Hello, everyone. Thanks for joining us tonight. We have our installment of Women's Health Matters, ACOOG's board-relevant webinar series, value-added benefit for our members. I'm Rupesh Patel. I'll be helping moderate. I want to thank the ACOOG staff, especially Andrew Krim, for helping make this happen. A few housekeeping notes. I would like to thank the France Foundation for its help with this webinar, and I'd like to thank Sage Therapeutics for supporting this webinar with an educational grant. Without having our sponsors, it would be hard for us to keep providing some of this content, so very excited to have it. If you have questions, use the Q&A function in Zoom. The last few minutes will be set up to answer those questions. You will not be able to ask or speak during the webinar. To get a credit, make sure you complete the post-test and evaluation after the session. In about 30 days, you'll receive an email with the survey link. Be sure to log back in and complete the survey. It asks how you've applied things from this session to your practice. This helps our CME committee in assessing the effectiveness of our activities that we're always trying to improve. I would like to introduce our speaker, Melissa Lott. Dr. Lott is a maternal fetal medicine specialist living in Chicago. She completed medical school at Midwestern University, Chicago College of Osteopathic Medicine. Her OBGYN residency was completed at MSU Com, St. Joseph, Mercy, Oakland, and Pontiac, Michigan. She completed her ACGME accredited MFM fellowship in Geisinger in Danville, Pennsylvania. She is a founder for the Center for Excellence in Diabetes Care and Pregnancy at Advocate Lutheran General Hospital. Her clinical interests include diabetes, decay in pregnancy, prediction and prevention of preterm birth, hypertensive disorders of pregnancy, and obesity in pregnancy. She currently works with Access Telecare providing MFM services via telemedicine as well as in-person as needed with Advocate Health and Rush Copley in Aurora of Chicago. For disclosure purposes, Dr. Lott has no financial relationships to disclose. We're in for a treat tonight, and I'm very excited to leave it to her now. Thanks. Great. Thank you, Dr. Patel. So I appreciate everybody that's logged in to join us. Tonight we will be discussing postpartum depression. We're going to look at improving patient identification, shared decision making, and then connections to care. Again, here's me. Our objectives today, so accurately identify signs, symptoms, and risk factors for postpartum depression in order to enhance diagnostic capabilities, evaluate critically the consequences of a missed or delayed postpartum depression diagnosis, and then assess the OBGYN's role in the interdisciplinary postpartum depression care model, focusing on shared decision making with patients and also collaboration with mental health and primary care professionals. So our definition of postpartum depression is a major depressive episode with onset of depressive symptoms in pregnancy or up to 12 months postpartum. So in order to look at the signs, symptoms, and risk factors, we'll start with a case study. We have a 35-year-old, G3, P2012, presenting for a follow-up visit four weeks after a vaginal delivery of a full-term neonate. Her pregnancy was complicated by gestational hypertension, which resolved completely following her delivery. She has a remote history of anxiety as a teenager for which she never required medication. She lives with her partner and their children. Her partner works full-time while she cares for the baby and the two young children that live at home. During the visit, she reports feeling stressed and tired. She feels that she has made a mistake having another child while having two children at home. She reports having trouble getting out of bed in the morning and feels that she is not bonding with her baby like she did with her two previous children. And she reports the inability to sleep at night because she is worried that the baby has stopped breathing. She gets up frequently to check on the infant throughout the night. So when we're thinking about the signs of perinatal depression, again, that clinical scenario is something I think we've all encountered in our clinical practice more than once. Our DSM-5 criteria include five or more of the following symptoms present during the same two-week period, including depressed mood or loss of interest and pleasure, and then additionally, one of the following. So depressed mood most of the day, either reported by the patient or noted by others, a marked decrease or interest and pleasure for many or almost all activities, significant weight loss or gain or a decrease or increase in appetite, insomnia or hypersomnia nearly every day, psychomotor agitation or slowing, fatigue or loss of energy nearly every day, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, recurrent thoughts of death, recurrent suicidal ideation without a plan, a specific plan, or even a suicide attempt. These symptoms also have to cause significant distress or impairment, and they can't be attributed to any other psychological effects from substance or other medical conditions. So our risk factors for postpartum depression include biologic, psychosocial, and or environmental, and we know that we can have many of these presenting as compounding factors. Biologic would include a family history, a personal mental health history of a depressive disorder or anxiety, history of psychiatric treatment during another pregnancy or at any other time in the lifetime, patients that have insomnia or other sleep-related problems. From a psychosocial standpoint, risk factors include young age, a patient that's a veteran or is dependent on a veteran, active duty service, a patient that has a lack of or decreased partner support, patients that are unemployed or incarcerated or if they have a partner that's incarcerated, and other environmental factors that can impact a patient and increase the risk of postpartum depression include psychological intimate partner violence and sexual intimate partner violence as well. So prevalence of perinatal depression onset usually occurs just prior to, most often during or within one year of pregnancy. Pre-pregnancy, it occurs about 27% of the time, and it's usually the time kind of immediately surrounding conception. Interpartum about 33% of the time, but most frequently, it's postpartum onset, which is about 40% of the time. We know that perinatal anxiety is a strong predictor of perinatal depression, about two-thirds of women that have perinatal depression also have one or more comorbid psychiatric conditions. Eighty-three percent of those are anxiety disorders. Up to 28% of patients that are diagnosed with perinatal anxiety may have comorbid depression, and up to 25% of women with perinatal depression will have symptoms for three years postpartum. So when we're looking at our case study, thinking back to our patient and everything that she identified, what would be the next appropriate step in identifying whether this patient may have perinatal depression? So the next appropriate step in identifying whether this patient may have perinatal depression? Okay, and the majority of those that have taken the poll got the answer correct. Our correct answer is B, to administer a screening tool such as EPDS or PHQ-9. So our strategies to improve diagnosis, initially when we look at our screening, the prevalence of mental illness in women was about 27% in 2021. During pregnancy, about one in five women will develop a mental health condition. ACOG recommends that everyone that's receiving well woman care, pre-pregnancy, prenatal, postpartum care be screened for depression and anxiety using standardized validated instruments. Most commonly, we're using the EPDS or the Edinburgh Postnatal Depression Scale, a PHQ-9, which is the patient health questionnaire, or the GAD-7, the Generalized Anxiety Disorder-7. A positive score for each of these, for the EPDS or the PHQ-9, would be greater than or equal to 10. For the GAD-7, a positive score is greater than or equal to 5. This screening should be performed multiple times during the perinatal period, so not just at the initial intake examination, but also we should consider administering this every visit, every other visit, but certainly more than one time throughout her pregnancy. And again, at the postpartum visits as well. So our screening tools, this is just an example. This is the EPDS. This is exactly what it looks like. We go ahead and we score it up. Again, a score greater than or equal to 10 is an increased risk. And the PHQ-9 here, again, featured just for your reference. Looking at questions, again, in the similar vein of feeling tired, little energy, attitude towards favorite activities, thinking about hurting yourself, persistent sadness, trouble concentrating on things. So for our case study, what is your next step after screening? She completed her EPDS and her score is 17. So again, greater than our threshold of 10. What would be the next most appropriate step in her care? A. Okay, great. So majority of responders chose to have a risk-benefit conversation regarding psychotherapy and pharmacotherapy, which is the next appropriate step. A new patient, she presents as a G3P2103 for postpartum checkup. She's two weeks following a preterm C-section for non-reassuring fetal status during preterm labor and her baby is still in the NICU. She reports that she's feeling stressed at home with two children to care for while she's trying to also visit the baby in the NICU. She's having sleep problems and her partner is in active military and stationed overseas. She completed her EPDS with a score of 14. She denies suicidal ideations, but she does admit to having a history of postpartum depression after the delivery of her first child that that did require medication therapy. So in addition to her history of postpartum depression, what are her additional risk factors for postpartum depression? A. Okay. So the majority of our viewers tonight chose A, which is the correct answer, just based on the ACOG practice bulletin, having sleep problems and active duty military. Obviously, this would be compounded by the fact that she had a cesarean delivery and her history of requiring medications for postpartum depression in the past. Okay. So moving forward to the consequences of missed or delayed postpartum depression diagnosis. So consequences include adverse obstetric, fetal, neonatal, and infant outcomes, including increased risk of complications such as stillbirth, preterm birth, fetal growth restriction in a low birth weight infant, impaired bonding with the neonate, adverse infant neurodevelopment, an increased risk for mental health concerns for the offspring, as well as negative economic consequences. The most severe forms include maternal and infant mortality, including suicide, overdose, poisoning. So another question to consider, we have our G3P0110 presenting at 32 weeks gestation who appears disheveled and really tired. She will not maintain eye contact with you or any of your staff members, and her fundal height is measuring six centimeters smaller than expected for her gestational age. An ultrasound performed in your office is consistent with fetal growth restriction. Her EPDS score is 19, and at 12 weeks gestation when she did her intake, her EPDS score was 13. There's no documentation that her EPDS score was discussed back at her intake evaluation. It's also noted that her BMI has decreased from a normal BMI to underweight BMI since the start of her pregnancy. She reports that she's not been sleeping well and has had persistent thoughts of her baby being stillborn like her last child was at 34 weeks gestation. Upon further questioning, she admits to a suicide attempt three days ago. So in addition to fetal growth restriction, which of the following is a potential consequence of unrecognized or untreated peripartum depression in this patient? Okay, great. So majority of participants chose C, impaired bonding with the neonate, which is the correct answer. This side I thought was really important just to demonstrate the importance of recognition and diagnosis of postpartum depression or peripartum depression as soon as possible. Again, with this side specifically noting she developed fetal growth restriction, she had a positive EPDS score at 12 weeks gestation, and she was left until 32 weeks when it was repeated again, and then she was clearly diagnosed, but she's already kind of suffering the consequences of that misdiagnosis earlier in the pregnancy. Okay, so what is our role as the OB-GYN in the interdisciplinary care of postpartum depression? When it comes to the OB-GYN, we are often the gatekeeper between the patient and any other specialists that they may need, right? Our psychiatrists, their primary care doctor, behavioral health, because we're seeing them most frequently throughout their obstetric care. Notably, though, it's important to recognize that for many patients, the OB-GYN is their only care provider. Many times OB-GYNs are treated as the PCP, as we all know, so oftentimes they may only have us to rely on, which makes it even more important that we are aware of the risk factors and the presenting symptoms and signs of peripartum and postpartum depression. So this is well within our scope as OB-GYNs to manage perinatal depression and anxiety. Psychotherapy and pharmacotherapy are efficacious treatments, and when they're used in tandem, the clinical benefits are enhanced. Our first-line treatment is referral to behavioral health sciences for psychotherapy after we have that risk-benefit conversation, and we want to make sure that we're utilizing shared decision-making with our patients. We can also initiate pharmacotherapy, which can be indicated and safely used intrapartum and during lactation, and we as OB-GYNs, this is well within our scope of practice to do this. Again, it's important to utilize shared decision-making to create a treatment plan for our patients. Shared decision-making is best used to determine the treatment approach for the patient, and we use this to initiate continued pharmacotherapy, especially during pregnancy and lactation. Again, having that thorough risk-benefit conversation and helping a patient understand the safety of these medications is a really important conversation that we have pretty much on a daily basis. Additional resources, we can use the National Pregnancy Registry for psychiatric medications to look at information and provide risk assessment about the psychopharmacotherapy that we can use for our patients as well. There's a resource for you if we're unclear about which medications we can use, but I'll also go ahead and review some of these options as we move forward. When we're discussing shared decision-making, there's many different models that we use. I think the easiest one that we can use is the SHARE model as demonstrated here. That acronym stands for Seeking Patients' Participation, Helping Them Explore and Compare Treatment Options, Assessing Their Values and Preferences, as well as Their Willingness to Participate in the Care Plan, Reaching a Decision with Your Patient Together, and then Evaluating Your Patient's Decision to Ensure that it Aligns with Our Therapeutic Goals. Our SHARE model and practice, things to think about are what questions would you ask? What would that conversation look like? A lot of times for me when I'm having these conversations with my patients in clinic, I start by saying it looks like we figured out why you've been feeling the way you've been feeling. We have a name for it. Are you ready to talk about other ways that we can start to help you feel better? What do you know about peripartum or postpartum depression? Are you familiar with the treatments that are available? And then guide the conversation depending on their answers. If they're saying, I'm not really sure, or I saw this TikTok video, or whatever other resource they may have, we can go ahead and go through, would you like me to review with you the options that are there for you? Are you willing to work together to help find a pathway that will help you start to feel better? Usually I go through and I discuss the risk and benefits of each option. So starting with psychotherapy, if we can get them in to see a behavioral health specialist, that would be ideal. We know that there's barriers to care there. So again, I will also discuss using pharmacotherapy as an adjunct to that, or to initiate pharmacotherapy if the patient has severe enough symptoms or if they're willing to do it. I'll ask them how they feel about the options, which one they think is going to help them the most, and then find out if there's anything that we think might get in the way of their treatment plan. Are they going to be able to travel to see a behavioral health therapist? Or do they have internet access at home where they can do a Zoom meeting with a therapist? Can they afford the medications? Are medications something that they'll actually take, or are they still feeling apprehensive about medication exposure during pregnancy or lactation? If there's any barriers to care, we could try to address that together to make sure that every possible barrier has been removed. Then once we decide on a treatment modality, let her know that she can always contact me if there's any questions that come up after she leaves, which is usually what happens. I would set an appointment to evaluate within the next two to three weeks once she's initiated her therapy. We talked about barriers to behavioral health care. We know that there's a paucity of access to mental health providers, limited coverage by commercial insurance carriers, societal stigma that comes along with seeking help and therapy. There's cultural beliefs that surround psychotherapy. A patient may have language barriers and have limited access to people that speak their native language, and also geographic locations. Will we have our patients in these rural locations? Do they have any behavioral health care providers nearby? Will they be able to access them via the internet if they don't have anybody physically close to them? Then again, is it in their budget? What are your thoughts? When you scan this, this will come up as ... You can either enter it into the QR code or you can enter into the chat, but I'm wondering what are some of the challenges that you feel like you've had when you were discussing postpartum depression with your patients? Have there been any strategies that have worked for you in facilitating their shared decision-making? Then also, how do you perceive your role in improving communication with behavioral health or primary care to manage your patients with postpartum or perinatal depression? Andrea Barr said a referral to behavioral health takes two to three months in my area. Kathleen Brown says a big challenge for me is the willingness of the patient to follow up. Another says PTs perceive that depression ... All right, people are entering answers very quickly. PT perceive that depression may mean that their babies will be taken away. PPD is still very stigmatized. I practice in a southern state and it is hard to break the barrier to disgust. Another is also lack of resources for short interval follow-up with behavioral health. It can be difficult to get patients in with behavioral health. Patients want help, but they don't want to take meds or go to counseling. Those are our answers. Okay. Yeah, and those all present really unique challenges when we're caring for these patients, right? The barriers to care, getting them in in a timely fashion, breaking that stigma, the societal stigma, the concerns about the children being taken away. I mean, that's just the thought of that, right? That's depression anxiety brain coming in, telling them, like, don't do this. They're going to take away your baby. Again, kind of working with patients in their shared decision-making, seeing where those barriers might be, and if we can kind of finesse that a little bit to encourage the patient to seek treatment. They may not be ready for it right away, and that's okay. But again, keeping a close eye on these patients and remembering to follow up with them at future visits to see if they've had a change, if they've done any further research, and maybe even providing them with some resources to help them for community resources that might be available nearby. Again, also recognizing, right, this is in the limitations of a 10 to 15-minute OB visit that you have. So sometimes we have to bring these patients back for a visit specifically to further discuss the treatment options and helping manage their perinatal or postpartum depression as well. Great. Thank you all for sharing. So our handoff to behavioral health services. When do we want to do this? I mean, ideally, as soon as we recognize that the patient has a diagnosis. Usually, I would recommend we refer as soon as we gain a diagnosis and patient expresses willingness, just because there are long wait times, just as some of our participants have alluded to. If the patient has a condition that requires care that you cannot provide, or if they're going to benefit from co-management, that's another great time to refer out. If they develop psychosis or another condition that requires a higher level of care, I mean, at that point, we're sending them to the emergency department to initiate maybe even inpatient therapy. But the best ways to do this is either to contact the psychiatrist or behavioral health therapist and do a warm handoff to let them know what's going on with the patient, see if there's any way that maybe we can improve the response time. And it's a big ask, I know that, but it doesn't hurt to ask. We can assist the patient in making the appointment. If it's going to fall on her to make the appointment and she's feeling apprehensive or nervous, can make the phone call while we're in the room with the patient. We can send the behavioral health services the patient summary information just so they have everything they need when they do meet with the patient. If we do see her, make sure that she's in treatment and then kind of close that loop on communication to see how things are going for her, if she experienced any barriers. It also does kind of help you get an idea of the services available in your area and what their responses are to your patients, making sure that we're referring to services that are going to be helpful and maybe even their staff might need some feedback if we're not getting appropriate response times, things like that. We can utilize online resources. They can allow telemedicine or in-person therapy, again, so these can be gathered in a single spot. But ACOG does recommend that we initiate the pharmacotherapy as well if needed, and then again, refer out as either co-management or again, they can just do behavioral health services if they're not interested in doing any pharmacotherapy. Back to our case study for her management, our patient states that she tried psychotherapy when she's a teenager. She didn't really find it helpful. She expressed her concern about her ability to engage in therapy regularly because her partner's out of the house much of the day for work. She's responsible for the children, so a lot of those duties fall on her. She doesn't really have the time to dedicate to an hour-long therapy session. She's interested in exploring other options for management of her symptoms. So ACOG recommendations for postpartum depression pharmacotherapy, ACOG does recommend SSRIs as a first-line pharmacotherapy for perinatal depression. SNRIs are a reasonable alternative. If there is no pharmacotherapy history, so if they haven't tried something that worked for them or tried something that didn't work for them, we could usually start with something like sertraline or escitalopram as first-line medications. For your SNRI, that would be something like bupropion. ACOG recommends consideration of bruxanolone administration in the postpartum period for either moderate to severe perinatal depression with the onset in the third trimester within four weeks postpartum, and then consideration of zaranolone as well in the postpartum timeframe, so within the first 12 months postpartum, kind of that longer duration. For depression that had its onset in the third trimester or within four weeks postpartum. So again, thinking about all of our options, remembering though that the bruxanolone does require IV administration, hospital admission, so to be mindful of that and how that might impact other things going on at home for our patients as well. When we're thinking about safety of medication during pregnancy and lactation, our general treatment approach, as always, we want to use the lowest effective dose, avoid polypharmacy if possible, and minimize switching medications. Remember, it does take two to four weeks to reach our therapeutic level, so we want to ensure that as we're starting medications and we're titrating that we give them time to develop the appropriate clinical response. Our symptom monitoring can be monitored with our screening tool, so administering a PHQ-9 or an EPDS again to help assess their clinical response is really helpful. Initiation and continuation of medication during pregnancy. So we have a lot of patients that come into pregnancy already taking a medication like an SSRI or an SNRI. We don't usually recommend down titration of medications, especially in the third trimester or in the postpartum timeframe. I would get a lot of referrals for patients as an MFM doctor that would say, oh, I was on this medication, my symptoms were well-controlled, but then my provider, whoever they may be, said that I should discontinue it to reduce the risk to the baby. That's not actually true. There's no data to support that it improves the innate outcomes and it increases the risk of exacerbation of the mental health condition for mom. Exacerbation of that mental health condition will lead to all the other complications that we discussed earlier in the webinar. Now we may need to up titrate our medications just due to the physiologic changes of pregnancy. So if we have a patient that was therapeutic when she came in and then she notes an increase in her symptoms as we get into the second or third trimester, she may need a slight dose increase to get herself back to stable neurotransmitters. The risks to the fetus of the antenatal exposure to our medications include persistent pulmonary hypertension of the newborn, transient neonatal adaptation syndrome, or some people may call this like a withdrawal, is more of what our patients would understand if we counseled them that way. Again, very, very low risk. A little bit higher risk of things like preeclampsia or even miscarriage. If a patient is on a medication and she wants to discontinue the medication at any point, either during the pregnancy, postpartum, we need to make sure that we're doing a progressive taper. We don't ever want to stop these medications all of a sudden. The taper should be gradually over two to four weeks. And again, that's after you've had that counseling in a shared decision-making matter. Medications during lactation. Patients that are lactating should not be discouraged from breastfeeding if that's their desire. The relative infant dose is significantly lower than that which mom is receiving. Any relative infant dose that's less than 10% of mom's dose is considered compatible with breastfeeding. There's databases. There's databases like Mother2Baby. There's various other databases that you could find that help us determine what medications would be safe for lactation, especially if it's something that's not as common as sertraline or escitalopram. Again, we want to engage in that shared decision-making discussion and then evaluate our benefits, mitigate the risks, and make sure that everybody's comfortable with the treatment plan as we move forward. Thinking about our case study, after we had a shared decision-making conversation, our patient decides to start pharmacotherapy for her depression symptoms. How do you plan to assess her responsiveness to therapy? Again, when we're looking at our treatment response, as we discussed previously, the correct answer here would be B, that we would schedule a return visit in four weeks. We would re-administer that EPDS and assess her response to medication that way. Assessing her response to intervention. Again, repeat the screen in four weeks. Re-evaluate the treatment plan. Clinical assessment. We have EPDS to give us hard data. We have a number. You're going to sit down. You're going to have a conversation with your patient. You're going to see how she's feeling. You know what her symptoms were previously, so you could always check in and see if she's noted an improvement. We want to evaluate every four weeks during pregnancy and in the postpartum timeframe. If you're unable to manage the patient, then I would do a handoff to her PCP. If she doesn't have a PCP, then that would be a time to initiate a referral. That way, again, too, if she's pregnant, we could start helping her find a PCP prior to delivery, so that we can ensure that she has a warm handoff for care after she delivers beyond that six weeks postpartum. If our patient doesn't have any improvement or minimal improvement after four weeks, she's not having any side effects, then we could go ahead and increase the dose. It just may not be a high enough dose to start her on. If she has any intolerable or serious side effects, we would taper the dose, or we could start a new antidepressant. Maximize our other treatments, including our therapy sessions. We can consider adding an additional medication if there hasn't been any improvement over four weeks. Again, traditionally, I'd like to avoid polypharmacy, so I would prefer to titrate the dose, if possible, and up titrate before adding a different medication. With our handoff to our primary care doctor, if you're not going to be the one managing the patient in the postpartum timeframe, then we would want to hand off to her PCP. We can contact them directly. We can send them a message in the EMR and provide a handoff. Ask the patient to make the appointment with the PCP, and then maybe even verify that she did, in fact, make that appointment. A lot of our EMRs do talk to each other, so sometimes we can see if they've actually done it. Sometimes they don't, if we have our own private practice or if their PCP is in a private practice. It's always nice to just kind of close a loop and follow up to be sure that she did make an appointment. We could send a summary of our visits to her PCP. Then again, bring the patient back in two, four, six weeks to ensure that she has established care and that we have accomplished that warm handoff with her primary care doctor. We're assessing her patient response and status. She reports that she had a significant improvement with pharmacotherapy for her postpartum depression. She wanted to continue the medication during the postpartum timeframe. She came back nine months later for her annual examination and reports that her mood has improved and has remained stable. At this point, she's feeling well, and she would like to discontinue her medication. What is our next best step? Great. The majority of our participants chose C, which is the correct answer. That's to initiate a taper schedule to slowly wean off the medication. Again, and then you would want to verify that she does follow up with her PCP and verify if she has a PCP or a behavioral therapist, if that's what she decided. When it comes to our taper, we want to consider tapering the antidepressant when she's been in remission, more than six months for depression, greater than or equal to 12 months for anxiety. Then we want to taper slowly to minimize the risk of relapse and discontinuation syndrome. Some people describe this as brain zaps, or they might notice a little bit of increase like agitation or activation. Additionally, it's important to establish a postpartum birth control plan, help them make informed decisions regarding family planning, ensure that they're in the right place, and when they're ready to have a family again, that they have access to those resources while it's still available to our patients. Our key points to remember, mental health conditions affect about one in five women during pregnancy. Undiagnosed and untreated depression can have adverse effects on the woman, the fetus, the child after they're born, including death. Validated screening tools such as the APDS, the GAD-7, and the PHQ-9 can help identify patients that are at increased risk or have developed peripartum or postpartum depression. A shared decision-making model with patients can help determine the best management option. And then we want to collaborate with our behavioral health specialists, psychiatrists, and primary care professionals to help improve patient care. It is well within the scope of practice for OBGYNs to initiate pharmacotherapy for their patients. And again, also, we can wean them off those medications if necessary. So our practice pearls today, we want to screen everyone receiving a well-woman exam, pre-pregnancy, prenatal, and postpartum care for depression and anxiety using our standardized and validated instruments. We want to use our shared decision-making model with our patients to determine the best management options. Pharmacotherapy, if desired, should be started in a timely manner, and that's something that we can do as OBGYNs. And then also, we want to refer patients to psychiatrists, behavioral health specialists, or their PCP appropriately in a timely manner, ideally sooner than later, because we all know how challenging it could be to get our patients into those appointments in a timely fashion. I want to thank you all for joining us tonight. And again, a special thank you to Sage Therapeutics for providing the educational grant to support the program tonight. And if there's any questions, you can go ahead and enter those into the chat. Please also remember to complete the evaluation at the end of the activity. There was a pre- and post-test, so hopefully you've also completed that as well. Thanks so much for a great lecture. We are starting to get some questions. Can you discuss dosage, taper, schedule? Dosage, taper, schedules, right. So, when it comes to tapering off for medication, a lot of that's going to be dose-dependent, and it's going to be dependent on the duration of their therapy. For patients that had recently initiated medications or on their, kind of on the lower end of the dose, something like sertraline 25 milligrams, we could start to taper that down where we would just have them take half a tablet every day for a week and then go down to half a tablet every other day for a week, and then that would kind of be considered their taper. If they're on a higher dose of medications, like I've had patients that were on 150 milligrams, 200 milligrams of something like sertraline, we're going to go a little bit slower. That's usually going to be about a four-week taper to bring them down. Again, usually, we're kind of decreasing by about 25% to 50% depending on the dose and the duration that they've been on over the course of two to four weeks. There was a question earlier from Jennifer Smith. Has anyone found one online therapy program better than another for PPD? I have not personally found there to be any specific group or anything that's been helpful. I'm trying to remember. One of the websites that I will at least commonly do, and I have no stake in the company, but I've used it and I've told my patients about it, is a webpage called psychologytoday.com. From on that website, the patient can enter their geographic location. They can enter what type of mental health specialists they're looking for. If it's going to be a clinical therapist, a social worker, if they're going to look for a PhD-level psychologist, that's one that can help. I think there's other things like BetterHelp as well that are resources that patients can kind of go online and do their own search. Also available on the majority of those, they will include if they include what insurances they accept, if they accept private insurance or not. Then they usually reach out to the therapist by sending an email, so the patient can send an email. Then in those discussions, they can have a conversation about what the cost would be if they take their insurance. That's kind of the best way that I've found for patients to find it. If you're working locally and there is someone that you can refer to that you have a good relationship with, or you have resources that are physically available to your patients in a close geographic area, like I'm in Chicago, so we have plenty of resources around depending on what the patient needs, then we can make those kind of handoffs to the specialists in the area. But for those of us that have patients that are in a rural location, if they're not going to be able to get out there physically, some of the offices are offering hybrid models where it's in person or via Zoom. Thankfully, the pandemic did really help us in this regard of making behavioral health services accessible via telemedicine, but that's another avenue that the patients can explore as well. Okay, a few more questions coming in. What's your go-to with breastfeeding? My go-to medication, honestly, and the most widely used that has the most data is sertraline. Sertraline, usually we start the patient off on 25 milligrams or 50 milligrams depending on her symptoms or if she's taken it before. That medication is very safe. It's well tolerated. There's a very minimal dose that crosses into the breast milk. Any other medication if the patient says, hey, I've used this medicine before. It worked really well. You can always go to infant risk or mother to baby, and they have very specific counseling about how much dose we think the baby gets from lactation, the safety with lactation, but SSRIs are considered first-line therapy. Okay, a few other questions coming in in that regard. Do you have a preferred medication that you like to use? I think you've mentioned that. I cannot get my patients to take SSRIs because the side effects are on Google, especially pulmonary hypertension. I don't know if you want to comment on that. The incidence of pulmonary hypertension in the newborn is so exceedingly low. I know it's listed there, but that's something that in the years that I've been doing this, at least half my patients for a while here in Chicago were on some kind of medication for their depression. It's skewed for me because I'm an MFM. Of course, they're referred to me for these things, but it's not something that we see regularly. Usually, when we have these patients that have babies that have significant risks of things like neonatal abstinence or withdrawal or that pulmonary hypertension, it's with high-dose medications. It's with polypharmacy if there are multiple medications for high dose. Truly, the only time that I've ever actually seen a baby withdraw from medications like SSRIs was a patient. She was on three different agents to control her depression and anxiety. That baby just looked a little jittery, had a little bit trouble feeding, didn't require a NICU stay. Overall, the risk is exceedingly low. I think when we have that conversation, risk-benefit, yes, it's listed, but it's such a low risk. The risks to the baby of mom not being treated are so high that, to me, the benefit of the medication clearly outweighs any potential risk. Yeah. I mean, personally, I never had a patient that had a baby with that sort of complication. I think even looking at the data, some of those comments are based on older studies, which is what I tell patients, and they weren't validated with further studies. Another question kind of along those lines was, I was trained we should wean them off by the third trimester because of the risk to the baby. No, please do not. Please do not do that. That is something that I know has been in, it was in training. People have learned that in training. It's something that I saw kind of regionally here in Chicagoland. Again, I think that's kind of an older way of thinking. Again, based on that older data, the supposed risk, but there's so much more data now over the past 10 to 15 years that demonstrates that the risks are exceedingly low, but the benefit to mom is really high because we already reviewed the risks of untreated depression, anxiety, and pregnancy. I would not recommend it. I recommend against doing that. I specifically counsel patients about that because I know that sometimes they get conflicting information either from their OBGYN or from other providers are stepping into the realm. We have other midwives or nurse practitioners that are providing care, PAs that are providing care. I think just educating the patient that's really not recommended because we increase the risk of exacerbation and also reminding them too, if they wanted to wean off of it, they can make whatever decision they want to, but then postpartum, the likelihood of their symptoms being exacerbated is really high. They've got hormonal shifts. They're not getting a lot of sleep. They're caring for a newborn, and it's going to take two to four weeks for us to get them therapeutic again if they do decide to restart treatment. It's safer really just to keep them on it throughout the pregnancy and postpartum even while lactating. Yeah, I totally agree. Sometimes when I talk to a patient, you'll see the patients that have been on medication for years and years, and really they're questioning whether they need it. Those are the patients I sometimes talk to about you might want to consider stopping if you really are questioning. Another question, not SSRI naive, but if a patient has not taken one in over five years, do you treat them as naive and start them on a low dose? I do. Yeah, I do. Then this was asked a few minutes before, do you recommend any other labs besides a TSH? That's a little bit challenging and kind of nuanced because it really depends on what the patient's presenting symptoms are. We know this can overlap. We think about a TSH. We think about anemia. These would be the two more common things, either hypothyroidism or patients that are anemic in terms of that fatigue. If they're sleeping more, if they're gaining weight for patients that are losing weight, again, a TSH would be helpful there. Most commonly, the rest of that's going to kind of be guided by the other symptoms that the patient is reporting. But yeah, TSH is a good place to start and a CBC if they haven't had one recently as well is usually where I begin. How do we work with the doula and midwives? They are hard to work with when trying to manage care with our patients. That is a really big question and I think it depends on where in the country you're practicing, what type of midwife and doula care they have because if you're in an area where it's lay midwives, if you're in an area where they're certified nurse midwives, their level of training is very different. We know that their backgrounds vary widely across. I think when I have a patient come in and she is really adamant about something that was shared by her doula, whatever the case may be, I will invite her to either have the doula on the phone so we can all have a conversation together. I will invite her to bring this person in to meet me at their prenatal visit. Again, this is me as the MFM, but if they have this other person that's kind of joining them for care and influencing their decision-making, then I really think it's important to have a team approach as we're looking at a shared decision-making model because a lot of times, and again, the locations I practice in the country, patients really will put a lot of weight on that doula and it's hard to kind of tease out their experience, where their expertise lies, but also kind of drawing attention to the point that they may not have the information necessary or be familiar with all of the data to make a truly informed recommendation to the patient. It's having that conversation gently because I don't want to kind of take the podium out from underneath their other providers, but also just kind of draw attention to the fact that we are the ones that have the medical expertise. We're the ones that are trained to read the data, to interpret the data, to apply it to our patients. We have ACOG on our side to help provide these guidelines. All of this that I discussed today is from our ACOG bulletins in terms of management for postpartum depression. So I think it's just having the conversation. At the end of the day, our jobs as physicians, we educate our patient, we make recommendations, they make decisions. They're allowed to make whatever decisions they make, even if we don't necessarily agree with them. Our job is to support them, to educate them, and then kind of leave that door open so in case they change their mind, they'll still feel comfortable to come back to us and have those conversations in the future. Yeah, I think your lecture has been really informative because some of the questions have alluded to and I think there's that underlying issue that there's a stigma that gets attached and blame and you get the patients coming in with, oh, I was told to stop all medications and they're not going to be prescribed because they're dangerous. And so there's a lot of barriers to overcome, which I think education and patient advocacy are very important. Yeah, definitely. Comment in the chat, document discussion and decisions with the patient. That was a comment. Is that what you said? Yeah, just making sure things are documented. Yeah, absolutely. I mean, Dr. Patel and I are practicing here in Illinois in Cook County, so we are well aware of the importance of documentation. But yeah, definitely always document, especially if the patient's refusing or just isn't quite ready for it. Yeah, it's one there to just kind of substantiate the fact that you've had those conversations that you discussed the risk and benefits and the patient declined it, but also something you refer to later when you look back to say, okay, I did have this conversation, maybe I'll revisit it again at this appointment to make sure that she's still feeling okay, to see if she's had any changes in her perception, if she's willing to consider other options or have a conversation again. Again, I try to leave these things a little bit open-ended if the patient seems standoffish, right? And we can assess that. I mean, most of us know how to assess that pretty early in our appointment if the patient's going to be receptive or not. So it might take a couple visits to warm them up to the idea of seeking other therapies because of all those barriers in the way. Yeah. One resource I use, which you didn't mention, but that I learned about along the way through my training was Reprotox. It requires a subscription, but it has a lot of good information. And sometimes when patients are on medications, I'll actually just print out that page, medication, and hand it out to the patient. Certainly when you talk about documentation, just a lot of things have zero risk. And if there's some risk, you just document it and have the discussion with the patient, but that's always important to do. Right. Yeah, absolutely. Comment here, this was really great. Learned a lot. Thank you. I feel better about medical management. Good. That's great. Again, this is coming from me as an MFM, right? So I'm a little bit more comfortable with medication management. I'm comfortable with these conversations. I have more time to have these conversations doing what I do. So again, I haven't lost sight of what we're doing as OBGYNs out there in the community and the constraints that our OBGYNs are under in the office and the comfort with these medications. Because a lot of time in residency, we may not get the training in medication management, right? Because some of us were trained, like you don't give medication. Some of us were trained to wean them off of the medications, right? So it depends on where we trained, where our comfort level lies. But at the end of the day, we really are kind of the gatekeepers. We know there's such limited access to care. So I'm hopeful that as we're training this next generation, that they're recognizing, one, this is really prevalent. And because it's so prevalent, we need to be ready to actively manage with our patients and engaging in that shared decision-making. Another comment. Great lecture. Thanks. I give you your kudos. Thanks. I don't think we have any more questions. So with that, I think we can end the lecture. I just want to thank you as well as our sponsors for this lecture today. It was really great and informative. So thank you, Dr. Lott. You are welcome. It was a blast. Thank you.

postpartum depression

patient identification

shared decision-making

screening tools

psychotherapy

pharmacotherapy

behavioral health care

coordinated care