By Walker Karraa, PhD.

Perinatal and/or postpartum depression affects more than 15% off all women during pregnancy or after birth. Many women are not diagnosed and therefore are not referred on to specialists who can help them with appropriate treatment. Last month, the Centers for Disease Control (CDC) announced an inaugural grant of 2.5 million dollars to University of Massachusetts Medical School researchers for the purpose of exploring the feasibility and effectiveness of obstetricians diagnosing and treating women suffering from perinatal or postpartum depression within their current obstetrical practice. The ability of obstetricians to identify and treat affected women may help to close the gap that exists in women receiving treatment, and ensure adequate care is available and provide the ability to monitor how the women respond to treatment. Creating a network of resources and providing OB access to psychiatric specialists for consultations can result in more women receiving more effective treatment faster from the provider they are already seeing. Dr. Walker Karraa, perinatal mental health expert interviewed on of the co-investigators, Dr. Nancy Byatt about this research grant and what it might mean for women suffering from perinatal depression. - Sharon Muza, Community Manager, Science & Sensibility.

Walker Karraa, PhD: How is this grant first of its kind?

Nancy Byatt, DO: This is the first time the Centers for Disease Control put forth a request for applications for the Evaluation of a Stepped Care Approach for Perinatal Depression Treatment in Obstetrics and Gynecology Clinics.

WK: How long have you and your colleagues been working on this grant?

NB: Our team began working on understanding how depression could be addressed in obstetric settings in 2010. Driven by our commitment to helping women get treatment by leveraging the obstetrical care setting, we were awarded two institutionally funded grants to conduct three formative research studies with obstetric providers and staff, postpartum patients and pregnant women.

Investigators Jeroan Allison, MD, Nancy Byatt, DO,
and Tiffany Moore Simas, MD.

Our preliminary studies evaluated the perspectives of obstetric providers and postpartum women, about ways to improve depression treatment in the obstetric setting. We found that barriers occurring at the patient, provider, and systems-level prevent perinatal women and obstetric providers from addressing depression. Our preliminary data led us to hypothesize that transforming obstetrical practice to include depression treatment would enhance women's access to and engagement in treatment and thereby improve depression outcomes.

WK: Tell us about the pilot study and how it revealed the gaps in treatment. What are the gaps identified? Why do you feel these gaps exist?

In our formative studies, and literature reviews, we identified a number of patient, provider, and systems-level barriers and facilitators to the treatment of perinatal depression and reviewed clinical, programmatic, and systems-level interventions. Provider and systems-level barriers include: (1) lack of obstetric provider training in technical aspects of depression care and communication skills; (2) absence of standardized processes and procedures for stepped depression care; (3) lack of mental health providers willing to treat pregnant women; (4) lack of referral networks; and, (5) inadequate capacity for follow-up and care coordination. These are exacerbated by patient-level barriers. Perinatal women report they fear stigma, losing parental rights, and being judged as an unfit mother. Many women perceive obstetric providers and staff as unsupportive, unavailable, and inadequately trained in depression. We have built the RAPPID program to address these critical barriers at the provider, patient, and system level.

WK: If readers wanted to learn more about your work and/or the gaps in treatment, what literature would you recommend?

NB: We have several peer-reviewed articles that summarize our work. (see the reference section below.)

WK: What was your original vision for MCPAP?

NB: We aimed to translate the successful Massachusetts Child Psychiatry Access Project (MCPAP) to address perinatal depression. MCPAP has transformed the delivery of child mental health services in Massachusetts by making immediate psychiatric consultation available to pediatricians, to address depression in obstetric settings. Our vision was that expanding MCPAP to create MCPAP for Moms, a new program that could provide obstetric, psychiatric, primary care and pediatric providers with access to care coordination and psychiatric telephone consultation to help them address perinatal depression. We aimed to create a population-based program that would help the entire state of Massachusetts address depression by building capacity of the frontline providers who are serving pregnant and postpartum women in their medical setting.

WK: Can you explain how the RAPPID program will be compared to the MCPAP program?

NB: To build on and address the limitations of MCPAP for Moms, we developed and pilot tested the Rapid Access to Perinatal Psychiatric Care in Depression (RAPPID) Program to create a more comprehensive intervention that is proactive, multifaceted, and practical. RAPPID aims to improve perinatal depression treatment and treatment response rates through: (1) access to the immediate resource provision/referrals and psychiatric telephone consultation for Ob/Gyn providers via MCPAP for Moms; (2) clinic-specific implementation of stepped care, including training support and toolkits; and, (3) proactive treatment engagement, patient monitoring, and stepped treatment response to depression screening/assessment. RAPPID was developed using formative data and feedback from key stakeholders.

We will compare two active interventions, enhanced usual care (access to MCPAP for Moms) vs. RAPPID in a cluster randomized controlled trial (RCT) in which we will randomize 12 Ob/Gyn clinics with diverse patient populations to either RAPPID or enhanced usual care.

WK: How is stepped care different than collaborative care?

NB: Stepped care models involve initial determination of treatment based on illness severity and intensification of care (such as stepwise increases in dose of antidepressant medication) for those with persistent illness.

WK: What has inspired your work in this field?

NB: I have been moved by women's stories and how hard it was for them to access the care that they needed and deserved. In the beginning of my career I was seeing this time and time again.

I am inspired by the women I serve. I have worked with countless pregnant and postpartum women. Perinatal women initially or in a prior pregnancy were not able to access the care they needed and deserved. This led me to want to make an impact beyond patient care and I envisioned a program would help pregnant and postpartum women access treatment for their depression.

WK: What are the most critical issues in perinatal mental health today?

NB: Despite having evidence based treatments available, depression is not detected among many pregnant and postpartum women and even if it is detected, many women will not be able to access treatment. Depression during pregnancy is twice as common as diabetes and it needs to be a routine part of obstetric care just as diabetes is a routine part of obstetric care.

References

1. Byatt N, Levin L, Ziedonis D, Moore Simas T, Allison J. To What Extent Does Screening and Referral Improve Depression Outcomes and Mental Health Care Utilization Among Perinatal Women? Obstetrics and Gynecology. In Press.
2. Byatt N, Rui X, Dinh K, Waring EM. Trends in Mental Health Care Use in Relation to Depressive Symptoms Among Pregnant Women. Archives of Women's Mental Health. 2015 Apr 7. Epub ahead of print.
3. Weinreb L, Byatt N, Moore Simas TA, Tenner K and Savageau JA. What happens to mental health treatment during pregnancy? Women's experience with prescribing providers. Psychiatr Q. 2014;85:349-355.
4. Byatt N, Biebel K, Friedman L, Debordes-Jackson G, Pbert L, Ziedonis D. Patient's Views on Depression Care in Obstetric Settings: How Do They Compare to the Views of Perinatal Health Care Professionals? General Hospital Psychiatry. 2013;35(6):598.
5. Byatt N, Biebel K, Debordes-Jackson G, Lundquist R, Moore Simas T, Weinreb L, Ziedonis D. Community Mental Health Provider Reluctance to Provide Pharmacotherapy May Be a Barrier to Addressing Perinatal Depression: A Preliminary Study. Psychiatric Quarterly. 2013;84(2):169-174.
6. Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):143-61.
7. Byatt N, Biebel K, Lundquist R, Moore Simas T, Debordes-Jackson G, Ziedonis D. Patient, Provider and System-level Barriers and Facilitators to Addressing Perinatal Depression. Journal of Reproductive and Infant Psychology. 2012;30(5):436-439.
8. Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):143-61.

About Nancy Byatt, D.O., M.S., M.B.A., F.A.P.M.

© Nancy Byatt

Nancy Byatt, D.O., M.S., M.B.A., F.A.P.M is a psychiatrist focused on improving health care systems to promote maternal mental health. Dr. Byatt is an Assistant Professor at UMass Medical School in the Departments of Psychiatry and Obstetrics and Gynecology. Byatt is a psychosomatic medicine psychiatrist with subspecialty expertise in perinatal mental health. She provides expert psychiatric consultation to obstetric, psychiatric, primary care and pediatric providers serving pregnant and postpartum women. She is the Founding and Statewide Medical Director of the Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms). MCPAP for Moms addresses perinatal depression across Massachusetts by providing mental health consultation and care coordination for medical providers serving pregnant and postpartum women.

Byatt's research focuses on developing innovative ways to improve the implementation and adoption of evidence-based depression treatment for pregnant and postpartum women. She has a Career Development Award that funds her research to help women access and engage in perinatal depression treatment in obstetric settings. She has also received federal funding from the Center for Disease Control to test an intensive, low-cost program that aims to ensure that pregnant and postpartum women with depression receive optimal treatment. Her academic achievements have led to numerous peer-reviewed publications and national awards.