert in human genomics at Magee-Womens Research Institute. After gathering a spinal fluid sample, they will phenotype the samples to try and identify potential biomarkers for depression. Already, Dr. Peters and his colleagues have published research describing biomarkers in a study of men and women who were treated for major depressive disorder.
“What we’d like to do is look for these metabolic anomalies in women. We’ll get a sample when they’re here, delivering. And we want to know if they have metabolic anomalies that relate to depressive disease,” Dr. Peters says. For Dr. Simhan, phenotyping is another potential tool in a multifaceted approach to addressing postpartum depression.
“I think if we understood the phenotype better from a biologic perspective, that might open the door for new therapeutic targets,” he says, emphasizing the importance of a biologic test being useful to those who deliver care. Because Magee encompasses both a large hospital and the research institute, it’s uniquely situated to help develop those tools, he adds.
“We’ve made a lot of strides in optimizing screening and trying to triage the appropriate care afterwards,” Dr. Simhan says, though he adds, “We’re not done, for sure.”