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Postpartum depression often tricky to diagnose
LAS VEGAS – Diagnosing postpartum depression can be tricky because of the wide range of body changes that occur during the postpartum period, but vigilance is warranted with mothers who express a lack of sleep and a lack of social support.
at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This gives you information about depression and insomnia. Make sure to ask about anxiety symptoms. Also ask about any thoughts of suicide or harming the infant, and support from family and friends when she’s under stress and taking care of the baby.”
According to Dr. Friedman, a perinatal and forensic psychiatrist at Case Western Reserve University, Cleveland, social risk factors for postpartum depression (PPD) include being a victim of intimate partner violence and/or abuse, negative life events, decreased social support, relationship issues, and socioeconomic status. Psychological risk factors include anxiety/depression in pregnancy, personal or family history of PPD, and substance misuse. Biological risk factors include medical illness, multiple births, and having an infant with low birth weight/prematurity.
PPD affects 10%-20% of new mothers and peaks at 12 weeks. Postpartum psychosis, meanwhile, occurs in about 1-2 of every 1,000 deliveries. Anxiety comorbidity is common.
In the neonatal intensive care unit (NICU), PPD rates might increase from 28% to 70% depending on the study. Risk factors include personal or family history, disturbed relationships, unfavorable socioeconomic factors, and stressful life events. Obstetrical risk factors might include conception by assisted reproductive technologies and having a stillbirth in the year before conception. NICU-specific risk factors include less-effective coping strategies, greater perception of maternal role disruption, and decreased perception of nursing support. “A lot of mothers [in the NICU] talk to me about being on a roller roaster every day about what’s going to happen with their baby,” Dr. Friedman said.
The most widely used measure to screen for PPD is the 10-item self-rating Edinburgh Postnatal Depression Scale . A total score of 10 or more is considered a flag for the need to follow up for possible depressive symptoms. She advises clinicians to pay particular attention to how patients respond to item No. 10 on the scale, which reads, “The thought of harming myself has occurred to me.” (Optional answers range from “Yes, quite often” to “Never.”) She also recommends administering the screen at both pediatric and obstetrical office visits, “because mothers are more likely to attend a pediatrics appointment than her own [postpartum] follow-up.”
The differential diagnosis of PPD includes the baby blues, postpartum psychosis, postpartum anxiety/PTSD, medical causes, substance use disorder, and PPD in bipolar disorder. Baby blues is not synonymous with PPD. It affects the majority (50%-80%) of new mothers and is characterized by emotional sensitivity, mood lability, and irritability. It usually occurs within 5 days and resolves by the second week post partum.
Postpartum psychosis (PPP) occurs in about 1-2 of every 1,000 deliveries, typically in the first 2 weeks after delivery. The onset occurs rapidly, and PPP is most frequently correlated with bipolar disorder over time. PPP itself is characterized by grandiose bizarre delusions, mood lability, hallucinations, confusion, and disorganized behavior. “This can occur as a new onset of mental illness as well, so getting collateral information about her behaviors is important,” she said.
Dr. Friedman explained that those events occur post partum largely because of sleep deprivation and increasing stress as the woman adjusts to a mothering role. Hormonal shifts also occur, with a drop in estrogen levels. Obstetrical complications also might factor in.
Postpartum obsessive-compulsive disorder (OCD) is commonly comorbid with PPD and is distinguished by ego-dystonic intrusive thoughts. The mother might have intense distress that she is going to harm the infant and might start to avoid holding the baby out of concern. “Common things I’ve heard from women with postpartum OCD are: ‘I’m afraid I’m going to put the baby in the microwave or in the oven instead of dinner’ or ‘I’m afraid I’m going to leave the baby in the car overnight and she’ll freeze to death,’ ” she said.
Postpartum PTSD can be triggered by a traumatic event experience in the birthing process, such as an emergency C-section. Affected mothers avoid the infant and hospital, “reexperience” the trauma, are easily startled, irritable, and disconnected. Dr. Friedman also noted that early parental PTSD symptoms predict sleep and eating problems in childhood and less sensitive/more controlling maternal behaviors.
Medical conditions that mimic PPD include anemia, thyroid disease, hypoactive delirium, infections, and alcohol/substance use disorder.
The best available data show that mothers with PPD are more withdrawn, disengaged, display more hostility, and are more likely to have disrupted attachment with their babies, Dr. Friedman said. They also are less likely to employ healthy child development practices and to breastfeed. Untreated depression might lead to psychotic symptoms, suicide, or homicide. Paternal PPD also occurs in an estimated 10% of fathers and is moderately correlated with maternal PPD.
Potential risks of PPD include impaired bonding, attachment disturbance, language development, cognitive skills, and behavior problems.
Potential risks of untreated PPD include child neglect or abuse because of active symptoms, suicide, and psychotic or maltreatment-related infanticide. “If the mother is taking about harming herself, I often ask: ‘Have you thought of what would happen to your baby if you were to take your own life?’ ” Dr. Friedman offered. Peripartum suicide risk is lower than in the general female population, but it represents about 20% of peripartum deaths. Overdose is the most common method. “However, uncommon and dramatic methods are more common in this population,” she said. “Teens and stigmatized single mothers are at greater risk.”
Dr. Friedman noted that clinicians face risk of a malpractice lawsuit if they fail to treat, abandon the patient, fail to provide informed consent, and if there are bad outcomes. The best approach is to proactively communicate with the patient, partner, pediatrics, and obstetrics. “Conduct an individual risk-benefit assessment with the individual patient’s history,” she advised. “Don’t do anything knee jerk. Consult when needed, document, and consider lactation and future pregnancy possibility in women of reproductive age.”
Nonpharmacologic therapy might be the first line of treatment for mild to moderate symptoms. Options include cognitive-behavioral therapy, interpersonal psychotherapy, family therapy, psychodynamic psychotherapy, and supportive psychotherapy. She recommends close follow-up and conducting a careful medication history. Electroconvulsive therapy remains a possibility.
If medication use is warranted, “weigh the benefits of breastfeeding with the usually low drug exposure of the infant,” Dr. Friedman advised. “We want to use the least number of medications at an effective dose to optimize treatment. Newer medications have less perinatal data. Sertraline and paroxetine are usually the preferred selective serotonin reuptake inhibitors in lactation. However, fluoxetine or citalopram might be used depending on the patient’s response history/use in pregnancy.”
Dr. Friedman reported no disclosures.
LAS VEGAS – Diagnosing postpartum depression can be tricky because of the wide range of body changes that occur during the postpartum period, but vigilance is warranted with mothers who express a lack of sleep and a lack of social support.
at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This gives you information about depression and insomnia. Make sure to ask about anxiety symptoms. Also ask about any thoughts of suicide or harming the infant, and support from family and friends when she’s under stress and taking care of the baby.”
According to Dr. Friedman, a perinatal and forensic psychiatrist at Case Western Reserve University, Cleveland, social risk factors for postpartum depression (PPD) include being a victim of intimate partner violence and/or abuse, negative life events, decreased social support, relationship issues, and socioeconomic status. Psychological risk factors include anxiety/depression in pregnancy, personal or family history of PPD, and substance misuse. Biological risk factors include medical illness, multiple births, and having an infant with low birth weight/prematurity.
PPD affects 10%-20% of new mothers and peaks at 12 weeks. Postpartum psychosis, meanwhile, occurs in about 1-2 of every 1,000 deliveries. Anxiety comorbidity is common.
In the neonatal intensive care unit (NICU), PPD rates might increase from 28% to 70% depending on the study. Risk factors include personal or family history, disturbed relationships, unfavorable socioeconomic factors, and stressful life events. Obstetrical risk factors might include conception by assisted reproductive technologies and having a stillbirth in the year before conception. NICU-specific risk factors include less-effective coping strategies, greater perception of maternal role disruption, and decreased perception of nursing support. “A lot of mothers [in the NICU] talk to me about being on a roller roaster every day about what’s going to happen with their baby,” Dr. Friedman said.
The most widely used measure to screen for PPD is the 10-item self-rating Edinburgh Postnatal Depression Scale . A total score of 10 or more is considered a flag for the need to follow up for possible depressive symptoms. She advises clinicians to pay particular attention to how patients respond to item No. 10 on the scale, which reads, “The thought of harming myself has occurred to me.” (Optional answers range from “Yes, quite often” to “Never.”) She also recommends administering the screen at both pediatric and obstetrical office visits, “because mothers are more likely to attend a pediatrics appointment than her own [postpartum] follow-up.”
The differential diagnosis of PPD includes the baby blues, postpartum psychosis, postpartum anxiety/PTSD, medical causes, substance use disorder, and PPD in bipolar disorder. Baby blues is not synonymous with PPD. It affects the majority (50%-80%) of new mothers and is characterized by emotional sensitivity, mood lability, and irritability. It usually occurs within 5 days and resolves by the second week post partum.
Postpartum psychosis (PPP) occurs in about 1-2 of every 1,000 deliveries, typically in the first 2 weeks after delivery. The onset occurs rapidly, and PPP is most frequently correlated with bipolar disorder over time. PPP itself is characterized by grandiose bizarre delusions, mood lability, hallucinations, confusion, and disorganized behavior. “This can occur as a new onset of mental illness as well, so getting collateral information about her behaviors is important,” she said.
Dr. Friedman explained that those events occur post partum largely because of sleep deprivation and increasing stress as the woman adjusts to a mothering role. Hormonal shifts also occur, with a drop in estrogen levels. Obstetrical complications also might factor in.
Postpartum obsessive-compulsive disorder (OCD) is commonly comorbid with PPD and is distinguished by ego-dystonic intrusive thoughts. The mother might have intense distress that she is going to harm the infant and might start to avoid holding the baby out of concern. “Common things I’ve heard from women with postpartum OCD are: ‘I’m afraid I’m going to put the baby in the microwave or in the oven instead of dinner’ or ‘I’m afraid I’m going to leave the baby in the car overnight and she’ll freeze to death,’ ” she said.
Postpartum PTSD can be triggered by a traumatic event experience in the birthing process, such as an emergency C-section. Affected mothers avoid the infant and hospital, “reexperience” the trauma, are easily startled, irritable, and disconnected. Dr. Friedman also noted that early parental PTSD symptoms predict sleep and eating problems in childhood and less sensitive/more controlling maternal behaviors.
Medical conditions that mimic PPD include anemia, thyroid disease, hypoactive delirium, infections, and alcohol/substance use disorder.
The best available data show that mothers with PPD are more withdrawn, disengaged, display more hostility, and are more likely to have disrupted attachment with their babies, Dr. Friedman said. They also are less likely to employ healthy child development practices and to breastfeed. Untreated depression might lead to psychotic symptoms, suicide, or homicide. Paternal PPD also occurs in an estimated 10% of fathers and is moderately correlated with maternal PPD.
Potential risks of PPD include impaired bonding, attachment disturbance, language development, cognitive skills, and behavior problems.
Potential risks of untreated PPD include child neglect or abuse because of active symptoms, suicide, and psychotic or maltreatment-related infanticide. “If the mother is taking about harming herself, I often ask: ‘Have you thought of what would happen to your baby if you were to take your own life?’ ” Dr. Friedman offered. Peripartum suicide risk is lower than in the general female population, but it represents about 20% of peripartum deaths. Overdose is the most common method. “However, uncommon and dramatic methods are more common in this population,” she said. “Teens and stigmatized single mothers are at greater risk.”
Dr. Friedman noted that clinicians face risk of a malpractice lawsuit if they fail to treat, abandon the patient, fail to provide informed consent, and if there are bad outcomes. The best approach is to proactively communicate with the patient, partner, pediatrics, and obstetrics. “Conduct an individual risk-benefit assessment with the individual patient’s history,” she advised. “Don’t do anything knee jerk. Consult when needed, document, and consider lactation and future pregnancy possibility in women of reproductive age.”
Nonpharmacologic therapy might be the first line of treatment for mild to moderate symptoms. Options include cognitive-behavioral therapy, interpersonal psychotherapy, family therapy, psychodynamic psychotherapy, and supportive psychotherapy. She recommends close follow-up and conducting a careful medication history. Electroconvulsive therapy remains a possibility.
If medication use is warranted, “weigh the benefits of breastfeeding with the usually low drug exposure of the infant,” Dr. Friedman advised. “We want to use the least number of medications at an effective dose to optimize treatment. Newer medications have less perinatal data. Sertraline and paroxetine are usually the preferred selective serotonin reuptake inhibitors in lactation. However, fluoxetine or citalopram might be used depending on the patient’s response history/use in pregnancy.”
Dr. Friedman reported no disclosures.
LAS VEGAS – Diagnosing postpartum depression can be tricky because of the wide range of body changes that occur during the postpartum period, but vigilance is warranted with mothers who express a lack of sleep and a lack of social support.
at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This gives you information about depression and insomnia. Make sure to ask about anxiety symptoms. Also ask about any thoughts of suicide or harming the infant, and support from family and friends when she’s under stress and taking care of the baby.”
According to Dr. Friedman, a perinatal and forensic psychiatrist at Case Western Reserve University, Cleveland, social risk factors for postpartum depression (PPD) include being a victim of intimate partner violence and/or abuse, negative life events, decreased social support, relationship issues, and socioeconomic status. Psychological risk factors include anxiety/depression in pregnancy, personal or family history of PPD, and substance misuse. Biological risk factors include medical illness, multiple births, and having an infant with low birth weight/prematurity.
PPD affects 10%-20% of new mothers and peaks at 12 weeks. Postpartum psychosis, meanwhile, occurs in about 1-2 of every 1,000 deliveries. Anxiety comorbidity is common.
In the neonatal intensive care unit (NICU), PPD rates might increase from 28% to 70% depending on the study. Risk factors include personal or family history, disturbed relationships, unfavorable socioeconomic factors, and stressful life events. Obstetrical risk factors might include conception by assisted reproductive technologies and having a stillbirth in the year before conception. NICU-specific risk factors include less-effective coping strategies, greater perception of maternal role disruption, and decreased perception of nursing support. “A lot of mothers [in the NICU] talk to me about being on a roller roaster every day about what’s going to happen with their baby,” Dr. Friedman said.
The most widely used measure to screen for PPD is the 10-item self-rating Edinburgh Postnatal Depression Scale . A total score of 10 or more is considered a flag for the need to follow up for possible depressive symptoms. She advises clinicians to pay particular attention to how patients respond to item No. 10 on the scale, which reads, “The thought of harming myself has occurred to me.” (Optional answers range from “Yes, quite often” to “Never.”) She also recommends administering the screen at both pediatric and obstetrical office visits, “because mothers are more likely to attend a pediatrics appointment than her own [postpartum] follow-up.”
The differential diagnosis of PPD includes the baby blues, postpartum psychosis, postpartum anxiety/PTSD, medical causes, substance use disorder, and PPD in bipolar disorder. Baby blues is not synonymous with PPD. It affects the majority (50%-80%) of new mothers and is characterized by emotional sensitivity, mood lability, and irritability. It usually occurs within 5 days and resolves by the second week post partum.
Postpartum psychosis (PPP) occurs in about 1-2 of every 1,000 deliveries, typically in the first 2 weeks after delivery. The onset occurs rapidly, and PPP is most frequently correlated with bipolar disorder over time. PPP itself is characterized by grandiose bizarre delusions, mood lability, hallucinations, confusion, and disorganized behavior. “This can occur as a new onset of mental illness as well, so getting collateral information about her behaviors is important,” she said.
Dr. Friedman explained that those events occur post partum largely because of sleep deprivation and increasing stress as the woman adjusts to a mothering role. Hormonal shifts also occur, with a drop in estrogen levels. Obstetrical complications also might factor in.
Postpartum obsessive-compulsive disorder (OCD) is commonly comorbid with PPD and is distinguished by ego-dystonic intrusive thoughts. The mother might have intense distress that she is going to harm the infant and might start to avoid holding the baby out of concern. “Common things I’ve heard from women with postpartum OCD are: ‘I’m afraid I’m going to put the baby in the microwave or in the oven instead of dinner’ or ‘I’m afraid I’m going to leave the baby in the car overnight and she’ll freeze to death,’ ” she said.
Postpartum PTSD can be triggered by a traumatic event experience in the birthing process, such as an emergency C-section. Affected mothers avoid the infant and hospital, “reexperience” the trauma, are easily startled, irritable, and disconnected. Dr. Friedman also noted that early parental PTSD symptoms predict sleep and eating problems in childhood and less sensitive/more controlling maternal behaviors.
Medical conditions that mimic PPD include anemia, thyroid disease, hypoactive delirium, infections, and alcohol/substance use disorder.
The best available data show that mothers with PPD are more withdrawn, disengaged, display more hostility, and are more likely to have disrupted attachment with their babies, Dr. Friedman said. They also are less likely to employ healthy child development practices and to breastfeed. Untreated depression might lead to psychotic symptoms, suicide, or homicide. Paternal PPD also occurs in an estimated 10% of fathers and is moderately correlated with maternal PPD.
Potential risks of PPD include impaired bonding, attachment disturbance, language development, cognitive skills, and behavior problems.
Potential risks of untreated PPD include child neglect or abuse because of active symptoms, suicide, and psychotic or maltreatment-related infanticide. “If the mother is taking about harming herself, I often ask: ‘Have you thought of what would happen to your baby if you were to take your own life?’ ” Dr. Friedman offered. Peripartum suicide risk is lower than in the general female population, but it represents about 20% of peripartum deaths. Overdose is the most common method. “However, uncommon and dramatic methods are more common in this population,” she said. “Teens and stigmatized single mothers are at greater risk.”
Dr. Friedman noted that clinicians face risk of a malpractice lawsuit if they fail to treat, abandon the patient, fail to provide informed consent, and if there are bad outcomes. The best approach is to proactively communicate with the patient, partner, pediatrics, and obstetrics. “Conduct an individual risk-benefit assessment with the individual patient’s history,” she advised. “Don’t do anything knee jerk. Consult when needed, document, and consider lactation and future pregnancy possibility in women of reproductive age.”
Nonpharmacologic therapy might be the first line of treatment for mild to moderate symptoms. Options include cognitive-behavioral therapy, interpersonal psychotherapy, family therapy, psychodynamic psychotherapy, and supportive psychotherapy. She recommends close follow-up and conducting a careful medication history. Electroconvulsive therapy remains a possibility.
If medication use is warranted, “weigh the benefits of breastfeeding with the usually low drug exposure of the infant,” Dr. Friedman advised. “We want to use the least number of medications at an effective dose to optimize treatment. Newer medications have less perinatal data. Sertraline and paroxetine are usually the preferred selective serotonin reuptake inhibitors in lactation. However, fluoxetine or citalopram might be used depending on the patient’s response history/use in pregnancy.”
Dr. Friedman reported no disclosures.
EXPERT ANALYSIS FROM NPA 2019
Statin adherence lower in women, minorities
Women, younger patients, and individuals from minority groups are significantly less likely to be adherent with their statins, and are at greater risk of hospitalization and death, a study has found.
In JAMA Cardiology, researchers report the outcomes of a retrospective cohort analysis involving 347,104 adults with atherosclerotic cardiovascular disease and stable statin prescriptions, who were treated within the Veterans Affairs Health System.
Statin adherence – defined as a medication possession ratio of 80% or above – was 87.7%. Patients on a moderate intensity of statin therapy were slightly more adherent than were patients on low- or high-intensity therapy.
The lowest levels of adherence were seen in the youngest patients. Those aged under 35 years had a 60% lower likelihood of adherence compared with the reference group aged 65-74 years, and those aged 35-44 years had a 47% lower likelihood of adherence. From age 55 on, adherence improved.
Women were 11% less likely to be adherent to statin therapy than were men. Adherence was significantly different among persons of different racial backgrounds and ethnicities: black patients were 42% less likely to be adherent compared with non-Hispanic whites, Asian patients were 18% less likely to be adherent, and Hispanic patients were 27% less likely to be adherent.
. Among patients with a medication possession ratio less than 50%, 13.4% were hospitalized for ischemic heart disease or ischemic stroke, compared with 11.5% of patients who had a medication possession ratio of 90% or above, even after adjustment for baseline characteristics.
Researchers saw a dose-response association between lower adherence and higher mortality. The incidence of death in the first year was 8.8% in patients with a medication possession ration below 50%, 7.5% for those with a ratio of 50%-69%, 6.3% for those with a ratio between 70% and 89%, and 5.7% among those with a medication possession ratio at or above 90%.
This effect was slightly attenuated by adjustment for adherence to other cardiac medications, but the association remained significant.
“Although statins are among the most effective drugs for the secondary prevention of [atherosclerotic cardiovascular disease], low adherence is a common problem,” wrote Dr. Fatima Rodriguez of Stanford (Calif.) University’s Division of Cardiovascular Medicine, and her coauthors. “Minorities have not been well represented in statin-related trials and more work is needed to implement strategies to improve guideline adherence in these populations.”
Stanford’s Division of Cardiovascular Medicine supported the study. The investigators have received funding from the Doris Duke Charitable Trust, the Department of Veterans Affairs Health Services Research and Development Service, the National Lipid Association, and Duke Clinical Research Institute.
SOURCE: Rodriguez F et al. JAMA Cardiol. 2019 Feb 13. doi: 10.1001/jamacardio.2018.4936.
Women, younger patients, and individuals from minority groups are significantly less likely to be adherent with their statins, and are at greater risk of hospitalization and death, a study has found.
In JAMA Cardiology, researchers report the outcomes of a retrospective cohort analysis involving 347,104 adults with atherosclerotic cardiovascular disease and stable statin prescriptions, who were treated within the Veterans Affairs Health System.
Statin adherence – defined as a medication possession ratio of 80% or above – was 87.7%. Patients on a moderate intensity of statin therapy were slightly more adherent than were patients on low- or high-intensity therapy.
The lowest levels of adherence were seen in the youngest patients. Those aged under 35 years had a 60% lower likelihood of adherence compared with the reference group aged 65-74 years, and those aged 35-44 years had a 47% lower likelihood of adherence. From age 55 on, adherence improved.
Women were 11% less likely to be adherent to statin therapy than were men. Adherence was significantly different among persons of different racial backgrounds and ethnicities: black patients were 42% less likely to be adherent compared with non-Hispanic whites, Asian patients were 18% less likely to be adherent, and Hispanic patients were 27% less likely to be adherent.
. Among patients with a medication possession ratio less than 50%, 13.4% were hospitalized for ischemic heart disease or ischemic stroke, compared with 11.5% of patients who had a medication possession ratio of 90% or above, even after adjustment for baseline characteristics.
Researchers saw a dose-response association between lower adherence and higher mortality. The incidence of death in the first year was 8.8% in patients with a medication possession ration below 50%, 7.5% for those with a ratio of 50%-69%, 6.3% for those with a ratio between 70% and 89%, and 5.7% among those with a medication possession ratio at or above 90%.
This effect was slightly attenuated by adjustment for adherence to other cardiac medications, but the association remained significant.
“Although statins are among the most effective drugs for the secondary prevention of [atherosclerotic cardiovascular disease], low adherence is a common problem,” wrote Dr. Fatima Rodriguez of Stanford (Calif.) University’s Division of Cardiovascular Medicine, and her coauthors. “Minorities have not been well represented in statin-related trials and more work is needed to implement strategies to improve guideline adherence in these populations.”
Stanford’s Division of Cardiovascular Medicine supported the study. The investigators have received funding from the Doris Duke Charitable Trust, the Department of Veterans Affairs Health Services Research and Development Service, the National Lipid Association, and Duke Clinical Research Institute.
SOURCE: Rodriguez F et al. JAMA Cardiol. 2019 Feb 13. doi: 10.1001/jamacardio.2018.4936.
Women, younger patients, and individuals from minority groups are significantly less likely to be adherent with their statins, and are at greater risk of hospitalization and death, a study has found.
In JAMA Cardiology, researchers report the outcomes of a retrospective cohort analysis involving 347,104 adults with atherosclerotic cardiovascular disease and stable statin prescriptions, who were treated within the Veterans Affairs Health System.
Statin adherence – defined as a medication possession ratio of 80% or above – was 87.7%. Patients on a moderate intensity of statin therapy were slightly more adherent than were patients on low- or high-intensity therapy.
The lowest levels of adherence were seen in the youngest patients. Those aged under 35 years had a 60% lower likelihood of adherence compared with the reference group aged 65-74 years, and those aged 35-44 years had a 47% lower likelihood of adherence. From age 55 on, adherence improved.
Women were 11% less likely to be adherent to statin therapy than were men. Adherence was significantly different among persons of different racial backgrounds and ethnicities: black patients were 42% less likely to be adherent compared with non-Hispanic whites, Asian patients were 18% less likely to be adherent, and Hispanic patients were 27% less likely to be adherent.
. Among patients with a medication possession ratio less than 50%, 13.4% were hospitalized for ischemic heart disease or ischemic stroke, compared with 11.5% of patients who had a medication possession ratio of 90% or above, even after adjustment for baseline characteristics.
Researchers saw a dose-response association between lower adherence and higher mortality. The incidence of death in the first year was 8.8% in patients with a medication possession ration below 50%, 7.5% for those with a ratio of 50%-69%, 6.3% for those with a ratio between 70% and 89%, and 5.7% among those with a medication possession ratio at or above 90%.
This effect was slightly attenuated by adjustment for adherence to other cardiac medications, but the association remained significant.
“Although statins are among the most effective drugs for the secondary prevention of [atherosclerotic cardiovascular disease], low adherence is a common problem,” wrote Dr. Fatima Rodriguez of Stanford (Calif.) University’s Division of Cardiovascular Medicine, and her coauthors. “Minorities have not been well represented in statin-related trials and more work is needed to implement strategies to improve guideline adherence in these populations.”
Stanford’s Division of Cardiovascular Medicine supported the study. The investigators have received funding from the Doris Duke Charitable Trust, the Department of Veterans Affairs Health Services Research and Development Service, the National Lipid Association, and Duke Clinical Research Institute.
SOURCE: Rodriguez F et al. JAMA Cardiol. 2019 Feb 13. doi: 10.1001/jamacardio.2018.4936.
FROM JAMA CARDIOLOGY
Key clinical point: Women, nonwhite, and younger patients are significantly less likely to be adherent to statin therapy.
Major finding: Women are 11% less likely than are men to adhere to statin therapy.
Study details: Retrospective cohort analysis involving 347,104 adults with atherosclerotic cardiovascular disease.
Disclosures: The Division of Cardiovascular Medicine at Stanford (Calif.) University supported the study. The investigators have received funding from the Doris Duke Charitable Trust, the Department of Veterans Affairs Health Services Research and Development Service, the National Lipid Association, and Duke Clinical Research Institute.
Source: Rodriguez F et al. JAMA Cardiol. 2019, Feb 13. doi: 10.1001/jamacardio.2018.4936.
Tranexamic acid shows improvements in heavy menstrual bleeding
new research suggests.
Writing in the Journal of Pediatric & Adolescent Gynecology, Sarah H. O’Brien, MD, from Nationwide Children’s Hospital and the Ohio State University, both in Columbus, and her coauthors presented the results of an open-label efficacy study of the competitive plasminogen inhibitor in 25 adolescent girls aged 10-19 years who attended pediatric hematology clinics for evaluation or management of heavy menstrual bleeding. The study participants were instructed to take 1,300 mg of tranexamic acid (two tablets) three times a day for up to 5 days during their monthly menstruation for three cycles.
The study found a significant improvement in mean menstrual impact questionnaire (MIQ) scores, which improved from a mean of 3 at baseline to 1.91 (P less than .001). Two-thirds of patients reported at least a one-point improvement from baseline, and all reported that this was clinically meaningful. At baseline, 84% of patients reported heavy to very heavy blood loss, but this decreased to 23% after treatment with tranexamic acid (P less than .001).
The study population included ten individuals (40%) with bleeding disorders. However, the researchers did not see a significant difference in response between those with bleeding disorders and those without.
While the treatment did not significantly affect school attendance (only 24% reported that their heavy bleeding limited school attendance), researchers did see a significant improvement in limitations on physical activities and on social and leisure activities. Patients who reported at baseline that their menstrual bleeding significantly affected their social and leisure activities had an average score improvement of 1.74, a greater than or equal to one point improvement. Participants also reported significant improvements in their Pictorial Blood Assessment Chart scores, which dropped from an average of 255 to 155 (P less than .001).
The treatment did not show any significant effects on hemoglobin or ferritin. The most common adverse events were sinonasal symptoms, such as nasal congestion, headache, and sinus pain, but no thrombotic or ocular adverse events were seen.
Dr. O’Brien and her coauthors wrote that one limitation of their study was using the MIQ score as their primary endpoint as opposed to a more objective measure, such as change in measured blood loss.
“However, a major factor that motivates patients with heavy menstrual bleeding to seek medical care is the negative impact of heavy menstrual bleeding on daily life,” they wrote.
The study drug was supplied by Ferring pharmaceuticals, and the study was supported by the Hemostasis and Thrombosis Research Society. One author disclosed receiving the Joan Fellowship in Pediatric Hemostasis and Thrombosis at Nationwide Children’s Hospital; no other authors said they had relevant financial disclosures.
SOURCE: O’Brien SH et al. J Pediatr Adol Gynec. 2019 Feb 4. doi: 10.1016/j.jpag.2019.01.009.
new research suggests.
Writing in the Journal of Pediatric & Adolescent Gynecology, Sarah H. O’Brien, MD, from Nationwide Children’s Hospital and the Ohio State University, both in Columbus, and her coauthors presented the results of an open-label efficacy study of the competitive plasminogen inhibitor in 25 adolescent girls aged 10-19 years who attended pediatric hematology clinics for evaluation or management of heavy menstrual bleeding. The study participants were instructed to take 1,300 mg of tranexamic acid (two tablets) three times a day for up to 5 days during their monthly menstruation for three cycles.
The study found a significant improvement in mean menstrual impact questionnaire (MIQ) scores, which improved from a mean of 3 at baseline to 1.91 (P less than .001). Two-thirds of patients reported at least a one-point improvement from baseline, and all reported that this was clinically meaningful. At baseline, 84% of patients reported heavy to very heavy blood loss, but this decreased to 23% after treatment with tranexamic acid (P less than .001).
The study population included ten individuals (40%) with bleeding disorders. However, the researchers did not see a significant difference in response between those with bleeding disorders and those without.
While the treatment did not significantly affect school attendance (only 24% reported that their heavy bleeding limited school attendance), researchers did see a significant improvement in limitations on physical activities and on social and leisure activities. Patients who reported at baseline that their menstrual bleeding significantly affected their social and leisure activities had an average score improvement of 1.74, a greater than or equal to one point improvement. Participants also reported significant improvements in their Pictorial Blood Assessment Chart scores, which dropped from an average of 255 to 155 (P less than .001).
The treatment did not show any significant effects on hemoglobin or ferritin. The most common adverse events were sinonasal symptoms, such as nasal congestion, headache, and sinus pain, but no thrombotic or ocular adverse events were seen.
Dr. O’Brien and her coauthors wrote that one limitation of their study was using the MIQ score as their primary endpoint as opposed to a more objective measure, such as change in measured blood loss.
“However, a major factor that motivates patients with heavy menstrual bleeding to seek medical care is the negative impact of heavy menstrual bleeding on daily life,” they wrote.
The study drug was supplied by Ferring pharmaceuticals, and the study was supported by the Hemostasis and Thrombosis Research Society. One author disclosed receiving the Joan Fellowship in Pediatric Hemostasis and Thrombosis at Nationwide Children’s Hospital; no other authors said they had relevant financial disclosures.
SOURCE: O’Brien SH et al. J Pediatr Adol Gynec. 2019 Feb 4. doi: 10.1016/j.jpag.2019.01.009.
new research suggests.
Writing in the Journal of Pediatric & Adolescent Gynecology, Sarah H. O’Brien, MD, from Nationwide Children’s Hospital and the Ohio State University, both in Columbus, and her coauthors presented the results of an open-label efficacy study of the competitive plasminogen inhibitor in 25 adolescent girls aged 10-19 years who attended pediatric hematology clinics for evaluation or management of heavy menstrual bleeding. The study participants were instructed to take 1,300 mg of tranexamic acid (two tablets) three times a day for up to 5 days during their monthly menstruation for three cycles.
The study found a significant improvement in mean menstrual impact questionnaire (MIQ) scores, which improved from a mean of 3 at baseline to 1.91 (P less than .001). Two-thirds of patients reported at least a one-point improvement from baseline, and all reported that this was clinically meaningful. At baseline, 84% of patients reported heavy to very heavy blood loss, but this decreased to 23% after treatment with tranexamic acid (P less than .001).
The study population included ten individuals (40%) with bleeding disorders. However, the researchers did not see a significant difference in response between those with bleeding disorders and those without.
While the treatment did not significantly affect school attendance (only 24% reported that their heavy bleeding limited school attendance), researchers did see a significant improvement in limitations on physical activities and on social and leisure activities. Patients who reported at baseline that their menstrual bleeding significantly affected their social and leisure activities had an average score improvement of 1.74, a greater than or equal to one point improvement. Participants also reported significant improvements in their Pictorial Blood Assessment Chart scores, which dropped from an average of 255 to 155 (P less than .001).
The treatment did not show any significant effects on hemoglobin or ferritin. The most common adverse events were sinonasal symptoms, such as nasal congestion, headache, and sinus pain, but no thrombotic or ocular adverse events were seen.
Dr. O’Brien and her coauthors wrote that one limitation of their study was using the MIQ score as their primary endpoint as opposed to a more objective measure, such as change in measured blood loss.
“However, a major factor that motivates patients with heavy menstrual bleeding to seek medical care is the negative impact of heavy menstrual bleeding on daily life,” they wrote.
The study drug was supplied by Ferring pharmaceuticals, and the study was supported by the Hemostasis and Thrombosis Research Society. One author disclosed receiving the Joan Fellowship in Pediatric Hemostasis and Thrombosis at Nationwide Children’s Hospital; no other authors said they had relevant financial disclosures.
SOURCE: O’Brien SH et al. J Pediatr Adol Gynec. 2019 Feb 4. doi: 10.1016/j.jpag.2019.01.009.
FROM THE JOURNAL OF PEDIATRIC & ADOLESCENT GYNECOLOGY
Key clinical point: Tranexamic acid appears to improve quality of life for adolescents with heavy menstrual bleeding.
Major finding: Patients treated with tranexamic acid reported significant improvements in mean menstrual impact questionnaire scores.
Study details: Open-label efficacy study in 25 adolescent girls with heavy menstrual bleeding.
Disclosures: The study drug was supplied by Ferring pharmaceuticals, and the study was supported by the Hemostasis and Thrombosis Research Society. One author disclosed receiving the Joan Fellowship in Pediatric Hemostasis and Thrombosis at Nationwide Children’s Hospital; no other authors said they had relevant financial disclosures.
Source: O’Brien SH et al. J Pediatr Adol Gynec. 2019 Feb 4. doi: 10.1016/j.jpag.2019.01.009.
Survey: Reproductive counseling is often MIA in IBD
LAS VEGAS – Inflammatory bowel disease (IBD) can disrupt both fertility and pregnancy, especially if it’s not fully controlled, and there’s a risk that the condition can be passed onto an unborn child. Still a new study suggests many patients with IBD don’t receive appropriate reproductive counseling.
Nearly two-thirds of 100 patients surveyed at a single center reported that no physician had talked to them about reproductive topics, and some said they’d considered not having children because of the condition. “Really fundamental subjects have not made their way into the interactions between patients and their care teams,” coauthor and gastroenterologist Sarah Streett, MD, AGAF, of Stanford (Calif.) University, said in an interview before the study was presented at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
IBD can lower fertility in both sexes and boost complications in pregnancy. “The good news is that almost all the medications used for IBD appear safe,” Dr. Streett said. “In fact, the safety risks for the baby and the pregnancy revolve around not having IBD under good control.”
Unfortunately, she said, misinformation is common. “Patients who become pregnant or are trying to become pregnant, and are worried about potential harm to the baby, will stop the medications due to incorrect information. Or they’ll be told by their health care team to stop their medications.”
Dr. Streett and study lead author Aarti Rao, MD, a gastroenterology fellow at Stanford, launched their study of IBD clinic patients to gain more understanding about patient knowledge. “We know from research already published that those with IBD have a lot of concerns about starting families and don’t have a lot of information to base their decision making on,” Dr. Streett said. “We wanted to evaluate that in our population and see how much people knew and what the need was.”
In 2018 and 2019, Dr. Streett and Dr. Rao gave an anonymous, validated 17-question survey to patients aged 18-45 with IBD. One hundred patients responded (median age = 30, 54% female, 59% white, 66% with incomes over $100,000, 52% with ulcerative colitis, 21% with prior IBD surgery, 71% with prior IBD hospitalization).
Just over a third – 35% – of the patients said they’d been counseled about reproductive health by a physician. This finding reflects findings in previous research, said Dr. Rao, who spoke in an interview.
Just 15% of those who’d undergone IBD surgery reported getting guidance about the effects of surgery on fertility.
More than a third (35%) of women and 15% of men said they’d considered not having children because of their IBD. In fact, “most potential dads and moms have the chance to do very well,” Dr. Streett said.
Without reproductive counseling, she added, parents won’t know about the risks of passing on IBD. According to Dr. Rao, there’s an estimated less than 5% chance that IBD will be passed on to children if one parent has the condition; the risk is much higher if both parents have it.
Going forward, “there’s a really urgent need for proactive counseling on the part of gastroenterologists and health care teams to give people of childbearing age the right information so they can be informed to make the best decisions,” Dr. Streett said.
The study was funded by a philanthropic grant. The study authors report no relevant disclosures.
SOURCE: Rao A et al. Crohn’s & Colitis Congress, Abstract P009.
LAS VEGAS – Inflammatory bowel disease (IBD) can disrupt both fertility and pregnancy, especially if it’s not fully controlled, and there’s a risk that the condition can be passed onto an unborn child. Still a new study suggests many patients with IBD don’t receive appropriate reproductive counseling.
Nearly two-thirds of 100 patients surveyed at a single center reported that no physician had talked to them about reproductive topics, and some said they’d considered not having children because of the condition. “Really fundamental subjects have not made their way into the interactions between patients and their care teams,” coauthor and gastroenterologist Sarah Streett, MD, AGAF, of Stanford (Calif.) University, said in an interview before the study was presented at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
IBD can lower fertility in both sexes and boost complications in pregnancy. “The good news is that almost all the medications used for IBD appear safe,” Dr. Streett said. “In fact, the safety risks for the baby and the pregnancy revolve around not having IBD under good control.”
Unfortunately, she said, misinformation is common. “Patients who become pregnant or are trying to become pregnant, and are worried about potential harm to the baby, will stop the medications due to incorrect information. Or they’ll be told by their health care team to stop their medications.”
Dr. Streett and study lead author Aarti Rao, MD, a gastroenterology fellow at Stanford, launched their study of IBD clinic patients to gain more understanding about patient knowledge. “We know from research already published that those with IBD have a lot of concerns about starting families and don’t have a lot of information to base their decision making on,” Dr. Streett said. “We wanted to evaluate that in our population and see how much people knew and what the need was.”
In 2018 and 2019, Dr. Streett and Dr. Rao gave an anonymous, validated 17-question survey to patients aged 18-45 with IBD. One hundred patients responded (median age = 30, 54% female, 59% white, 66% with incomes over $100,000, 52% with ulcerative colitis, 21% with prior IBD surgery, 71% with prior IBD hospitalization).
Just over a third – 35% – of the patients said they’d been counseled about reproductive health by a physician. This finding reflects findings in previous research, said Dr. Rao, who spoke in an interview.
Just 15% of those who’d undergone IBD surgery reported getting guidance about the effects of surgery on fertility.
More than a third (35%) of women and 15% of men said they’d considered not having children because of their IBD. In fact, “most potential dads and moms have the chance to do very well,” Dr. Streett said.
Without reproductive counseling, she added, parents won’t know about the risks of passing on IBD. According to Dr. Rao, there’s an estimated less than 5% chance that IBD will be passed on to children if one parent has the condition; the risk is much higher if both parents have it.
Going forward, “there’s a really urgent need for proactive counseling on the part of gastroenterologists and health care teams to give people of childbearing age the right information so they can be informed to make the best decisions,” Dr. Streett said.
The study was funded by a philanthropic grant. The study authors report no relevant disclosures.
SOURCE: Rao A et al. Crohn’s & Colitis Congress, Abstract P009.
LAS VEGAS – Inflammatory bowel disease (IBD) can disrupt both fertility and pregnancy, especially if it’s not fully controlled, and there’s a risk that the condition can be passed onto an unborn child. Still a new study suggests many patients with IBD don’t receive appropriate reproductive counseling.
Nearly two-thirds of 100 patients surveyed at a single center reported that no physician had talked to them about reproductive topics, and some said they’d considered not having children because of the condition. “Really fundamental subjects have not made their way into the interactions between patients and their care teams,” coauthor and gastroenterologist Sarah Streett, MD, AGAF, of Stanford (Calif.) University, said in an interview before the study was presented at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
IBD can lower fertility in both sexes and boost complications in pregnancy. “The good news is that almost all the medications used for IBD appear safe,” Dr. Streett said. “In fact, the safety risks for the baby and the pregnancy revolve around not having IBD under good control.”
Unfortunately, she said, misinformation is common. “Patients who become pregnant or are trying to become pregnant, and are worried about potential harm to the baby, will stop the medications due to incorrect information. Or they’ll be told by their health care team to stop their medications.”
Dr. Streett and study lead author Aarti Rao, MD, a gastroenterology fellow at Stanford, launched their study of IBD clinic patients to gain more understanding about patient knowledge. “We know from research already published that those with IBD have a lot of concerns about starting families and don’t have a lot of information to base their decision making on,” Dr. Streett said. “We wanted to evaluate that in our population and see how much people knew and what the need was.”
In 2018 and 2019, Dr. Streett and Dr. Rao gave an anonymous, validated 17-question survey to patients aged 18-45 with IBD. One hundred patients responded (median age = 30, 54% female, 59% white, 66% with incomes over $100,000, 52% with ulcerative colitis, 21% with prior IBD surgery, 71% with prior IBD hospitalization).
Just over a third – 35% – of the patients said they’d been counseled about reproductive health by a physician. This finding reflects findings in previous research, said Dr. Rao, who spoke in an interview.
Just 15% of those who’d undergone IBD surgery reported getting guidance about the effects of surgery on fertility.
More than a third (35%) of women and 15% of men said they’d considered not having children because of their IBD. In fact, “most potential dads and moms have the chance to do very well,” Dr. Streett said.
Without reproductive counseling, she added, parents won’t know about the risks of passing on IBD. According to Dr. Rao, there’s an estimated less than 5% chance that IBD will be passed on to children if one parent has the condition; the risk is much higher if both parents have it.
Going forward, “there’s a really urgent need for proactive counseling on the part of gastroenterologists and health care teams to give people of childbearing age the right information so they can be informed to make the best decisions,” Dr. Streett said.
The study was funded by a philanthropic grant. The study authors report no relevant disclosures.
SOURCE: Rao A et al. Crohn’s & Colitis Congress, Abstract P009.
REPORTING FROM THE CROHN’S & COLITIS CONGRESS
Key clinical point: Patients with inflammatory bowel disease aren’t getting proper guidance regarding fertility, pregnancy, and genetic risks.
Major finding: Among surveyed patients, 65% said they’d never received reproductive counseling from a physician.
Study details: Single-center survey of 100 patients (median age = 30, 54% female).
Disclosures: The study was funded by a philanthropic grant. The study authors report no relevant disclosures.
Source: Rao A et al. Crohn’s & Colitis Congress 2019, Abstract P009.
USPSTF recommends counseling for perinatal depression prevention
according to a B recommendation from the U.S. Preventive Services Task Force.
The Task Force determined that counseling interventions are effective in preventing perinatal depression, defined as a major or minor depressive episode during pregnancy or within the first year after delivery. The condition affects an estimated 12% of new mothers in the United States each year, according to lead author Susan J. Curry, PhD, of the University of Iowa, Iowa City, and her colleagues.
The recommendation, published in JAMA, applies to “pregnant persons and persons who are less than 1 year postpartum who do not have a current diagnosis of depression but are at increased risk of developing depression,” according to the authors (JAMA. 2019 Feb 12;321(6):580-7).
Risk factors for development of perinatal depression include:
- Past history of depression.
- Current depressive symptoms (that do not reach a diagnostic threshold).
- History of physical or sexual abuse.
- Unplanned or unwanted pregnancy.
- Stressful life events.
- Lack of social and financial support.
- Intimate partner violence.
- Pregestational or gestational diabetes.
- Complications during pregnancy.
- Adolescent parenthood.
- Low socioeconomic status.
- Lack of social support.
After reviewing the evidence, the USPSTF found a moderate net benefit for counseling interventions, particularly cognitive behavioral therapy and interpersonal therapy, for preventing perinatal depression in women at risk. Counseling sessions reviewed for this recommendation ranged from 4 to 20 meetings (median, 8 meetings).
The USPSTF found inadequate evidence to assess the harms and benefits of other noncounseling interventions, including pharmacologic therapy.
In the evidence review accompanying the recommendations, Elizabeth A. O’Connor, PhD, of Kaiser Permanente, Portland, Ore., and her colleagues analyzed data from 50 studies including 22,385 individuals; 20 of these studies were randomized, controlled trials of counseling interventions (JAMA. 2019 Feb 12;321(6):588-601).
Overall, the likelihood of perinatal depression was significantly lower among women who received counseling, compared with controls, among more than 3,000 women in those studies (pooled risk ratio 0.61). Absolute risk differences for perinatal depression ranged from a 1% increased reduction in controls to a 32% increased reduction among women who received counseling. The effects were strongest for cognitive behavioral therapy and interpersonal therapy as interventions. No adverse events were reported in the counseling intervention studies.
In three studies of health system interventions, the researchers found a benefit for interventions vs. controls, but the difference was not statistically significant.
Trials of most other alternative interventions including infant sleep advice, birth-experience postpartum debriefing, omega-3 fatty acid supplementation, expressive writing, antidepressants, and yoga did not show statistical significance in benefit for reducing perinatal depression.
Only one of three randomized controlled trials of physical activity found a statistically significant group difference.
A trial of nortriptyline to prevent perinatal depression showed no benefit, compared with placebo. A sertraline study of found “a smaller percentage of participants taking sertraline had a depression recurrence, compared with those taking placebo,” the investigators wrote. In these two studies, women who took nortriptyline showed no adverse effects, and those in a trial involving sertraline reported significantly more dizziness and drowsiness compared with placebo patients.
The evidence review was limited by the small number of quality studies, especially studies of alternative interventions. More research is needed; however, the findings support data from similar reviews and support the potential for counseling to prevent perinatal depression, particularly in women at increased risk for perinatal depression, Dr. O’Connor and her associates said.
The USPSTF is supported by the Agency for Healthcare Research and Quality. Coauthor Dr. Michelle L. Henninger reported receiving grants from Pfizer IGLC (Independent Grants for Learning & Change) outside the submitted work. Coauthor Dr. Bradley N. Gaynes reported receiving personal fees from LivaNova and Johnson & Johnson outside the submitted work. The remaining researchers had no financial conflicts to disclose.
SOURCE: Curry SJ et al. JAMA. 2019;321(6):580-7; O’Connor E et al. JAMA. 2019;321(6):588-601.
A proactive approach to prevention and management of perinatal depression as recommended by the USPSTF can potentially improve outcomes for new mothers and their babies, Marlene P. Freeman, MD, wrote in an accompanying editorial. She identified three key challenges to implementing the USPSTF recommendations: identifying women at risk, connecting them to evidence-based treatment, and assessing outcomes after treatment. 
The development of screening tools would help clinicians identify women at risk for perinatal depression, Dr. Freeman said. No such tool currently exists, but in the meantime, “women at risk may be identified by targeting those with histories of depression, subthreshold depressive symptoms, and certain sociodemographic factors (i.e., economically disadvantaged, single/young, unplanned pregnancy).”
The counseling interventions shown to be effective in preventing perinatal depression – cognitive behavioral therapy and interpersonal psychotherapy – require education and training outside the time limitations and expertise of many clinicians providing obstetric care, she noted.
“The delivery of effective care on a large scale will require creative solutions,” such as the use of telehealth and smartphone platforms, and the involvement of multidisciplinary teams to care for women with severe illness, Dr. Freeman said. “In addition, a substantial number of reproductive-aged women have serious psychiatric disorders and will be identified as at risk for perinatal depression, although their needs may be more comprehensive,” she wrote. “Women who are identified as at risk for perinatal depression may have psychotic disorders, bipolar spectrum disorders, anxiety disorders, and substance use disorders, and there is comorbidity among psychiatric disorders. Therefore, systematic provisions for referral and treatment for other psychiatric disorders should be considered.” Further research is needed to explore treatment options including pharmacotherapy for women with severe psychiatric disorders.
However, she expressed optimism that the recommendations for screening and counseling for perinatal depression are valuable, and they “may return great dividends in the form of enhanced well-being of mothers and their offspring.”
Dr. Freeman is affiliated with the department of psychiatry at Massachusetts General Hospital, Boston. She commented in an editorial accompanying the article by Curry et al. (JAMA. 2019 Feb 12;321[6]:550-2). Dr. Freeman disclosed relationships with companies including Takeda, JayMac, Sage, Otsuka, Alkermes, Janssen, and Sunovion; she also disclosed serving on an independent data safety and monitoring committee for Janssen (Johnson & Johnson); and editing the GOED (Global Organization for EPA & DHA Omega-3) newsletter.
A proactive approach to prevention and management of perinatal depression as recommended by the USPSTF can potentially improve outcomes for new mothers and their babies, Marlene P. Freeman, MD, wrote in an accompanying editorial. She identified three key challenges to implementing the USPSTF recommendations: identifying women at risk, connecting them to evidence-based treatment, and assessing outcomes after treatment.
The development of screening tools would help clinicians identify women at risk for perinatal depression, Dr. Freeman said. No such tool currently exists, but in the meantime, “women at risk may be identified by targeting those with histories of depression, subthreshold depressive symptoms, and certain sociodemographic factors (i.e., economically disadvantaged, single/young, unplanned pregnancy).”
The counseling interventions shown to be effective in preventing perinatal depression – cognitive behavioral therapy and interpersonal psychotherapy – require education and training outside the time limitations and expertise of many clinicians providing obstetric care, she noted.
“The delivery of effective care on a large scale will require creative solutions,” such as the use of telehealth and smartphone platforms, and the involvement of multidisciplinary teams to care for women with severe illness, Dr. Freeman said. “In addition, a substantial number of reproductive-aged women have serious psychiatric disorders and will be identified as at risk for perinatal depression, although their needs may be more comprehensive,” she wrote. “Women who are identified as at risk for perinatal depression may have psychotic disorders, bipolar spectrum disorders, anxiety disorders, and substance use disorders, and there is comorbidity among psychiatric disorders. Therefore, systematic provisions for referral and treatment for other psychiatric disorders should be considered.” Further research is needed to explore treatment options including pharmacotherapy for women with severe psychiatric disorders.
However, she expressed optimism that the recommendations for screening and counseling for perinatal depression are valuable, and they “may return great dividends in the form of enhanced well-being of mothers and their offspring.”
Dr. Freeman is affiliated with the department of psychiatry at Massachusetts General Hospital, Boston. She commented in an editorial accompanying the article by Curry et al. (JAMA. 2019 Feb 12;321[6]:550-2). Dr. Freeman disclosed relationships with companies including Takeda, JayMac, Sage, Otsuka, Alkermes, Janssen, and Sunovion; she also disclosed serving on an independent data safety and monitoring committee for Janssen (Johnson & Johnson); and editing the GOED (Global Organization for EPA & DHA Omega-3) newsletter.
A proactive approach to prevention and management of perinatal depression as recommended by the USPSTF can potentially improve outcomes for new mothers and their babies, Marlene P. Freeman, MD, wrote in an accompanying editorial. She identified three key challenges to implementing the USPSTF recommendations: identifying women at risk, connecting them to evidence-based treatment, and assessing outcomes after treatment.
The development of screening tools would help clinicians identify women at risk for perinatal depression, Dr. Freeman said. No such tool currently exists, but in the meantime, “women at risk may be identified by targeting those with histories of depression, subthreshold depressive symptoms, and certain sociodemographic factors (i.e., economically disadvantaged, single/young, unplanned pregnancy).”
The counseling interventions shown to be effective in preventing perinatal depression – cognitive behavioral therapy and interpersonal psychotherapy – require education and training outside the time limitations and expertise of many clinicians providing obstetric care, she noted.
“The delivery of effective care on a large scale will require creative solutions,” such as the use of telehealth and smartphone platforms, and the involvement of multidisciplinary teams to care for women with severe illness, Dr. Freeman said. “In addition, a substantial number of reproductive-aged women have serious psychiatric disorders and will be identified as at risk for perinatal depression, although their needs may be more comprehensive,” she wrote. “Women who are identified as at risk for perinatal depression may have psychotic disorders, bipolar spectrum disorders, anxiety disorders, and substance use disorders, and there is comorbidity among psychiatric disorders. Therefore, systematic provisions for referral and treatment for other psychiatric disorders should be considered.” Further research is needed to explore treatment options including pharmacotherapy for women with severe psychiatric disorders.
However, she expressed optimism that the recommendations for screening and counseling for perinatal depression are valuable, and they “may return great dividends in the form of enhanced well-being of mothers and their offspring.”
Dr. Freeman is affiliated with the department of psychiatry at Massachusetts General Hospital, Boston. She commented in an editorial accompanying the article by Curry et al. (JAMA. 2019 Feb 12;321[6]:550-2). Dr. Freeman disclosed relationships with companies including Takeda, JayMac, Sage, Otsuka, Alkermes, Janssen, and Sunovion; she also disclosed serving on an independent data safety and monitoring committee for Janssen (Johnson & Johnson); and editing the GOED (Global Organization for EPA & DHA Omega-3) newsletter.
according to a B recommendation from the U.S. Preventive Services Task Force.
The Task Force determined that counseling interventions are effective in preventing perinatal depression, defined as a major or minor depressive episode during pregnancy or within the first year after delivery. The condition affects an estimated 12% of new mothers in the United States each year, according to lead author Susan J. Curry, PhD, of the University of Iowa, Iowa City, and her colleagues.
The recommendation, published in JAMA, applies to “pregnant persons and persons who are less than 1 year postpartum who do not have a current diagnosis of depression but are at increased risk of developing depression,” according to the authors (JAMA. 2019 Feb 12;321(6):580-7).
Risk factors for development of perinatal depression include:
- Past history of depression.
- Current depressive symptoms (that do not reach a diagnostic threshold).
- History of physical or sexual abuse.
- Unplanned or unwanted pregnancy.
- Stressful life events.
- Lack of social and financial support.
- Intimate partner violence.
- Pregestational or gestational diabetes.
- Complications during pregnancy.
- Adolescent parenthood.
- Low socioeconomic status.
- Lack of social support.
After reviewing the evidence, the USPSTF found a moderate net benefit for counseling interventions, particularly cognitive behavioral therapy and interpersonal therapy, for preventing perinatal depression in women at risk. Counseling sessions reviewed for this recommendation ranged from 4 to 20 meetings (median, 8 meetings).
The USPSTF found inadequate evidence to assess the harms and benefits of other noncounseling interventions, including pharmacologic therapy.
In the evidence review accompanying the recommendations, Elizabeth A. O’Connor, PhD, of Kaiser Permanente, Portland, Ore., and her colleagues analyzed data from 50 studies including 22,385 individuals; 20 of these studies were randomized, controlled trials of counseling interventions (JAMA. 2019 Feb 12;321(6):588-601).
Overall, the likelihood of perinatal depression was significantly lower among women who received counseling, compared with controls, among more than 3,000 women in those studies (pooled risk ratio 0.61). Absolute risk differences for perinatal depression ranged from a 1% increased reduction in controls to a 32% increased reduction among women who received counseling. The effects were strongest for cognitive behavioral therapy and interpersonal therapy as interventions. No adverse events were reported in the counseling intervention studies.
In three studies of health system interventions, the researchers found a benefit for interventions vs. controls, but the difference was not statistically significant.
Trials of most other alternative interventions including infant sleep advice, birth-experience postpartum debriefing, omega-3 fatty acid supplementation, expressive writing, antidepressants, and yoga did not show statistical significance in benefit for reducing perinatal depression.
Only one of three randomized controlled trials of physical activity found a statistically significant group difference.
A trial of nortriptyline to prevent perinatal depression showed no benefit, compared with placebo. A sertraline study of found “a smaller percentage of participants taking sertraline had a depression recurrence, compared with those taking placebo,” the investigators wrote. In these two studies, women who took nortriptyline showed no adverse effects, and those in a trial involving sertraline reported significantly more dizziness and drowsiness compared with placebo patients.
The evidence review was limited by the small number of quality studies, especially studies of alternative interventions. More research is needed; however, the findings support data from similar reviews and support the potential for counseling to prevent perinatal depression, particularly in women at increased risk for perinatal depression, Dr. O’Connor and her associates said.
The USPSTF is supported by the Agency for Healthcare Research and Quality. Coauthor Dr. Michelle L. Henninger reported receiving grants from Pfizer IGLC (Independent Grants for Learning & Change) outside the submitted work. Coauthor Dr. Bradley N. Gaynes reported receiving personal fees from LivaNova and Johnson & Johnson outside the submitted work. The remaining researchers had no financial conflicts to disclose.
SOURCE: Curry SJ et al. JAMA. 2019;321(6):580-7; O’Connor E et al. JAMA. 2019;321(6):588-601.
according to a B recommendation from the U.S. Preventive Services Task Force.
The Task Force determined that counseling interventions are effective in preventing perinatal depression, defined as a major or minor depressive episode during pregnancy or within the first year after delivery. The condition affects an estimated 12% of new mothers in the United States each year, according to lead author Susan J. Curry, PhD, of the University of Iowa, Iowa City, and her colleagues.
The recommendation, published in JAMA, applies to “pregnant persons and persons who are less than 1 year postpartum who do not have a current diagnosis of depression but are at increased risk of developing depression,” according to the authors (JAMA. 2019 Feb 12;321(6):580-7).
Risk factors for development of perinatal depression include:
- Past history of depression.
- Current depressive symptoms (that do not reach a diagnostic threshold).
- History of physical or sexual abuse.
- Unplanned or unwanted pregnancy.
- Stressful life events.
- Lack of social and financial support.
- Intimate partner violence.
- Pregestational or gestational diabetes.
- Complications during pregnancy.
- Adolescent parenthood.
- Low socioeconomic status.
- Lack of social support.
After reviewing the evidence, the USPSTF found a moderate net benefit for counseling interventions, particularly cognitive behavioral therapy and interpersonal therapy, for preventing perinatal depression in women at risk. Counseling sessions reviewed for this recommendation ranged from 4 to 20 meetings (median, 8 meetings).
The USPSTF found inadequate evidence to assess the harms and benefits of other noncounseling interventions, including pharmacologic therapy.
In the evidence review accompanying the recommendations, Elizabeth A. O’Connor, PhD, of Kaiser Permanente, Portland, Ore., and her colleagues analyzed data from 50 studies including 22,385 individuals; 20 of these studies were randomized, controlled trials of counseling interventions (JAMA. 2019 Feb 12;321(6):588-601).
Overall, the likelihood of perinatal depression was significantly lower among women who received counseling, compared with controls, among more than 3,000 women in those studies (pooled risk ratio 0.61). Absolute risk differences for perinatal depression ranged from a 1% increased reduction in controls to a 32% increased reduction among women who received counseling. The effects were strongest for cognitive behavioral therapy and interpersonal therapy as interventions. No adverse events were reported in the counseling intervention studies.
In three studies of health system interventions, the researchers found a benefit for interventions vs. controls, but the difference was not statistically significant.
Trials of most other alternative interventions including infant sleep advice, birth-experience postpartum debriefing, omega-3 fatty acid supplementation, expressive writing, antidepressants, and yoga did not show statistical significance in benefit for reducing perinatal depression.
Only one of three randomized controlled trials of physical activity found a statistically significant group difference.
A trial of nortriptyline to prevent perinatal depression showed no benefit, compared with placebo. A sertraline study of found “a smaller percentage of participants taking sertraline had a depression recurrence, compared with those taking placebo,” the investigators wrote. In these two studies, women who took nortriptyline showed no adverse effects, and those in a trial involving sertraline reported significantly more dizziness and drowsiness compared with placebo patients.
The evidence review was limited by the small number of quality studies, especially studies of alternative interventions. More research is needed; however, the findings support data from similar reviews and support the potential for counseling to prevent perinatal depression, particularly in women at increased risk for perinatal depression, Dr. O’Connor and her associates said.
The USPSTF is supported by the Agency for Healthcare Research and Quality. Coauthor Dr. Michelle L. Henninger reported receiving grants from Pfizer IGLC (Independent Grants for Learning & Change) outside the submitted work. Coauthor Dr. Bradley N. Gaynes reported receiving personal fees from LivaNova and Johnson & Johnson outside the submitted work. The remaining researchers had no financial conflicts to disclose.
SOURCE: Curry SJ et al. JAMA. 2019;321(6):580-7; O’Connor E et al. JAMA. 2019;321(6):588-601.
FROM JAMA
Interactive parenting, life skill intervention improves self-esteem in teen mothers
than did those who received standard care, according to Joanne E. Cox, MD, director of primary care at Boston Children’s Hospital and Harvard Medical School, and her associates.
A total of 140 mothers who were aged less than 19 years when they delivered and whose child was aged less than 12 months were included in the study published in Pediatrics. Of this group, 72 received the intervention, which included a series of five 1-hour, one-on-one, interactive modules adapted from the Nurturing and Ansell-Casey Life Skills curricula, delivered over the infant’s first 15 months, in addition to standard teen-tot clinic care. The remaining 68 mothers received teen-tot care alone.
While overall maternal self-esteem decreased in both the intervention and control groups when measured at 36 months, the intervention group experienced a significantly smaller decrease from baseline (P = .011). Similarly, the intervention group had higher scores regarding preparedness for motherhood (P = .011), acceptance of infant (P = .008), and expected relationship with infant (P = .029).
Of the 52 mothers in the intervention group and 48 mothers in the control group for whom pregnancy data was available at 36 months, 42% in the intervention group had a repeat pregnancy, compared with 67% in the control group (adjusted odds ratio, 0.20; 95% confidence interval, 0.06-0.75; P = .017).
The study findings “highlight the positive impact of pairing medical services with comprehensive social services and parenting education and can inform future policy and services for teen parents. These positive effects also have potential to improve long-term outcomes for teens and their children,” Dr. Cox and her associates concluded.
The study authors reported no conflicts of interest. The study was supported in part by a grant from the Office of Adolescent Pregnancy Programs, the Edgerley Family Endowment, a Leadership Education in Adolescent Health training grant, the Maternal and Child Health Bureau, and the Health Resources and Services Administration.
[email protected]
SOURCE: Cox JE et al. Pediatrics. 2019 Feb 12. doi: 10.1542/peds.2018-2303.
than did those who received standard care, according to Joanne E. Cox, MD, director of primary care at Boston Children’s Hospital and Harvard Medical School, and her associates.
A total of 140 mothers who were aged less than 19 years when they delivered and whose child was aged less than 12 months were included in the study published in Pediatrics. Of this group, 72 received the intervention, which included a series of five 1-hour, one-on-one, interactive modules adapted from the Nurturing and Ansell-Casey Life Skills curricula, delivered over the infant’s first 15 months, in addition to standard teen-tot clinic care. The remaining 68 mothers received teen-tot care alone.
While overall maternal self-esteem decreased in both the intervention and control groups when measured at 36 months, the intervention group experienced a significantly smaller decrease from baseline (P = .011). Similarly, the intervention group had higher scores regarding preparedness for motherhood (P = .011), acceptance of infant (P = .008), and expected relationship with infant (P = .029).
Of the 52 mothers in the intervention group and 48 mothers in the control group for whom pregnancy data was available at 36 months, 42% in the intervention group had a repeat pregnancy, compared with 67% in the control group (adjusted odds ratio, 0.20; 95% confidence interval, 0.06-0.75; P = .017).
The study findings “highlight the positive impact of pairing medical services with comprehensive social services and parenting education and can inform future policy and services for teen parents. These positive effects also have potential to improve long-term outcomes for teens and their children,” Dr. Cox and her associates concluded.
The study authors reported no conflicts of interest. The study was supported in part by a grant from the Office of Adolescent Pregnancy Programs, the Edgerley Family Endowment, a Leadership Education in Adolescent Health training grant, the Maternal and Child Health Bureau, and the Health Resources and Services Administration.
[email protected]
SOURCE: Cox JE et al. Pediatrics. 2019 Feb 12. doi: 10.1542/peds.2018-2303.
than did those who received standard care, according to Joanne E. Cox, MD, director of primary care at Boston Children’s Hospital and Harvard Medical School, and her associates.
A total of 140 mothers who were aged less than 19 years when they delivered and whose child was aged less than 12 months were included in the study published in Pediatrics. Of this group, 72 received the intervention, which included a series of five 1-hour, one-on-one, interactive modules adapted from the Nurturing and Ansell-Casey Life Skills curricula, delivered over the infant’s first 15 months, in addition to standard teen-tot clinic care. The remaining 68 mothers received teen-tot care alone.
While overall maternal self-esteem decreased in both the intervention and control groups when measured at 36 months, the intervention group experienced a significantly smaller decrease from baseline (P = .011). Similarly, the intervention group had higher scores regarding preparedness for motherhood (P = .011), acceptance of infant (P = .008), and expected relationship with infant (P = .029).
Of the 52 mothers in the intervention group and 48 mothers in the control group for whom pregnancy data was available at 36 months, 42% in the intervention group had a repeat pregnancy, compared with 67% in the control group (adjusted odds ratio, 0.20; 95% confidence interval, 0.06-0.75; P = .017).
The study findings “highlight the positive impact of pairing medical services with comprehensive social services and parenting education and can inform future policy and services for teen parents. These positive effects also have potential to improve long-term outcomes for teens and their children,” Dr. Cox and her associates concluded.
The study authors reported no conflicts of interest. The study was supported in part by a grant from the Office of Adolescent Pregnancy Programs, the Edgerley Family Endowment, a Leadership Education in Adolescent Health training grant, the Maternal and Child Health Bureau, and the Health Resources and Services Administration.
[email protected]
SOURCE: Cox JE et al. Pediatrics. 2019 Feb 12. doi: 10.1542/peds.2018-2303.
FROM PEDIATRICS
Supreme Court halts Louisiana abortion law from taking effect
The U.S. Supreme Court has temporarily barred a Louisiana law that would require stricter requirements for physicians who provide abortion care, the first abortion-related decision for the current conservative-leaning high court.
In a Feb. 7, 2019, order, Supreme Court justices stopped the law from moving forward until they can decide whether to accept the case for oral argument. The law in question would require Louisiana physicians who perform abortions to have admitting privileges at a hospital within 30 miles of the clinic where they offer abortion care.
A group of health professionals sued over the Louisiana statute after it was enacted in 2014, arguing that the requirement was unconstitutional because it placed an undue burden on women seeking abortions. A federal court agreed, concluding that the law would leave a significant number of Louisiana women unable to get an abortion. The state appealed to the 5th U.S. Circuit Court of Appeals, which reversed the decision in January 2019. The physician plaintiffs then urged the Supreme Court to stop the law, scheduled to take effect on Feb. 4 while the case continued through the courts. The health professionals argue that no physicians in Louisiana would be available to perform abortions after 17 weeks of pregnancy if the law proceeds and that only one physician in the state would be available to provide an abortion in the earlier stages of pregnancy. Attorneys for the state countered that health providers are overestimating the law’s effect and requested that the measure be allowed to go forward.
In a Feb. 1 order, the Supreme Court provided the plaintiffs a short stay while they reviewed briefs in the case. Then, in a 5-4 decision on Feb. 7, the majority court halted the legal challenge indefinitely until they can decide whether to take up the case.
Four justices – Clarence Thomas, Samuel Alito, Neil Gorsuch, and Brett Kavanaugh – dissented from the majority, writing that they would have allowed Louisiana to enforce the law. Chief Justice John Roberts joined the high court’s four more liberal justices in stopping the law’s enactment.
The plaintiffs’ petition to the Supreme Court is due in April. If the case is accepted, oral arguments would likely be scheduled for fall 2019 or winter 2020, according to court analysts.
The U.S. Supreme Court has temporarily barred a Louisiana law that would require stricter requirements for physicians who provide abortion care, the first abortion-related decision for the current conservative-leaning high court.
In a Feb. 7, 2019, order, Supreme Court justices stopped the law from moving forward until they can decide whether to accept the case for oral argument. The law in question would require Louisiana physicians who perform abortions to have admitting privileges at a hospital within 30 miles of the clinic where they offer abortion care.
A group of health professionals sued over the Louisiana statute after it was enacted in 2014, arguing that the requirement was unconstitutional because it placed an undue burden on women seeking abortions. A federal court agreed, concluding that the law would leave a significant number of Louisiana women unable to get an abortion. The state appealed to the 5th U.S. Circuit Court of Appeals, which reversed the decision in January 2019. The physician plaintiffs then urged the Supreme Court to stop the law, scheduled to take effect on Feb. 4 while the case continued through the courts. The health professionals argue that no physicians in Louisiana would be available to perform abortions after 17 weeks of pregnancy if the law proceeds and that only one physician in the state would be available to provide an abortion in the earlier stages of pregnancy. Attorneys for the state countered that health providers are overestimating the law’s effect and requested that the measure be allowed to go forward.
In a Feb. 1 order, the Supreme Court provided the plaintiffs a short stay while they reviewed briefs in the case. Then, in a 5-4 decision on Feb. 7, the majority court halted the legal challenge indefinitely until they can decide whether to take up the case.
Four justices – Clarence Thomas, Samuel Alito, Neil Gorsuch, and Brett Kavanaugh – dissented from the majority, writing that they would have allowed Louisiana to enforce the law. Chief Justice John Roberts joined the high court’s four more liberal justices in stopping the law’s enactment.
The plaintiffs’ petition to the Supreme Court is due in April. If the case is accepted, oral arguments would likely be scheduled for fall 2019 or winter 2020, according to court analysts.
The U.S. Supreme Court has temporarily barred a Louisiana law that would require stricter requirements for physicians who provide abortion care, the first abortion-related decision for the current conservative-leaning high court.
In a Feb. 7, 2019, order, Supreme Court justices stopped the law from moving forward until they can decide whether to accept the case for oral argument. The law in question would require Louisiana physicians who perform abortions to have admitting privileges at a hospital within 30 miles of the clinic where they offer abortion care.
A group of health professionals sued over the Louisiana statute after it was enacted in 2014, arguing that the requirement was unconstitutional because it placed an undue burden on women seeking abortions. A federal court agreed, concluding that the law would leave a significant number of Louisiana women unable to get an abortion. The state appealed to the 5th U.S. Circuit Court of Appeals, which reversed the decision in January 2019. The physician plaintiffs then urged the Supreme Court to stop the law, scheduled to take effect on Feb. 4 while the case continued through the courts. The health professionals argue that no physicians in Louisiana would be available to perform abortions after 17 weeks of pregnancy if the law proceeds and that only one physician in the state would be available to provide an abortion in the earlier stages of pregnancy. Attorneys for the state countered that health providers are overestimating the law’s effect and requested that the measure be allowed to go forward.
In a Feb. 1 order, the Supreme Court provided the plaintiffs a short stay while they reviewed briefs in the case. Then, in a 5-4 decision on Feb. 7, the majority court halted the legal challenge indefinitely until they can decide whether to take up the case.
Four justices – Clarence Thomas, Samuel Alito, Neil Gorsuch, and Brett Kavanaugh – dissented from the majority, writing that they would have allowed Louisiana to enforce the law. Chief Justice John Roberts joined the high court’s four more liberal justices in stopping the law’s enactment.
The plaintiffs’ petition to the Supreme Court is due in April. If the case is accepted, oral arguments would likely be scheduled for fall 2019 or winter 2020, according to court analysts.
Most pregnant women want guidance on prenatal whole-genome sequencing
according to results from a survey published in Obstetrics & Gynecology.
Nearly half said they would want clear guidance from clinicians before undergoing the noninvasive procedure.
“Prenatal whole-genome sequencing offers significantly more fetal information than women can currently receive, and it is not surprising that, when faced with a tremendous range of information, many women want recommendations from their clinicians,” Haley K. Sullivan from the National Institutes of Health Clinical Center and National Human Genome Research Institute and colleagues wrote. “Our data suggest that most women prefer a directive interaction with their clinician when deciding what types of genetic information to receive from prenatal whole-genome sequencing.”
Research coordinators from the Inova Translational Medicine Institute offered 805 pregnant women a survey on their preferences for prenatal whole-genome sequencing between June and August 2017; of these, 553 women answered (69% response rate). The women responded to questions about what type of information they would like to receive if they were to undergo prenatal whole-genome sequencing and what role a clinician would preferably play in the decision-making process. The researchers divided the survey into sections based on actionability, severity, prevalence, and age of onset.
According to the survey results, 90% of respondents wanted information on serious treatable childhood-onset diseases from prenatal whole-genome sequencing results, while 40% said they did not want to receive results based on nonmedical traits such as eye color, height, or athletic ability.
With regard to clinician role, 45% of women said they wanted all options presented with clear recommendations from a clinician on which tests to order, 26% wanted all options presented but with a joint decision-making process, 13% wanted all options presented but independent decision making, and 11% wanted the clear recommendation from clinicians alone.
The respondents said the most common reason for wanting to undergo prenatal whole-genome sequencing was to prepare “financially, medically, or psychologically” for a child with special needs, the researchers said.
“This represents a departure from the current state of genetic counseling, where nondirectiveness is a central tenet, and is contrary to the 45% of ob.gyns. who said in a previous survey that they should not be at all directive when counseling patients on prenatal whole-genome sequencing,” the authors wrote. “Given this clear patient desire for guidance, there is a vital opportunity for the American College of Obstetricians and Gynecologists to provide leadership and recommendations as prenatal whole-genome sequencing is adopted into clinical practice.”
Limitations in the study include asking the respondents to make hypothetical decisions, using examples to describe genetic conditions that might have skewed decision making; asking women to pick only one reason for wanting the sequencing information from a list of predetermined options, when many reasons may be important to them; social desirability bias in the responses, if women are reluctant to pick a choice they perceive as less socially acceptable; and a potential systematic difference between women who were and were not enrolled as survey participants. The respondents also were from the Northern Virginia area, which may not be generalizable to a national population of patients, the researchers said.
This study was supported by the Intramural Research Program of the National Human Genome Research Institute and the Clinical Center Department of Bioethics, National Institutes of Health. The authors reported no relevant conflicts of interest.
SOURCE: Sullivan HK et al. Obstet Gynecol. 2019 Mar. doi: 10.1097/AOG.0000000000003121.
according to results from a survey published in Obstetrics & Gynecology.
Nearly half said they would want clear guidance from clinicians before undergoing the noninvasive procedure.
“Prenatal whole-genome sequencing offers significantly more fetal information than women can currently receive, and it is not surprising that, when faced with a tremendous range of information, many women want recommendations from their clinicians,” Haley K. Sullivan from the National Institutes of Health Clinical Center and National Human Genome Research Institute and colleagues wrote. “Our data suggest that most women prefer a directive interaction with their clinician when deciding what types of genetic information to receive from prenatal whole-genome sequencing.”
Research coordinators from the Inova Translational Medicine Institute offered 805 pregnant women a survey on their preferences for prenatal whole-genome sequencing between June and August 2017; of these, 553 women answered (69% response rate). The women responded to questions about what type of information they would like to receive if they were to undergo prenatal whole-genome sequencing and what role a clinician would preferably play in the decision-making process. The researchers divided the survey into sections based on actionability, severity, prevalence, and age of onset.
According to the survey results, 90% of respondents wanted information on serious treatable childhood-onset diseases from prenatal whole-genome sequencing results, while 40% said they did not want to receive results based on nonmedical traits such as eye color, height, or athletic ability.
With regard to clinician role, 45% of women said they wanted all options presented with clear recommendations from a clinician on which tests to order, 26% wanted all options presented but with a joint decision-making process, 13% wanted all options presented but independent decision making, and 11% wanted the clear recommendation from clinicians alone.
The respondents said the most common reason for wanting to undergo prenatal whole-genome sequencing was to prepare “financially, medically, or psychologically” for a child with special needs, the researchers said.
“This represents a departure from the current state of genetic counseling, where nondirectiveness is a central tenet, and is contrary to the 45% of ob.gyns. who said in a previous survey that they should not be at all directive when counseling patients on prenatal whole-genome sequencing,” the authors wrote. “Given this clear patient desire for guidance, there is a vital opportunity for the American College of Obstetricians and Gynecologists to provide leadership and recommendations as prenatal whole-genome sequencing is adopted into clinical practice.”
Limitations in the study include asking the respondents to make hypothetical decisions, using examples to describe genetic conditions that might have skewed decision making; asking women to pick only one reason for wanting the sequencing information from a list of predetermined options, when many reasons may be important to them; social desirability bias in the responses, if women are reluctant to pick a choice they perceive as less socially acceptable; and a potential systematic difference between women who were and were not enrolled as survey participants. The respondents also were from the Northern Virginia area, which may not be generalizable to a national population of patients, the researchers said.
This study was supported by the Intramural Research Program of the National Human Genome Research Institute and the Clinical Center Department of Bioethics, National Institutes of Health. The authors reported no relevant conflicts of interest.
SOURCE: Sullivan HK et al. Obstet Gynecol. 2019 Mar. doi: 10.1097/AOG.0000000000003121.
according to results from a survey published in Obstetrics & Gynecology.
Nearly half said they would want clear guidance from clinicians before undergoing the noninvasive procedure.
“Prenatal whole-genome sequencing offers significantly more fetal information than women can currently receive, and it is not surprising that, when faced with a tremendous range of information, many women want recommendations from their clinicians,” Haley K. Sullivan from the National Institutes of Health Clinical Center and National Human Genome Research Institute and colleagues wrote. “Our data suggest that most women prefer a directive interaction with their clinician when deciding what types of genetic information to receive from prenatal whole-genome sequencing.”
Research coordinators from the Inova Translational Medicine Institute offered 805 pregnant women a survey on their preferences for prenatal whole-genome sequencing between June and August 2017; of these, 553 women answered (69% response rate). The women responded to questions about what type of information they would like to receive if they were to undergo prenatal whole-genome sequencing and what role a clinician would preferably play in the decision-making process. The researchers divided the survey into sections based on actionability, severity, prevalence, and age of onset.
According to the survey results, 90% of respondents wanted information on serious treatable childhood-onset diseases from prenatal whole-genome sequencing results, while 40% said they did not want to receive results based on nonmedical traits such as eye color, height, or athletic ability.
With regard to clinician role, 45% of women said they wanted all options presented with clear recommendations from a clinician on which tests to order, 26% wanted all options presented but with a joint decision-making process, 13% wanted all options presented but independent decision making, and 11% wanted the clear recommendation from clinicians alone.
The respondents said the most common reason for wanting to undergo prenatal whole-genome sequencing was to prepare “financially, medically, or psychologically” for a child with special needs, the researchers said.
“This represents a departure from the current state of genetic counseling, where nondirectiveness is a central tenet, and is contrary to the 45% of ob.gyns. who said in a previous survey that they should not be at all directive when counseling patients on prenatal whole-genome sequencing,” the authors wrote. “Given this clear patient desire for guidance, there is a vital opportunity for the American College of Obstetricians and Gynecologists to provide leadership and recommendations as prenatal whole-genome sequencing is adopted into clinical practice.”
Limitations in the study include asking the respondents to make hypothetical decisions, using examples to describe genetic conditions that might have skewed decision making; asking women to pick only one reason for wanting the sequencing information from a list of predetermined options, when many reasons may be important to them; social desirability bias in the responses, if women are reluctant to pick a choice they perceive as less socially acceptable; and a potential systematic difference between women who were and were not enrolled as survey participants. The respondents also were from the Northern Virginia area, which may not be generalizable to a national population of patients, the researchers said.
This study was supported by the Intramural Research Program of the National Human Genome Research Institute and the Clinical Center Department of Bioethics, National Institutes of Health. The authors reported no relevant conflicts of interest.
SOURCE: Sullivan HK et al. Obstet Gynecol. 2019 Mar. doi: 10.1097/AOG.0000000000003121.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point: A majority of pregnant women surveyed said they wanted information on childhood-onset genetic diseases, with almost half wanting clear clinical recommendations before deciding to undergo noninvasive prenatal whole-genome sequencing.
Major finding: Of the respondents, 90% said they wanted information on serious treatable childhood-onset conditions.
Study details: A survey of 553 pregnant women coordinated by the Inova Translational Medicine Institute.
Disclosures: This study was supported by the Intramural Research Program of the National Human Genome Research Institute and the Clinical Center Department of Bioethics, National Institutes of Health. The authors reported no relevant conflicts of interest.
Source: Sullivan HK et al. Obstet Gynecol. 2019 Mar. doi: 10.1097/AOG.0000000000003121.
FDA: 246 new reports on breast implant-associated lymphoma
The Food and Drug Administration has identified 457 unique cases of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and 9 related deaths since 2010, and received 246 new medical device reports (MDRs) regarding BIA-ALCL between September 2017 and September 2018, according to an update from the agency’s Center for Devices and Radiological Health.
That brings the total number of reports to 660; however, that number reflects duplicative cases, Binita Ashar, MD, a general surgeon and the director of the division of surgical devices at the center, said in a statement.
“These types of increases in the MDRs are to be expected and may include past cases that were not previously reported to the FDA,” Dr. Ashar said, addressing the high number of new reports. “The increased number of MDRs contributes to our evolving understanding of BIA-ALCL and represents a more thorough and comprehensive analysis.”
BIA-ALCL is a type of non-Hodgkin lymphoma and a known risk from breast implants that was first communicated by the FDA in 2011. Regular updates have been provided with respect to related medical device reports, cases, deaths, and known risks.
“We hope that this information prompts providers and patients to have important, informed conversations about breast implants and the risk of BIA-ALCL. At the same time, we remain committed to working in partnership with all stakeholders to continue to study, understand, and provide updates about this important public health issue,” Dr. Ashar said.
To that end, the center also issued a Letter to Health Care Providers to “encourage those who regularly treat patients, including primary care physicians and gynecologists, to learn about BIA-ALCL in patients with breast implants.”
Patients and providers are encouraged to file MDRs with the FDA via MedWatch, the FDA Safety Information and Adverse Event Reporting program, she said.
The Food and Drug Administration has identified 457 unique cases of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and 9 related deaths since 2010, and received 246 new medical device reports (MDRs) regarding BIA-ALCL between September 2017 and September 2018, according to an update from the agency’s Center for Devices and Radiological Health.
That brings the total number of reports to 660; however, that number reflects duplicative cases, Binita Ashar, MD, a general surgeon and the director of the division of surgical devices at the center, said in a statement.
“These types of increases in the MDRs are to be expected and may include past cases that were not previously reported to the FDA,” Dr. Ashar said, addressing the high number of new reports. “The increased number of MDRs contributes to our evolving understanding of BIA-ALCL and represents a more thorough and comprehensive analysis.”
BIA-ALCL is a type of non-Hodgkin lymphoma and a known risk from breast implants that was first communicated by the FDA in 2011. Regular updates have been provided with respect to related medical device reports, cases, deaths, and known risks.
“We hope that this information prompts providers and patients to have important, informed conversations about breast implants and the risk of BIA-ALCL. At the same time, we remain committed to working in partnership with all stakeholders to continue to study, understand, and provide updates about this important public health issue,” Dr. Ashar said.
To that end, the center also issued a Letter to Health Care Providers to “encourage those who regularly treat patients, including primary care physicians and gynecologists, to learn about BIA-ALCL in patients with breast implants.”
Patients and providers are encouraged to file MDRs with the FDA via MedWatch, the FDA Safety Information and Adverse Event Reporting program, she said.
The Food and Drug Administration has identified 457 unique cases of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and 9 related deaths since 2010, and received 246 new medical device reports (MDRs) regarding BIA-ALCL between September 2017 and September 2018, according to an update from the agency’s Center for Devices and Radiological Health.
That brings the total number of reports to 660; however, that number reflects duplicative cases, Binita Ashar, MD, a general surgeon and the director of the division of surgical devices at the center, said in a statement.
“These types of increases in the MDRs are to be expected and may include past cases that were not previously reported to the FDA,” Dr. Ashar said, addressing the high number of new reports. “The increased number of MDRs contributes to our evolving understanding of BIA-ALCL and represents a more thorough and comprehensive analysis.”
BIA-ALCL is a type of non-Hodgkin lymphoma and a known risk from breast implants that was first communicated by the FDA in 2011. Regular updates have been provided with respect to related medical device reports, cases, deaths, and known risks.
“We hope that this information prompts providers and patients to have important, informed conversations about breast implants and the risk of BIA-ALCL. At the same time, we remain committed to working in partnership with all stakeholders to continue to study, understand, and provide updates about this important public health issue,” Dr. Ashar said.
To that end, the center also issued a Letter to Health Care Providers to “encourage those who regularly treat patients, including primary care physicians and gynecologists, to learn about BIA-ALCL in patients with breast implants.”
Patients and providers are encouraged to file MDRs with the FDA via MedWatch, the FDA Safety Information and Adverse Event Reporting program, she said.
Obstetric hospitalists can screen for postpartum depression
Postpartum depression (PPD) is the most common complication of pregnancy, and onset can occur at any time from pregnancy until up to 1 year post partum.1,2 The immediate postpartum period is a time during which care is shared among multiple providers for both mother and child, and the transition from inpatient to outpatient postpartum care can impede communication between those caring for the patient in each setting. In 2018, the American College of Obstetricians and Gynecologists published a committee opinion emphasizing the importance of the “fourth trimester” and calling for health care providers to assist women in navigating the transition from pre- to postpartum care.3 An important consideration of perinatal care is mental health care for the mother, including screening and care for postpartum depression; however, the optimal role for the obstetric hospitalist in providing such services has been unclear.
Estimates of the prevalence of PPD in new mothers in the United States varied by state from 8% to 20% in 2012, with an overall average of 12%.2 Left untreated, PPD may result in significant negative outcomes for women, their children, and families. The depressive symptoms of PPD may persist for months or years afterward,4 with one study finding elevated depressive symptoms in women up to 11 years post partum.5 Suicide is also a leading cause of pregnancy-related mortality associated with depressive symptoms.6-9 In addition, maternal postpartum depression symptoms have been associated with impaired mother-infant bonding at 6 months of age10 and decreased cognitive and fine motor development of children at 18 months.11
Importance of screening
Evidence from the literature shows that, without proper screening, approximately 50% of cases of PPD go undiagnosed, and that increasing the number of women being screened by perinatal providers is an important first step to improving outcomes.12-18 Current recommendations for the timing and frequency of screening for PPD vary among the published guidelines. ACOG recommends screening at least once during the perinatal period for depression and anxiety using a standardized, validated tool; an update of the ACOG committee opinion in 2018 also states: “It is recommended that all obstetrician-gynecologists and other obstetric care providers complete a full assessment of mood and emotional well-being (including screening for PPD and anxiety with a validated instrument) during the comprehensive postpartum visit for each patient.”19 The American Medical Association adopted new policies in 2017 promoting the implementation of a routine protocol for depression screening of perinatal women.20 The American Academy of Pediatrics recommends more frequent screening, with assessments at the 1-, 2-, 4-, and 6-month visits.21 Finally, the U.S. Preventive Services Task Force recommends screening for depression in the general population including pregnant and postpartum women.22
Multiple standardized, validated screening instruments are available for detecting possible symptoms of PPD, including the most widely used tools: the Edinburgh Postnatal Depression Scale (EPDS)19,23 and the Patient Health Questionnaire (PHQ-9).24 Two recent studies have shown that screening women for symptoms of PPD with a validated tool may reduce the duration or severity of depressive symptoms,25,26 further reinforcing the need to ensure that women experiencing symptoms of PPD are identified and treated early.
The inpatient hospitalization for labor, delivery, and birth of a child has not traditionally been viewed as an opportunity for PPD screening. While private practitioners and obstetric medical group practices typically have inquired about and documented the individual patient’s mental health history and risk factors for PPD, the obstetric hospitalist is most commonly meeting a patient in labor or in a postpartum encounter for the first time. As obstetric practices grow ever more consolidated, and as obstetric hospitalist care is implemented for a variety of reasons including, but not limited to, preventing burnout among private practitioners, serving as a safety net for all inpatient obstetric services, and increasing standardization in obstetric triage and obstetric emergency departments,
Barriers remain
Despite the need for early detection of PPD, screening practices remain inconsistent. A literature review of health care provider practices showed only one in four physicians reported using screening tools; obstetrician-gynecologists were most likely (36%) to use screening tools, followed by family practitioners (31%), with pediatricians the least likely (7%).27 This low rate is at least partially the result of perceived barriers to screening among health care providers, which contributes to underdiagnosis. A survey of more than 200 physicians who were members of ACOG showed that the top three barriers restricting screening practices were time constraints, inadequate training, and a lack of knowledge of the diagnostic criteria.28
Since 2017, Dignity Health has instituted routine screening of all inpatient postpartum patients at its 29 birth centers in Arizona, California, and Nevada. In this program, of which I am a physician participant, more than 30,000 women have been screened with the EPDS. In addition to providing screening, Dignity Health staff (physicians, certified nurse midwives, nurse practitioners, registered nurses, social workers, mental health therapists, lactation consultants, health educators, and others) have received in-person Perinatal Mental Health training. In this way, the entire care team coordinates inpatient screening and referral to outpatient care providers – thus bridging the gap in postpartum mental health care. For those patients who screen positive while an inpatient, a psychiatric telemedicine appointment is provided and, if necessary, short-course medications can be prescribed until the patient has outpatient follow-up and continuity of care. While we as obstetric hospitalists and community obstetrician-gynecologists recognize that inpatient postpartum screening may be limited in its sensitivity for capturing all women who will go on to develop PPD, there is definitely a benefit to having a discussion about PPD and maternal mental health early and often throughout the postpartum period. For many women suffering in silence, a 6-week postpartum outpatient visit is too late, especially given that approximately one-third of women are lost to postpartum follow-up.29,30
Addressing barriers
A growing number of states have enacted policies to address the challenge of peripartum behavioral health needs, and several states – Illinois, Massachusetts, New Jersey, and West Virginia – now mandate routine PPD screening by health care providers.31 However, few of these laws or policies contain specific guidance, such as the optimal timing for screening, instead leaving the details to providers.32 The proper identification and management of PPD cannot be achieved by state-level policy mandates alone, but must include clinician buy-in and participation.
Obstetricians play an essential role in the identification and treatment of PPD. Among nonpsychiatric specialists, obstetrician-gynecologists are the most likely providers to see and screen during the perinatal period.33 In addition, women prefer to receive help for PPD from either their obstetric practitioners or a mental-health specialists located at the obstetric clinic, and are more likely to receive mental-health services if they are provided at the same location as that of the obstetric provider.34,35 According to ACOG’s new guidance on the fourth trimester, obstetricians are encouraged to take responsibility for women’s care immediately after birth, and this care would include contact with all mothers within the first 3 weeks post partum, at follow-up visits as needed, and for a comprehensive postpartum visit at 12 weeks.3
Our specialty has and will continue to evolve, and obstetric hospitalists will play an ever more essential role in the care of women during their inpatient obstetric admission. Whether we are a patient’s primary inpatient obstetric provider or a practice extender for single or multigroup practice, we are in a unique role to screen, begin treatment for, and offer anticipatory guidance for maternal mental health and postpartum depression disorders. Obstetric hospitalists can be a bridge between inpatient and outpatient follow-up and catalysts for implementing universal inpatient PPD screening. Our role presents an opportunity to start the discussion early and often in the fourth trimester and to make a significant difference in addressing this critical unmet need in postnatal care.
Dr. van Dis is the medical director of the Ob Hospitalist Group in Burbank, Calif. She disclosed she received editorial assistance from Erik MacLaren, PhD, of Boston Strategic Partners Inc., with funding support from Sage Therapeutics Inc. E-mail [email protected].
References
1. Centers for Disease Control and Prevention. Postpartum Depression. 2017.
2. Morb Mortal Wkly Rep. 2017;66(6):153-8.
3. Obstet Gynecol. 2018;131(5):e140-e150.
4. Harv Rev Psychiatry. 2014;22(1):1-22.
5. JAMA Psychiatry. 2018;75(3):247-53.
6. J Womens Health (Larchmt). 2016;25(12):1219-24.
7. J Psychiatr Res. 2017;84:284-91.
8. Br J Psychiatry. 2003;183:279-81.
9. Obstet Gynecol Surv. 2005;60(3):183-90.
10. Arch Womens Ment Health. 2016;19(1):87-94.
11. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1335-45.
12. J Reprod Med. 1999;44(4):351-8.
13. J Behav Health Serv Res. 2004;31(2):117-33.
14. J Clin Psychiatry. 2016;77(9):1189-200.
15. Am J Obstet Gynecol. 2000;182(5):1080-2.
16. J Fam Pract. 2001;50(2):117-22.
17. Obstet Gynecol. 1999;93(5 Pt 1):653-7.
18. J Womens Health (Larchmt). 2010;19(3):477-90.
19. Obstet Gynecol. 2018;132:e208-12.
20. “Physicians back programs to address maternal mortality, depression,” AMA, Nov. 15, 2017
21. Pediatrics. 2019 Jan 1;143(1):e20183260.
22. JAMA. 2016;315(4):380-7.
23. Br J Psychiatry. 1987;150:782-6.
24. Ann Fam Med. 2009;7(1):63-70.
25. Obstet Gynecol. 2016;127(5):917-25.
26. Pediatrics. 2017 Oct;140(4). pii: e20170110.
27. Womens Health Issues. 2015;25(6):703-10.
28. J Psychosom Obstet Gynaecol. 2011;32(1):27-34.
29. Matern Child Health J. 2016;20(Suppl 1):22-7.
30. National Committee for Quality Assurance. Prenatal and Postpartum Care (PPC). 2018.
31. Psychiatr Serv. 2015;66(3):324-8.
32. Postpartum Support International. Legislation. 2018.
33. American Academy of Pediatrics, American College of Obstetricians and Gynecologists, eds. Guidelines for Perinatal Care. 7th ed. (Elk Grove Village, IL: Washington, DC: American Academy of Pediatrics; American College of Obstetricians and Gynecologists; Oct 2012.)
34. Birth. 2009;36(1):60-9.
35. Gen Hosp Psychiatry. 2009;31(2):155-62.
Postpartum depression (PPD) is the most common complication of pregnancy, and onset can occur at any time from pregnancy until up to 1 year post partum.1,2 The immediate postpartum period is a time during which care is shared among multiple providers for both mother and child, and the transition from inpatient to outpatient postpartum care can impede communication between those caring for the patient in each setting. In 2018, the American College of Obstetricians and Gynecologists published a committee opinion emphasizing the importance of the “fourth trimester” and calling for health care providers to assist women in navigating the transition from pre- to postpartum care.3 An important consideration of perinatal care is mental health care for the mother, including screening and care for postpartum depression; however, the optimal role for the obstetric hospitalist in providing such services has been unclear.
Estimates of the prevalence of PPD in new mothers in the United States varied by state from 8% to 20% in 2012, with an overall average of 12%.2 Left untreated, PPD may result in significant negative outcomes for women, their children, and families. The depressive symptoms of PPD may persist for months or years afterward,4 with one study finding elevated depressive symptoms in women up to 11 years post partum.5 Suicide is also a leading cause of pregnancy-related mortality associated with depressive symptoms.6-9 In addition, maternal postpartum depression symptoms have been associated with impaired mother-infant bonding at 6 months of age10 and decreased cognitive and fine motor development of children at 18 months.11
Importance of screening
Evidence from the literature shows that, without proper screening, approximately 50% of cases of PPD go undiagnosed, and that increasing the number of women being screened by perinatal providers is an important first step to improving outcomes.12-18 Current recommendations for the timing and frequency of screening for PPD vary among the published guidelines. ACOG recommends screening at least once during the perinatal period for depression and anxiety using a standardized, validated tool; an update of the ACOG committee opinion in 2018 also states: “It is recommended that all obstetrician-gynecologists and other obstetric care providers complete a full assessment of mood and emotional well-being (including screening for PPD and anxiety with a validated instrument) during the comprehensive postpartum visit for each patient.”19 The American Medical Association adopted new policies in 2017 promoting the implementation of a routine protocol for depression screening of perinatal women.20 The American Academy of Pediatrics recommends more frequent screening, with assessments at the 1-, 2-, 4-, and 6-month visits.21 Finally, the U.S. Preventive Services Task Force recommends screening for depression in the general population including pregnant and postpartum women.22
Multiple standardized, validated screening instruments are available for detecting possible symptoms of PPD, including the most widely used tools: the Edinburgh Postnatal Depression Scale (EPDS)19,23 and the Patient Health Questionnaire (PHQ-9).24 Two recent studies have shown that screening women for symptoms of PPD with a validated tool may reduce the duration or severity of depressive symptoms,25,26 further reinforcing the need to ensure that women experiencing symptoms of PPD are identified and treated early.
The inpatient hospitalization for labor, delivery, and birth of a child has not traditionally been viewed as an opportunity for PPD screening. While private practitioners and obstetric medical group practices typically have inquired about and documented the individual patient’s mental health history and risk factors for PPD, the obstetric hospitalist is most commonly meeting a patient in labor or in a postpartum encounter for the first time. As obstetric practices grow ever more consolidated, and as obstetric hospitalist care is implemented for a variety of reasons including, but not limited to, preventing burnout among private practitioners, serving as a safety net for all inpatient obstetric services, and increasing standardization in obstetric triage and obstetric emergency departments,
Barriers remain
Despite the need for early detection of PPD, screening practices remain inconsistent. A literature review of health care provider practices showed only one in four physicians reported using screening tools; obstetrician-gynecologists were most likely (36%) to use screening tools, followed by family practitioners (31%), with pediatricians the least likely (7%).27 This low rate is at least partially the result of perceived barriers to screening among health care providers, which contributes to underdiagnosis. A survey of more than 200 physicians who were members of ACOG showed that the top three barriers restricting screening practices were time constraints, inadequate training, and a lack of knowledge of the diagnostic criteria.28
Since 2017, Dignity Health has instituted routine screening of all inpatient postpartum patients at its 29 birth centers in Arizona, California, and Nevada. In this program, of which I am a physician participant, more than 30,000 women have been screened with the EPDS. In addition to providing screening, Dignity Health staff (physicians, certified nurse midwives, nurse practitioners, registered nurses, social workers, mental health therapists, lactation consultants, health educators, and others) have received in-person Perinatal Mental Health training. In this way, the entire care team coordinates inpatient screening and referral to outpatient care providers – thus bridging the gap in postpartum mental health care. For those patients who screen positive while an inpatient, a psychiatric telemedicine appointment is provided and, if necessary, short-course medications can be prescribed until the patient has outpatient follow-up and continuity of care. While we as obstetric hospitalists and community obstetrician-gynecologists recognize that inpatient postpartum screening may be limited in its sensitivity for capturing all women who will go on to develop PPD, there is definitely a benefit to having a discussion about PPD and maternal mental health early and often throughout the postpartum period. For many women suffering in silence, a 6-week postpartum outpatient visit is too late, especially given that approximately one-third of women are lost to postpartum follow-up.29,30
Addressing barriers
A growing number of states have enacted policies to address the challenge of peripartum behavioral health needs, and several states – Illinois, Massachusetts, New Jersey, and West Virginia – now mandate routine PPD screening by health care providers.31 However, few of these laws or policies contain specific guidance, such as the optimal timing for screening, instead leaving the details to providers.32 The proper identification and management of PPD cannot be achieved by state-level policy mandates alone, but must include clinician buy-in and participation.
Obstetricians play an essential role in the identification and treatment of PPD. Among nonpsychiatric specialists, obstetrician-gynecologists are the most likely providers to see and screen during the perinatal period.33 In addition, women prefer to receive help for PPD from either their obstetric practitioners or a mental-health specialists located at the obstetric clinic, and are more likely to receive mental-health services if they are provided at the same location as that of the obstetric provider.34,35 According to ACOG’s new guidance on the fourth trimester, obstetricians are encouraged to take responsibility for women’s care immediately after birth, and this care would include contact with all mothers within the first 3 weeks post partum, at follow-up visits as needed, and for a comprehensive postpartum visit at 12 weeks.3
Our specialty has and will continue to evolve, and obstetric hospitalists will play an ever more essential role in the care of women during their inpatient obstetric admission. Whether we are a patient’s primary inpatient obstetric provider or a practice extender for single or multigroup practice, we are in a unique role to screen, begin treatment for, and offer anticipatory guidance for maternal mental health and postpartum depression disorders. Obstetric hospitalists can be a bridge between inpatient and outpatient follow-up and catalysts for implementing universal inpatient PPD screening. Our role presents an opportunity to start the discussion early and often in the fourth trimester and to make a significant difference in addressing this critical unmet need in postnatal care.
Dr. van Dis is the medical director of the Ob Hospitalist Group in Burbank, Calif. She disclosed she received editorial assistance from Erik MacLaren, PhD, of Boston Strategic Partners Inc., with funding support from Sage Therapeutics Inc. E-mail [email protected].
References
1. Centers for Disease Control and Prevention. Postpartum Depression. 2017.
2. Morb Mortal Wkly Rep. 2017;66(6):153-8.
3. Obstet Gynecol. 2018;131(5):e140-e150.
4. Harv Rev Psychiatry. 2014;22(1):1-22.
5. JAMA Psychiatry. 2018;75(3):247-53.
6. J Womens Health (Larchmt). 2016;25(12):1219-24.
7. J Psychiatr Res. 2017;84:284-91.
8. Br J Psychiatry. 2003;183:279-81.
9. Obstet Gynecol Surv. 2005;60(3):183-90.
10. Arch Womens Ment Health. 2016;19(1):87-94.
11. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1335-45.
12. J Reprod Med. 1999;44(4):351-8.
13. J Behav Health Serv Res. 2004;31(2):117-33.
14. J Clin Psychiatry. 2016;77(9):1189-200.
15. Am J Obstet Gynecol. 2000;182(5):1080-2.
16. J Fam Pract. 2001;50(2):117-22.
17. Obstet Gynecol. 1999;93(5 Pt 1):653-7.
18. J Womens Health (Larchmt). 2010;19(3):477-90.
19. Obstet Gynecol. 2018;132:e208-12.
20. “Physicians back programs to address maternal mortality, depression,” AMA, Nov. 15, 2017
21. Pediatrics. 2019 Jan 1;143(1):e20183260.
22. JAMA. 2016;315(4):380-7.
23. Br J Psychiatry. 1987;150:782-6.
24. Ann Fam Med. 2009;7(1):63-70.
25. Obstet Gynecol. 2016;127(5):917-25.
26. Pediatrics. 2017 Oct;140(4). pii: e20170110.
27. Womens Health Issues. 2015;25(6):703-10.
28. J Psychosom Obstet Gynaecol. 2011;32(1):27-34.
29. Matern Child Health J. 2016;20(Suppl 1):22-7.
30. National Committee for Quality Assurance. Prenatal and Postpartum Care (PPC). 2018.
31. Psychiatr Serv. 2015;66(3):324-8.
32. Postpartum Support International. Legislation. 2018.
33. American Academy of Pediatrics, American College of Obstetricians and Gynecologists, eds. Guidelines for Perinatal Care. 7th ed. (Elk Grove Village, IL: Washington, DC: American Academy of Pediatrics; American College of Obstetricians and Gynecologists; Oct 2012.)
34. Birth. 2009;36(1):60-9.
35. Gen Hosp Psychiatry. 2009;31(2):155-62.
Postpartum depression (PPD) is the most common complication of pregnancy, and onset can occur at any time from pregnancy until up to 1 year post partum.1,2 The immediate postpartum period is a time during which care is shared among multiple providers for both mother and child, and the transition from inpatient to outpatient postpartum care can impede communication between those caring for the patient in each setting. In 2018, the American College of Obstetricians and Gynecologists published a committee opinion emphasizing the importance of the “fourth trimester” and calling for health care providers to assist women in navigating the transition from pre- to postpartum care.3 An important consideration of perinatal care is mental health care for the mother, including screening and care for postpartum depression; however, the optimal role for the obstetric hospitalist in providing such services has been unclear.
Estimates of the prevalence of PPD in new mothers in the United States varied by state from 8% to 20% in 2012, with an overall average of 12%.2 Left untreated, PPD may result in significant negative outcomes for women, their children, and families. The depressive symptoms of PPD may persist for months or years afterward,4 with one study finding elevated depressive symptoms in women up to 11 years post partum.5 Suicide is also a leading cause of pregnancy-related mortality associated with depressive symptoms.6-9 In addition, maternal postpartum depression symptoms have been associated with impaired mother-infant bonding at 6 months of age10 and decreased cognitive and fine motor development of children at 18 months.11
Importance of screening
Evidence from the literature shows that, without proper screening, approximately 50% of cases of PPD go undiagnosed, and that increasing the number of women being screened by perinatal providers is an important first step to improving outcomes.12-18 Current recommendations for the timing and frequency of screening for PPD vary among the published guidelines. ACOG recommends screening at least once during the perinatal period for depression and anxiety using a standardized, validated tool; an update of the ACOG committee opinion in 2018 also states: “It is recommended that all obstetrician-gynecologists and other obstetric care providers complete a full assessment of mood and emotional well-being (including screening for PPD and anxiety with a validated instrument) during the comprehensive postpartum visit for each patient.”19 The American Medical Association adopted new policies in 2017 promoting the implementation of a routine protocol for depression screening of perinatal women.20 The American Academy of Pediatrics recommends more frequent screening, with assessments at the 1-, 2-, 4-, and 6-month visits.21 Finally, the U.S. Preventive Services Task Force recommends screening for depression in the general population including pregnant and postpartum women.22
Multiple standardized, validated screening instruments are available for detecting possible symptoms of PPD, including the most widely used tools: the Edinburgh Postnatal Depression Scale (EPDS)19,23 and the Patient Health Questionnaire (PHQ-9).24 Two recent studies have shown that screening women for symptoms of PPD with a validated tool may reduce the duration or severity of depressive symptoms,25,26 further reinforcing the need to ensure that women experiencing symptoms of PPD are identified and treated early.
The inpatient hospitalization for labor, delivery, and birth of a child has not traditionally been viewed as an opportunity for PPD screening. While private practitioners and obstetric medical group practices typically have inquired about and documented the individual patient’s mental health history and risk factors for PPD, the obstetric hospitalist is most commonly meeting a patient in labor or in a postpartum encounter for the first time. As obstetric practices grow ever more consolidated, and as obstetric hospitalist care is implemented for a variety of reasons including, but not limited to, preventing burnout among private practitioners, serving as a safety net for all inpatient obstetric services, and increasing standardization in obstetric triage and obstetric emergency departments,
Barriers remain
Despite the need for early detection of PPD, screening practices remain inconsistent. A literature review of health care provider practices showed only one in four physicians reported using screening tools; obstetrician-gynecologists were most likely (36%) to use screening tools, followed by family practitioners (31%), with pediatricians the least likely (7%).27 This low rate is at least partially the result of perceived barriers to screening among health care providers, which contributes to underdiagnosis. A survey of more than 200 physicians who were members of ACOG showed that the top three barriers restricting screening practices were time constraints, inadequate training, and a lack of knowledge of the diagnostic criteria.28
Since 2017, Dignity Health has instituted routine screening of all inpatient postpartum patients at its 29 birth centers in Arizona, California, and Nevada. In this program, of which I am a physician participant, more than 30,000 women have been screened with the EPDS. In addition to providing screening, Dignity Health staff (physicians, certified nurse midwives, nurse practitioners, registered nurses, social workers, mental health therapists, lactation consultants, health educators, and others) have received in-person Perinatal Mental Health training. In this way, the entire care team coordinates inpatient screening and referral to outpatient care providers – thus bridging the gap in postpartum mental health care. For those patients who screen positive while an inpatient, a psychiatric telemedicine appointment is provided and, if necessary, short-course medications can be prescribed until the patient has outpatient follow-up and continuity of care. While we as obstetric hospitalists and community obstetrician-gynecologists recognize that inpatient postpartum screening may be limited in its sensitivity for capturing all women who will go on to develop PPD, there is definitely a benefit to having a discussion about PPD and maternal mental health early and often throughout the postpartum period. For many women suffering in silence, a 6-week postpartum outpatient visit is too late, especially given that approximately one-third of women are lost to postpartum follow-up.29,30
Addressing barriers
A growing number of states have enacted policies to address the challenge of peripartum behavioral health needs, and several states – Illinois, Massachusetts, New Jersey, and West Virginia – now mandate routine PPD screening by health care providers.31 However, few of these laws or policies contain specific guidance, such as the optimal timing for screening, instead leaving the details to providers.32 The proper identification and management of PPD cannot be achieved by state-level policy mandates alone, but must include clinician buy-in and participation.
Obstetricians play an essential role in the identification and treatment of PPD. Among nonpsychiatric specialists, obstetrician-gynecologists are the most likely providers to see and screen during the perinatal period.33 In addition, women prefer to receive help for PPD from either their obstetric practitioners or a mental-health specialists located at the obstetric clinic, and are more likely to receive mental-health services if they are provided at the same location as that of the obstetric provider.34,35 According to ACOG’s new guidance on the fourth trimester, obstetricians are encouraged to take responsibility for women’s care immediately after birth, and this care would include contact with all mothers within the first 3 weeks post partum, at follow-up visits as needed, and for a comprehensive postpartum visit at 12 weeks.3
Our specialty has and will continue to evolve, and obstetric hospitalists will play an ever more essential role in the care of women during their inpatient obstetric admission. Whether we are a patient’s primary inpatient obstetric provider or a practice extender for single or multigroup practice, we are in a unique role to screen, begin treatment for, and offer anticipatory guidance for maternal mental health and postpartum depression disorders. Obstetric hospitalists can be a bridge between inpatient and outpatient follow-up and catalysts for implementing universal inpatient PPD screening. Our role presents an opportunity to start the discussion early and often in the fourth trimester and to make a significant difference in addressing this critical unmet need in postnatal care.
Dr. van Dis is the medical director of the Ob Hospitalist Group in Burbank, Calif. She disclosed she received editorial assistance from Erik MacLaren, PhD, of Boston Strategic Partners Inc., with funding support from Sage Therapeutics Inc. E-mail [email protected].
References
1. Centers for Disease Control and Prevention. Postpartum Depression. 2017.
2. Morb Mortal Wkly Rep. 2017;66(6):153-8.
3. Obstet Gynecol. 2018;131(5):e140-e150.
4. Harv Rev Psychiatry. 2014;22(1):1-22.
5. JAMA Psychiatry. 2018;75(3):247-53.
6. J Womens Health (Larchmt). 2016;25(12):1219-24.
7. J Psychiatr Res. 2017;84:284-91.
8. Br J Psychiatry. 2003;183:279-81.
9. Obstet Gynecol Surv. 2005;60(3):183-90.
10. Arch Womens Ment Health. 2016;19(1):87-94.
11. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1335-45.
12. J Reprod Med. 1999;44(4):351-8.
13. J Behav Health Serv Res. 2004;31(2):117-33.
14. J Clin Psychiatry. 2016;77(9):1189-200.
15. Am J Obstet Gynecol. 2000;182(5):1080-2.
16. J Fam Pract. 2001;50(2):117-22.
17. Obstet Gynecol. 1999;93(5 Pt 1):653-7.
18. J Womens Health (Larchmt). 2010;19(3):477-90.
19. Obstet Gynecol. 2018;132:e208-12.
20. “Physicians back programs to address maternal mortality, depression,” AMA, Nov. 15, 2017
21. Pediatrics. 2019 Jan 1;143(1):e20183260.
22. JAMA. 2016;315(4):380-7.
23. Br J Psychiatry. 1987;150:782-6.
24. Ann Fam Med. 2009;7(1):63-70.
25. Obstet Gynecol. 2016;127(5):917-25.
26. Pediatrics. 2017 Oct;140(4). pii: e20170110.
27. Womens Health Issues. 2015;25(6):703-10.
28. J Psychosom Obstet Gynaecol. 2011;32(1):27-34.
29. Matern Child Health J. 2016;20(Suppl 1):22-7.
30. National Committee for Quality Assurance. Prenatal and Postpartum Care (PPC). 2018.
31. Psychiatr Serv. 2015;66(3):324-8.
32. Postpartum Support International. Legislation. 2018.
33. American Academy of Pediatrics, American College of Obstetricians and Gynecologists, eds. Guidelines for Perinatal Care. 7th ed. (Elk Grove Village, IL: Washington, DC: American Academy of Pediatrics; American College of Obstetricians and Gynecologists; Oct 2012.)
34. Birth. 2009;36(1):60-9.
35. Gen Hosp Psychiatry. 2009;31(2):155-62.
