Hello and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director of SMI Advisor. I am pleased that you are joining us today for today's SMI Advisor webinar, Silent Storms, Unraveling Perinatal Mental Health. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoting to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to help your patients. Next slide. Today's webinar has been designated for one AMA PRA category credit for physicians, one CE credit for psychologists, one CE credit for social workers, and one nursing continuing professional development contact hour. Credit for participating in today's webinar will be available until October 24, 2023. Next slide. Slides from the presentation today are available to you to download in the webinar chat. Select the link to view. Next slide. Captioning for today's presentation is also available. Click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcript to option captions in a side window. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We're going to reserve 10 to 15 minutes at the end of the talk today to answer your questions. And now I have the pleasure to introduce you to the faculty for today's webinar, Dr. Laura Papa. Dr. Papa is a licensed clinical psychologist with a wealth of experience in perinatal mental health and trauma. Her areas of expertise include perinatal loss, perinatal mood and anxiety disorders, traumatic birth experiences, and domestic violence. Currently, she serves as the Director of Behavioral Health Education for Northwestern University's Family Medicine Residency Program at Erie Humboldt Park, where she plays a pivotal role in shaping the future of mental health care by training the next generation of family medicine practitioners. Dr. Papa, what a pleasure it is to have you today. Thank you for leading today's webinar. Of course. Thank you so much for that introduction. And I am ready to get started. So I just want to clarify, I have nothing to disclose. And so for today's presentation, there are a few things that you're going to leave today's presentation with. So one is being able to recognize factors for serious mental illness, particular to the perinatal stage. Also differentiate between different kinds and different health-related concerns within the perinatal stage. And what I would probably say is the most important piece, be able to leave today with some ideas for how to improve awareness and foster de-stigmatization across the board and within your practice. So I figured it would be important to start with why. Why is it that this topic is important? And so of course, we all know that this is a public health issue for women. But I want to clarify that this does not pertain only to women. It impacts everyone. It impacts the families. It impacts employers. And there are many ways in which this happens. And so a recent study actually showed that the cost of untreated perinatal mental health conditions for the 2017 cohort were approximately $14 billion. And that averages out to close to $32,000 per mother-baby unit. When we look at these financial implications more closely, what we see is that the most costly components that are relevant to mental illness are related to productivity loss, absenteeism, because the pregnant person or postpartum person cannot make it to work, and of course, unemployment, which is terrible. And if we start to look at other consequences and how this is such an important topic, I think everyone in this call is probably well aware of the negative impact that untreated mental health concerns can have on babies, on the offspring, and so things like low birth weight, things like attachment difficulties, and so forth. I mean, there's a lot of research in this area. And to me, one of the most important ones and one that I really want to highlight is that mental health concerns are actually the leading cause of OB complications in the United States. And to me, this is very sad because it is something that we can help prevent. And there are so many things that we can be doing. And so hopefully this presentation helps. So throughout the presentation, you're going to hear me use the word perinatal stage. And I use O'Hara and Wisner's definition for the perinatal stage, which is that period between the person becoming pregnant and up to a year postpartum. Throughout the presentation, I will be talking about unipolar depression, bipolar disorder, and postpartum psychosis as the main disorders that we address when we talk about serious mental illness. I do want to share that I will be touching on other conditions such as anxiety disorders, the baby blues, and also OCD because these are very prevalent among the perinatal period. And it is important to know how to differentiate between these disorders, but they're not considered serious mental illnesses. The one last thing I want to add is that my presentation is mostly based on cisgender women as traditional pregnancy carriers. However, I really do want to open the discussion of how this impacts non-binary populations and non-heterosexual relationships. So I do welcome those conversations and questions. All right. So we're going to get started with unipolar perinatal depression. So when we look at the prevalence in the literature, we really see anywhere from 10 to 20%. And really, that means that one in every seven to 10 pregnant women and one of every five to eight postpartum women will develop a depressive disorder. And if you do the math again, I'm doing a lot of the math for you, you're thinking about half a million women per year, which is such a high number. So when we're looking at symptoms, they're going to look very similar to those symptoms of a major depressive episode. The one thing that I want to highlight are how these really manifest within this population. So we're going to see an inability to take care of self and take care of baby. You're going to see that lack of fulfillment and joy in parenthood. And of course, the difficulty connecting with the baby. So I will be talking a little bit more about this in the treatment section, which comes later in the presentation. But I always highlight the importance of that connection, mother, child, and how they are bonding, because that is really crucial. And so we can talk a little bit more about that. In terms of risk factors, having a prior major depressive episode is going to be one of the biggest risk factors right next to perinatal anxiety. That is very crucial. Inadequate social support, I mean, that makes sense, because if the person does not, this is a huge moment for an individual's life. Many changes occur during this stage. And so not having adequate support, of course, it's going to put people at a disadvantage. High levels of stress. And then prior perinatal losses, fetal demise, those are also risk factors for perinatal depression. Now, when we talk about treatment, the first thing I want to clarify is the importance of distinguishing between depression and the baby blues. So when we talk about depression, we're really looking into at least two weeks or more of these very strong depressive symptoms, whereas the baby blues typically happens as hormones fluctuate postpartum. And you're really looking at those first 11 days postpartum, and you see that the individual that gave birth is weepy, some difficulties attaching. But as time goes by, people are able to start feeling better on their own without any treatment. But again, we're looking at about 11 days postpartum. It is important to highlight that 85% to 90% of women will experience the baby blues. So it is very, very common. Not all baby blues translates to perinatal depression. And then the other piece I want to highlight in relation to treatment is anxiety, because we know that anxiety, perinatal anxiety, is a major risk factor for perinatal depression. And so it is sometimes really difficult to differentiate between symptoms of anxiety and depression because there is quite an overlap in symptomology. And the literature doesn't do a great job at covering this overlap and really explaining how to differentiate between the two, although I think we are starting to see some changes in that area. And so some of the ways in which I try to conceptualize this lack of literature or this gap in knowledge, well, one way is that as mental health providers and as providers in general, sometimes we normalize anxiety-related concerns or anxiety-related symptoms, particularly in this stage, because we do expect some degree of nervousness, of anxiety, right? But sometimes we normalize it, creating a bit of a problem for the patient. Another way in which I try to understand this gap is that as providers, I think we're very well-trained at assessing depression. And it makes sense, because there are some serious risk factors that don't happen necessarily with anxiety or go as hand-in-hand with anxiety, such as suicide or risk to harm to the child. And I think sometimes we're so focused on trying to assess for those depressive symptoms that we forget about some other really important symptoms. So another point that I want to make related to anxiety disorders is that despite it being a major risk factor for depression, we just don't know really well how to look for it. And so many times these disorders will display themselves as somatic complaints, right? And what's tricky about it is that pregnancy in particular can mimic several bodily sensations that are going to happen also in anxiety disorders, such as nausea, upset stomach, sensitive bladder. And so asking the right questions and trying to really pinpoint what's causing this anxiety is going to be very helpful to the treatment of perinatal depression and, of course, anxiety. As I listed here, there are many treatments for unipolar perinatal depression. We will spend some significant time towards the end talking about them. But of course, therapy, group therapy, bright light therapy, pharmacology, exercise, and yoga. All right, moving on to the next, we have bipolar disorder. So the prevalence of this disorder varies quite a bit. So it depends on the criteria used in the literature. So depending on whether individuals were looking at bipolar 1 versus 2 versus the entire bipolar spectrum, which in that case were looking more at that 20% in prevalence, the symptoms are going to be very similar to general population bipolar disorder with a few symptoms really specific to this population. So for example, the delusions are going to be more so related to the child or the parenting, the impulsivity, the poor judgment that distractibility may impact or may be related to parenting as well. Prior diagnosis of bipolar disorder or prior psychotic episode is going to put the individual at a really high risk for relapse at this time in this perinatal stage. Women with a history of bipolar disorder in their family may also have their first episode during pregnancy or postpartum. So that first month, postpartum is a particularly vulnerable time for individuals. And then sleep deprivation is a major trigger for the onset of a bipolar episode or a manic episode. So it is very important to consider sleep within the treatment. And again, we will come back to this, to the treatment aspects. The other one that I want to highlight when you have individuals with treatment-resistant depression, you may also be looking at bipolar disorder. So it's something that I encourage you to look a little closer and consider bipolar disorder. So treatment, you want to make sure that you are assessing several times throughout the pregnancy and not just one baseline and one postpartum. Psychopharmacology and ongoing monitoring and management is going to be crucial. Bright light therapy and electroconvulsive therapy are also appropriate treatments. All right. And then postpartum psychosis, we do see the prevalence being a lot smaller than for the other disorders. The postpartum period is a particularly risky time for the onset of a psychotic episode. It increases individuals' vulnerability more than any other time in a woman's life. So it is very important to keep a close eye on individuals during this time. So in relation to the symptoms, the onset of postpartum psychosis is actually quite distinct to regular psychosis. So I figured we would spend some time talking about those. So one of the distinctions is timing. So postpartum psychosis will typically occur within the first few weeks of postpartum, usually within the first two months. So that timing aspect is very particular to the perinatal population. Then triggers. So while we don't fully understand the full reason or cause of postpartum psychosis, we do know that there's a hormonal component and that hormonal fluctuations are changing during or after childbirth. And that is playing a key role. And so this unique trigger, again, is very particular to the perinatal or postpartum psychosis and not the general population psychosis. And then the symptom presentation is going to be slightly different, like I mentioned earlier, with bipolar disorder. So it'll typically present with symptoms such as severe mood swings, as we know, confusion, hallucinations. Now, the hallucinations are often going to be related to the baby. The delusions are often going to be related to or have some themes of harm or danger to the baby or harm and danger to self, to the mom. And of course, we're going to see a lot of disorganized behavior. So Osborne 2019 does identify different profiles for the psychotic presentation. Risk factors, as I mentioned a few seconds ago, the postpartum period is a huge risk factor. Personal history, family history of bipolar disorder, and of course, prior episodes of psychosis, if this is an individual's first pregnancy. And again, here we see sleep loss. Sleep loss is crucial or unfortunately, it's quite detrimental to the individual's health. There is treatment. So of course, we're going to look at medication. We're going to look at electroconvulsive therapy and support. Support is going to be very, very important for this population. So, so far, we've covered the three serious mental illnesses. We've also talked about anxiety, despite it not being a serious mental illness, but it typically goes hand in hand with perinatal depression. And last, I also wanted to talk about OCD. So OCD is not considered a serious mental illness. However, it is, we see it quite often in this population. It is no longer classified under anxiety disorders, as many of you may know. What's interesting about OCD is that the prevalence is quite high for during pregnancy. So we're looking at close to 8% during pregnancy, but then there's a gradual increase, reaching close to 17% postpartum. So that is, that is a number that is quite high. When we're looking at symptoms of OCD, it may show in some ways, or it may resemblance, it has resemblances and distinctions compared to general population OCD. So what we're seeing in general population OCD is the obsessions, the compulsions, or both. And that we're seeing also in the perinatal stage. But what's particularly different or distinct in this phase, in the perinatal phase, is that obsessions are actually going to revolve mostly about harm to infant and intrusive thoughts of aggression towards the infant are also prevalent. So what's interesting is that what we see is that harm to infant typically happens in the perinatal or the before pre-delivery period, in the pregnancy period, and then towards the postpartum period. We tend to see more of these thoughts being geared to contamination and that type of harm to the child. So the compulsions may be related to cleaning and washing postpartum, which is distinct to general population OCD. So another important reason why I wanted to make sure that we highlighted OCD and we spent some time talking about it is because sometimes in some presentations it's going to be hard to distinguish between psychosis and obsessions. And so I figured we could spend some time distinguishing these two and talking briefly about it. So insight is going to be one of the key components. So with OCD, people generally have significant insight into the rational component of their obsessions. So even though they may struggle to control it, they do identify that they're not quite real or true. Whereas in psychosis, especially during an active episode, of course, individuals are going to lack this insight and it may be a little tougher for them to identify the unrealistic nature of some of the delusions. Also in OCD, people tend to not be compelled to act on their thoughts. Oftentimes, they feel a lot of shame over the thoughts. So they're egotistotic. Whereas in psychosis, thoughts are egocentronic. And so they are more likely to act on some of these thoughts. And the last piece that I want to distinguish is between beliefs and intrusions. So in psychosis, delusions are often deeply, deeply ingrained beliefs, again, especially in that active episode. And so it shapes the person's perception of reality. Whereas in OCD, like I mentioned earlier, the obsessive thinking, it's unwanted. It's uncomfortable. It causes a lot of distress, a lot of anxiety. So risk factors for OCD, of course, a history of the diagnosis, and the postpartum episode or period. Treatment, it's going to involve psychopharmacology, but also CBT and exposure and response prevention programs. There have been several research clinical trials done with the combination of CBT and ERP and have been found to be very successful. All right, so now that we've covered all of the data, let's talk about what do we do with this information. So as I mentioned earlier, or actually it was mentioned by Dr. Cohen in the introduction, so I work mostly with residents right now, family medicine residents. And so I get to observe them quite a bit in clinic. And we always talk about, or I always share with them, that I really discourage the use of the PHQ-9 for good and accurate assessment. I'm sorry, no, let me erase that. PHQ-2, not PHQ-9. PHQ-9 is great. The problem with the PHQ-2 is that it's pretty high in face validity. The questions are very obviously asking about depression. And so when we have an individual who is hesitant about wanting to share how they're feeling and hesitant about acknowledging depression, they're less likely to endorse those two items. However, the PHQ-9 definitely asks about an array of symptoms. And so it makes it a lot easier for individuals to feel comfortable reporting some of the symptoms. So both the PHQ-9 and the EPDS, the Enenberg, are reliable and valid scales for this population, so highly encouraged to use them. The reason why I like the PHQ-9, it's because it's going to capture some of these somatic symptoms that we talked about earlier with anxiety disorders. And although the Enenberg is still fantastic and it's going to capture other comorbidities, really the combination of both is great. So simultaneous administration is ideal, but either one is fantastic for this population. I also want to plug here that the EPDS has been shown to be great for the assessment and valid for the assessment of perinatal depression among dads. So we do have data showing fluctuations in mood for dads. We do know that they experience perinatal mood disorders as well. And so it is important to assess wherever possible or try to offer some support. If you are in a place where you can do this and you can also incorporate the partner into the discussion, I highly encourage the use of the EPDS as it is a validated tool. We also have the MDQ, which is the one up there with the purple heading. The MDQ is a screener for bipolar disorders. It is a great tool. It is a valid tool. It can help really ask and assess all the questions that you need to successfully assess and diagnose bipolar disorder. What I highly encourage you to do is to highlight the importance that these symptoms need to have happened within the same period of time. So the symptoms have to be simultaneous. And I would highly encourage you to ask the patient to give examples about the endorsed items to make sure that whatever it is that they are endorsing is in line, of course, with the diagnosis. Unfortunately, we don't have any validated screening tool to measure psychotic disorders. And part of this is that psychotic disorders can present themselves in such diverse ways. It isn't an algorithm that you can use to really narrow down that diagnostic approach. However, there are some guidelines that I encourage you to follow. So doing a really thorough psychiatric history and the beginning of treatment, I think that's crucial because that's going to give you a lot of data for things that you need to be looking at. So is there psychiatric history? Is there depression, mania, both, family history, substance use? Is there substance use? History, I also always tell my residents, talk about current suicidal ideation, but also ask about the history of suicidal ideation because you may find out that there were times that were really, really difficult for a person. And you want to make sure that you have accurate data. The importance of finding the right language for to ask these questions and the language that will help you feel genuine when asking and also capture the right information and feel the person feel comfortable with you is so, so, so important. I cannot highlight that enough. Being validating, so saying something like, I know the, let's say, postpartum. I know you just had a baby. And I know how overwhelming that can be. A lot of people during this time will talk about wanting to hurt themselves or even wanting to hurt their babies because they are having such a hard time. Has that ever happened to you? Something like that. So relaying empathy and really trying to approach it non-judgmentally because that's going to open the door for the individual to really share what they're feeling, to really share their concerns. And the fact that you're saying, hey, I actually do know that this is a thing, it's going to help the individual feel that they're not alone and de-stigmatize. Very, very important. So now we're going to get into treatment recommendations. So I'm going to talk briefly about all three conditions. So the first one being unipolar depression. So there are several therapies that have been validated with this population. This is the research we have. It doesn't mean that other approaches are not good. It just seems that these are the ones that have been studied the most, particularly CBT. So it is the most widely accessible in primary care type settings as well. So we're going to see CBT being used not only by mental health providers, but also by medical providers, for example. In CBT, just a brief overview, the therapist is really going to emphasize how a patient's current negative thoughts really impact how they behave in the present. And it impacts how their future well-being will be. So the goal of CBT is going to be to assess, to challenge, and ultimately to use cognitive restructuring to reshape some of these unhelpful beliefs that we all have to a degree. So very, very useful. The therapist does play an active role in guiding the conversation, particularly in the beginning. The clinician is going to provide a lot of psychoeducation and, of course, important strategies to manage the stress. Then we have behavioral activation, which is one I use quite often. So it is a treatment for depression and mood disorders in general, not just for the perinatal stage. And it's based on the theory that as individuals become depressed or depression increases, people tend to engage in more avoidance and more isolation. I'm sure this is not going to come to surprise to many of you. And then what happens is that this avoidance and isolation then serves to maintain and truly worsens the symptoms of depression. So the goal of treatment is actually going to be to help individuals little by little gradually decrease the avoidance, decrease that isolation, and increase engagement in activities that have been shown in the past to be very helpful and to improve mood. So typically what you want to do as a clinician is assess what are the activities that made them feel good in the past. Then we have interpersonal therapy. This is a manualized treatment approach. It addresses more interpersonal problems or concerns associated with depression. There are different versions of IPT. So we have a longer version or a shorter version that can also be very effectively used in primary care and has been shown to be effective in primary care. And ultimately, the central idea in interpersonal therapy is that the symptoms are stemming from, or can be understood, rather, as a response to current difficulties in everyday interactions and relationships with other people. And so in particular to this population, women are really helped to identify these triggers for depression, explore relationships, use strategies and teach strategies to help promote self-awareness around these issues and around these relationships. Sometimes you may do mood timelines or go to circles of support, et cetera, how to ask for help. So very psychoeducation-focused in a way. Then we have group therapy. When we talk about group therapy within the context of this population, we're really looking or mostly looking at CBT. It's the one that has most of the research available is related to CBT for this population. And I think it's a great approach. And we're going to talk a little bit more about groups in a bit. But it's a great approach for less resource-intensive alternatives. So I highly encourage it. Bright light therapy is actually a treatment that's been proven to be very effective for seasonal depression. But there is really good data showing that it can also be effective in this population with really minimal to no side effects for the perinatal patient. So really great option. Then, of course, support groups. Support groups have been shown repeatedly to be very helpful during this stage. And I think it's such a wonderful, wonderful tool when you have people that are going through similar things and they can share their experience. It can be so, so, so empowering. Exercise. So there are recent studies that have shown quite promising results. However, it is important to remember that there is limited data with exercise in the perinatal population in relation to serious mental illness. So studies are limited by a smaller sample size. And then yoga. Yoga has been shown to be effective, similar to exercise or cardio, I should have said. It is great. However, more research is needed, as we also have a smaller sample size. All right. For bipolar disorder, a few things that are crucial is to make sure that, as a provider, you are identifying the disorder early, that you're monitoring symptoms, and that you're providing effective treatment. You want to make sure that you are screening several times throughout treatment or throughout your work with the patient, that you are providing options for psychopharmacology, and also that ongoing management. Bright light therapy has been shown to be very effective. However, it's important to remember that this is a great option as an addition, an add-on to medication. So it cannot be the only treatment for bipolar disorder. It is a great option for this population, like I said, because it is safe, and it will help with some of those lingering symptoms that, especially a bipolar depression, that are hard to improve. So in combination with medication is a great option. And then we have ECT, which is carried out under anesthesia. And it is quite a viable choice for this population, particularly when they're experiencing more severe mood episodes, or they're not responding well to medication. I like to think of ECT as a good option for those patients that are really struggling with self-care, so really having a hard time getting out of bed, and having a hard time bathing, eating, drinking, so basic life functioning, those with severe suicidal ideation, or, of course, if they're dealing with psychosis. If we think about it, it's important to remember that an extended period of incapacitation can post serious harm to the individual and or to the child. And so it is important to look at this treatment if you do have a patient who is struggling so severely. And then postpartum psychosis. We're also going to start with ECT. So ECT is going to be the primary approach for those individuals, again, that are experiencing more severe symptoms like catatonia, intense agitation, and persistent refusal to eat or drink fluids. We definitely want to make sure that we are addressing those concerns. Psychopharmacology, of course, it's going to be very, very important. And then support. So I find that support is crucial for all of these disorders, really, but particularly in this population, because we want to make sure that whoever is going to be the main source of support for the individual, whether it's mom, dad, partner, whomever, that they understand the condition, that they're able to recognize and identify some of the symptoms, and that they are providing the right level of care that they can, and consulting or taking to the ER or the doctor's office, whatever needed. All right. So now that we've covered all of these treatment approaches, so how do we destigmatize? How do we help this to get better? Because we're not talking about it enough. And so I want to go back to something I mentioned a few slides back. Offer group therapy and or support groups. If you are in an agency or a program that is seeing for whatever reason people in the perinatal stage, it is highly encouraged to have some form of group, whether it's a formal therapy group or support group. Why that is, is because people are sharing their experiences. Like I mentioned earlier, it can be so empowering. I've created perinatal groups in many of the agencies where I went. I'm so lucky here that they already had them when I came in. But it is so, such a crucial component to treatment to help people not feel isolated and not feel like they're alone and not feel shame for the thoughts that they're having, the concerns that they're having. This is my own practice, but I do like to invite parent, sorry, the other parent or partner into treatment, ideally during third trimester. It can be sooner or later, depending on each situation. Of course, if there is IPV, I would not encourage this. But if it is a relationship that we do think that the parent is going to be involved in helping the birthing parent with child care and child related concerns, that we do want to make sure that they're coming in. And that is true for many reasons. We want to make sure that they know what to expect. Sometimes setting accurate expectations is hard. And so we want to make sure that we're assessing their expectations and creating more appropriate expectations for what this period, the postpartum period is going to look like. If we are working with someone obviously with serious mental illness, we want to make sure that we're talking plenty about sleep and how to try to disrupt the sleeping period as little as possible. Sometimes I've had situations where the mom is not the person with a serious mental illness, but dad is. And so that conversation would come up as well. Setting realistic expectations for each family system. Okay. And it may not be mom and dad, right? It may be different partners. It may be parents of the person carrying the pregnancy. So we want to make sure that we are starting these conversations early on and helping them succeed. Okay. Like I mentioned earlier, we got to make sure that we're asking the right questions in a way that feels genuine and appropriate with who we are and how we are. Okay. So making sure to do that as well. And then know the data. This is a very important piece. So knowing the data for mental health related concerns is going to help realize folks that they're not alone. It's going to help normalize their concerns. When people realize that they're not alone dealing with similar challenges, it can reduce symptoms of isolation or symptoms of feeling abnormal, which is definitely something that we want to reduce. Of course, that having more data is going to also challenge stereotypes. It's going to challenge misconceptions that people have about mental health. And when we are addressing, right, that misinformation, then people are less likely to associate mental health concerns with these negative stereotypes, which is so, so, so important. It is also key to encourage public awareness, encourage education. Awareness is going to lead to more informed discussions and then creation of more informed initiatives, right? And so in turn, it's going to improve mental health literacy, serious mental illness literacy, and reduce misinformation, of course. Empathy and understanding. Learning about serious mental illness really cultivates empathy and understanding. At least for me, that's how I see it. We need to understand that we're not all the same and we all have different challenges and struggles and really be able to be understanding and empathic towards one another. And of course, all of these strategies are aimed at improving society and challenging discrimination, okay? If we can challenge discrimination and advocate for policies that protect the rights of those individuals, then we can actually look at better treatment options and a reduction in mental illness. So that is it. Here are some of my references. Thank you so, so much. Dr. Papa, thank you for such a helpful presentation on an important topic. A number of questions have come in. Not surprisingly, people are obviously very engaged in this topic. So there are a number of questions around bright light therapy. So I often think of it as an adjunctive therapy, but I was wondering what do you know about it? Do you have any anecdotal or evidence about the use of bright light therapy? Yeah, yeah. So it is, you will have to use it in conjunction with medication. Absolutely. It's typically going to be very helpful for those individuals that are struggling with pretty severe depression. And so it's going to, yeah, it's typically never used alone. It's also going to help quite a bit with regulating circadian rhythm and improving sleep patterns. So it's a great resource. It does have to be prescribed by a psychiatrist. Great. So, you know, one thing that we often think about is that maybe the first line, and this is kind of where you work, first line of where this might be seen might be in the OBGYN's office or by the nurse in that office. And I'm wondering at what point do you, and this was one of the questions, at what point do you think about moving them over to specially mental health, to a psychiatrist? What do you teach your residents or what should we know about when you move them from primary care OBGYN over to specially mental health? Yeah. So when the policy we have here at the clinic, whenever it is classified as under serious mental illness, we do like them to see a psychiatrist specialized in perinatal mental health, which we're so lucky to have here because there are nuances for this population that we're not necessarily going to see in the general population. So when it comes to serious mental illness, we definitely want to refer out, not refer out, but work as a team, right? When it comes to more traditional or more commonly seen mental health related concerns, I always talk to the residents about the importance of providing education, thoroughly assessing. I really, like I said, I really discourage them from doing the PHQ-2, even though that is, I know, very common practice, but really assessing not only the symptoms, but also the individual's context. What is their life like? Because they may just need a bit more support than what the clinic can offer. And so if we know, if we have a more holistic picture of the situation, then we can make sure that we create a system that works for the patient. So it varies a lot. It varies a lot, but the way I approach it, if it's serious mental illness, I try to refer out if they tried, their rule also, if they've tried to SSRIs, for example, or antidepressant medication and hasn't been effective, then they also refer to a psychiatrist because like we said, if we're looking at persistent depressive symptoms, we may be looking at bipolar disorder, for example. So we want to make sure that we're addressing it effectively. Great. Someone wrote in and I think they, you know, really are representing a lot of the pressures, which is, you know, there's a lot of pressures and expectations on women to breastfeed. And of course it's not easy for everyone, or it's not something that every woman wants to do. And I'm wondering if you think a little bit about, as I'm sure you do, but this person's asking, how do you think about the pressures around breastfeeding, those expectations and their role in some of the perinatal mood disorders? Yeah. So first of all, I want to clarify my face was because I'm not seeing the chat and I thought you were going to ask about pressures in terms of time and productivity, which I know is such an important thing. When it comes to breastfeeding, that's a wonderful question. I hate it when I hear the, well, you know, I should be breastfeeding or partners really pushing breastfeeding. The way I approach it and my take on it is I ask the mom what they want to do. They typically say, I want to breastfeed. Sometimes they don't. It varies a lot. Actually, I'd say it's like 50, 50 anecdotal evidence. And I always try to explore, you know, what, what makes you want to continue trying to breastfeed? What is it that are, are there reasons why it would feel good to not breastfeed? Because ultimately what we do know is that mothers with increased anxiety and depression, which is caused by this inability to, to have the child latch on and to be able to breastfeed, it creates more harm to the child than not. And so it's really important to relay that education and say, you know, it's just not healthy to continue pushing something if it's not working, because there are other alternatives that can be extremely healthy as well. Right. And so, and this, and this writer in said, sometimes people, mothers or, or their partners just need permission to not breastfeed. And so I thought that was a really good, a really good way to put it is giving them permission. So, interesting question here. What about post-placement? And this is a little bit just to the right of the topic, post-placement depression for adopted parents. So adopted parents who may also, where, where do we refer them or what do we think about for the, for those? Yeah. So as I was preparing this presentation, I was actually thinking about that. I don't have the answers because I have not worked a whole lot with this population and I wish I had a better answer. What I do know is that typically, and again, this is anecdotal evidence, but typically when there are situations of adoption right after birth or readjusting to a new family system, the agencies through who the adoption went through typically offers a ton of support, including group therapy for parents, for the kid, whenever appropriate, of course, not for a baby and also for surrogate parents. So there are a lot of different options, but. I see. So going back to the, the service where you kind of have been working on the adoption or the surrogacy often is a good place to start. I'd say so. Yeah. Someone wrote out and, and, and is thinking about, you know, once they leave the hospital and of course need ongoing support, therapy, et cetera. And for those of our clients who don't have private insurance, be able to. And so how do we as providers or clinicians find therapists or clinics that are experts in perinatal mood disorders, anxiety disorders, psychosis, how do we find those folks? Is there a way to kind of find them? How do you, how do you identify in your city? Who's good in the community? Yeah. And this is particularly relevant to patients that are maybe underinsured. Is that correct? Yeah. So federally qualified health centers are typically a great place to start because these are agencies that I happen to work at one, which is why I'm bringing it up. They're agencies that offer that are not allowed to turn away patients and they offer an array of different services, typically including psychiatry, perinatal services, ongoing primary care services. So I, I I'd start there because I think that is a fantastic place to start. Typically they also have behavioral health options, although not always. And that varies across states. I also want to say that there are some legislative initiatives that recently came out to try to improve coverage for, for Medicaid patients. But I understand that this is only a very small part of the population that we see, for example, of an FQHC. So it's tough, it's tough. It's, it's not a system that is developed to help folks that are not well, that do not have all of the resources, you know, there are a lot of very significant challenges. Right. So, I mean, of course we're speaking to the whole group of the mental health system, right? FQHCs are one of our excellent models around the country of systems that are, like you said, open doors that will take anybody, right? And that includes postpartum. And so I really appreciate you bringing up and highlighting FQHCs and folks should know, clinicians like myself and yourself should know of those in our community so that, and, and develop a relationship with clinicians there so that you can do a warm transfer and ensure that people can get an appointment and ensure that they show up for the first appointment. And if not, that we catch them somehow. So I appreciate the fact that you're highlighting FQHCs. Let me just ask you one more question because it's something that you brought up a lot and that it's in complete contrast with that moment after you have a baby, which is sleep, right? So we all struggle after our, after we have a child, whether we're the partner, the individual who gave birth, et cetera. But you also pointed out many, many times that getting good sleep is an important protective factor to onset of, you know, depression, mania, psychosis. So when you're talking to families and saying to really take care to try to get sleep, is this where you say the support comes in and that you really build kind of this network so that the parents can get sleep? Tell me a little bit about what you kind of reference. Yeah, absolutely. So when I bring family in, one of the first sessions, what I do is explore expectations. I want to hear from them what it is that they envision these first few months looking like. Sleep is one that typically comes up because it's unpredictable. We don't know the temperament of the baby. We don't know what this is going to look like. And so I, what I do very early on, probably the first session, I discuss the implications of not sleeping and how it can be quite triggering for the mom, pushing her into an episode. And so we problem solve what improving sleep could look like within the reality of that family, right? So if there is a partner that's very involved, we are going to prioritize mom's sleep and try to have dad do a lot or much of the night work. And, or maybe reducing the amount of times that mom is waking up if it's not possible to do that trade off fully. Other things, you know, during the day, what are some things that you can do to sleep during the day? So really just structuring the day and structuring the 24 hour cycle to getting enough sleep and getting to regular patterns of sleep because disorganized sleep is also not going to help. And so creating a pattern and a schedule that works for the patient and that varies, but it's, it's super important to bring it up right away and make it a conversation that's going right. Really appreciate that. Well, Dr. Papa, it's been a pleasure. I'm sorry to cut you off. I know that we probably have more to say. I want to ensure that we have enough time to let people get to their next appointment. So let me move on to our next slide. And if there are before we shift, I'm sorry, I want to take a moment, let everybody know that SMI advisor is available via their mobile device. They can use the app to access resources, education, upcoming events. And I'll note that the PHQ-9 is in the app, just as you mentioned today. And so they can actually use the app right in the clinical encounter to, to deliver the PHQ-9. It automatically scores and gives you an interpretation. So this is a wonderful tool that links to what you talked about today. Next slide. If there are any topics, next slide. If there are any topics covered in the webinar today that you would like to discuss with colleagues in the mental health field, post a question or comment on the SMI advisors discussion board. This is an easy way to network and share ideas with other clinicians who participated in this webinar. And I know you guys can really help each other. If anybody has any questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from our consultation service. This service is available to all mental health clinicians, peer support specialists, administrators, or anyone working in the mental health field who works with those with serious mental illness. It's completely free and a confidential service. And we answer within 24 hours during the work week. Next slide. For those of you who participated today, I know that this webinar might be of interest to you. It's called postpartum psychosis or birthing people of color falling through the treatment gap. We didn't get a chance today to talk about different race and ethnicity, but we all know that that's important, including Dr. Papa, who reminded me of this as we started today. So in this webinar, which is completely free, they're going to have experts plus a panelist was shared with lived experience in this area of postpartum psychosis. So it's going to be a really powerful webinar. You can register at the link here and it's also in the chat. Next slide. To claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends, please click next and to complete the program evaluation. The system then verifies your attendance for credit claim. This may take up to an hour and can vary based on local, regional, and national web traffic and usage of the Zoom platform, but please ensure that you check back, do the evaluation to get your credit. Next slide. And please join us next week on September 8th as Dr. Brian Miller presents on insomnia, hyperarousal, and suicide and psychosis. This free webinar will be Friday, September 8th at noon Eastern time. Thank you, Dr. Papa. Thank you to our audience for joining us today and until next time, take care, everyone. Bye-bye.

perinatal mental health

depression

bipolar disorder

postpartum psychosis

anxiety

OCD

early intervention

cognitive behavioral therapy

medication

support groups