“I can’t sleep when my baby sleeps, I’m too worried about every little thing. Why didn’t anyone tell me it would be like this? I thought I could do this but now I am not sure at all.”

“I’m so angry and irritable that my family and friends are losing patience with me. They pushed me to come in today. I don’t want to take medication but I can’t go on like this. Something has to change”

“I didn’t think I would be this overwhelmed every day. I am failing at everything.”

I have heard parents of very young children utter some version of the above “why is this so hard?” statements more times than I can remember. If you work in a clinic that provides obstetric (OB) care, you likely have as well. I still don’t have a good answer (except the snarky one about living in a country that doesn’t support children and families). Why didn’t this come up in a meaningful way in 9 months of frequent medical visits? 

Adding a child or children to a family is a frantic turning point in life that means watching the person you have always been grow shockingly distant.  Although the challenges of this transition are universal, our society views perinatal mood challenges as if they are a surprise; seemingly waiting for parents to grow weary enough that they crack under the pressure.  What is a better alternative?– bolstering support, education and early intervention, and creating a safe and caring space for a parent to give voice to what it means to be born along with their baby. This should be the aim of every health care team interacting with pregnant and parenting individuals. To that end, here is a list that may interest you if you are, a) just getting started or, b) looking to expand your efforts to serve the perinatal population in your clinic.  This list is by no means exhaustive, but if you are uncertain how to get started the following four points may serve to help navigate your team toward  screening, establishing  pathways to care, identifying risk factor awareness, and mastering the basic prevention and intervention skills.

1. Screen at multiple points in care with the Edinburgh Postnatal Depression Scale (EPDS): Among other things the EPDS is a convenient way to pinpoint the target of a brief intervention.

• Entry to OB care 
• 28 weeks pregnancy
• 3 weeks postpartum or first postpartum visit
• 8 weeks postpartum or when patient returns for annual wellness visit/to discuss birth control 
• If patient expresses concern, shows symptoms or is interested at any other point in time

Additional recommended screenings at entry to OB care and in postpartum period include the 5P’s (https://www.in.gov/laboroflove/files/5%20Ps%20Screening%20Tool.pdf) as well as questions related to need for parenting support, access to food, housing, transportation and an interpersonal violence screening tool

2. Create robust internal pathways: The location where parents receive OB care is often the only place they reach out for support. External specialty care is often difficult to access or overwhelmed by demand. With this in mind:

• Set up pathways to notify behavioral health of elevated screening results. This could include EHR functionality that auto-notifies BHC and provider when EPDS score is 9 or 12 or if  any thoughts of self-harm are endorsed. Alternatively, train medical assistants to review screenings and manually notify behavioral health. 
• Standardize warm handoffs with a BHC at every new OB appointment and at least one other point in pregnancy care or at the first postpartum visit.
• Easy, education-rich and low-stigma access to SSRI’s and other medications with favorable risk/benefit profile. This can be as simple as empowering BHCs to request med initiation from providers without requiring an additional clinic visit.
• Additional opportunities for engagement include brief educational signs or pamphlets in exam rooms and waiting rooms, engaging educational content such as videos or activities in group or individual OB visits, incentivize “healthy pregnancy activities” such as at least one behavioral health contact.

3. Increase awareness of common risk factors for perinatal mood challenges: 

• History of or current mental health or substance abuse issues: Particularly if untreated or undertreated. Many women discontinue psychiatric medications or MAT without medical advice when they find out they are pregnant, although continuing treatment is often the best option.
• Feeding difficulties: Particularly if breastfeeding is highly valued and is problematic or not possible or frequent pumping of breastmilk is required.
• Social stressors: Intimate partner violence, relational conflict, membership in a marginalized group, insufficient or unstable housing, childcare issues, food insecurity, teenage/youthful pregnancy.
• Fussy/hard to soothe babies: Can include poor fit between parental expectations and baby’s temperament.
• History of miscarriage, abortion, neonatal loss, infertility, assisted reproductive treatment.
• Current or past medical issues complicating pregnancy or childbirth: Some common ones include diabetes, hypertension, advanced maternal age, preterm delivery, babies with medical needs or NICU stays, unplanned c-section, emergency medical interventions at time of delivery or traumatic delivery.

4.  Prevention and basic intervention skills: All BHC’s should be trained and ready to engage in discussion related to risk/protective factors and interventions for perinatal mood disorders.  Interventions will be most effective if provided quickly when symptoms emerge and if a partner or support person is involved at some point in care. 

• Sleep: Newborns often sleep in very short stretches. Meet prenatally if possible and again post partum to address sleep and how to prioritize a minimum 4 hours uninterrupted plus 1-2 additional hours of sleep in each 24 hour period through shift sleeping or engaging outside supports.
• Nutrition/hydration needs: It is surprisingly easy to forget to eat and drink while caring for an infant or young child. The intervention can be as simple as a discussion of how many times to refill the water bottle every day to get enough and  favorite low-prep, nutritious foods with brainstorming about how to access/have ready.
• Support: The social isolation and emotional drain of caring for an infant or young child may be the biggest trigger for worsening mood.  Learn about your patient’s specific needs for support and help them plan to access supports. See here for some ideas for community support across the US: https://www.postpartum.net/get-help/locations/united-states/
• Time away from caregiving:  A goal of 2 hours per week without caregiving responsibilities is a decent start. Maintain a solution-focused mindset as there are more reasons that parents do not get time to themselves than I can list here.
• Stay calm when women open up about scary thoughts they may be having. Stay curious and supportive and educate yourself about when to worry or intervene immediately (several resources below).
• Key clinical tools: Interpersonal Psychotherapy, brief mindfulness strategies, CBT, MI, warmth, authenticity, hope.

Finally, do not be discouraged if you can’t do it all.  Pick one small thing to work on and stay focused on it until it is going smoothly before trying to add another.  For help, look to the growing body of expertise on this issue, some are listed below.

Further resources for reading and training:

ACOG 2015 opinion on screening: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression?IsMobileSet=false

Postpartum Support International: https://www.postpartum.net/

Massachusetts General Center for Women’s Health: https://womensmentalhealth.org/

Karen Kleiman’s Books: https://postpartumstress.com/books/ 

Postpartum Progress: https://postpartumprogress.com/ 

Pacific Postpartum Support Society: http://postpartum.org/

USPSTF Final Recommendation on Perinatal Depression, Preventative Interventions: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/perinatal-depression-preventive-interventions