So, good evening, and welcome to the American Psychiatric Association's Looking Beyond webinar series. Thank you all for joining us this evening. As we launch our summer lineup, which will actually be focused on maternal mental health for the next few months, so hopefully you will tune in for the next series of webinars. My name is Dr. Regina James, and I'm the Deputy Medical Director and Chief for the Division of Diversity and Health Equity here at the APA. I'd like to open our webinar series with the land acknowledgement. I'd like to humbly acknowledge the land on which my home sits, the homeland of its first people, the Piscataway and the Susquehannock Indian Nations. We pay respect to their elders, past and present, and acknowledge that it is our collective responsibility to support and pursue policies and practices that respect this land and its first peoples. Thank you. So, now let's get started with the webinar. First, I always like to give thank you to the American Psychiatric Association as an organization. So, starting off with our CEO and Medical Director, Dr. Saul Levin, our APA President, Dr. Petrus Levinas, the APA Board of Trustees, councils, committees, caucuses, and administration, all of them for their contributions and continuous support for work that advances mental health equity. And I'd especially like to thank Ms. Madonna Delfish, who is the Senior Program Manager in the Division of Diversity and Health Equity, who helped organize this webinar session. Next, let me introduce our esteemed moderator, Dr. Lina Mattel. Dr. Mattel is board certified in psychiatry, psychosomatic medicine, and addiction medicine. She is the Associate Vice Chair for Diversity, Equity, and Inclusion, and Chief of the Division of Women's Mental Health in the Department of Psychiatry at Brigham and Women's Hospital. She serves as Program Director for the Women's Mental Health Fellowship. She co-chairs the Justice, Equity, Diversion, and Inclusion Committee in the Department of Psychiatry. She's Medical Director for Equity, Substance Use Disorder, and Community Partnerships for the Massachusetts Child Psychiatry Access Programs for Moms, which is a consultation service for providers seeing pregnant and postpartum women with mental health and substance use conditions. I'd like to pass the mic now to Dr. Mattel. Thank you so much for joining us. Thank you, Dr. James, for the introduction and for the invitation to be here. I'm just going to start sharing my slides. My hope today is just to give a brief overview of the topic that we're here to discuss together as a panel. I, as Dr. James said, I'm a perinatal psychiatrist. I have been doing this work from the perspective of the intersection of psychiatry and medical and obstetric health for quite some time. Today, I want to just tell you a little bit about the impact of perinatal mental health conditions just to ground us a little bit in why we do what we do, do a little bit of introduction to what we are talking about when we're talking about screening for perinatal emotional concerns, and then open it up to my colleagues here on the panel who we plan to have a lively discussion and think a little bit about what the impact and the implementation of these screening tools and approaches can be. I think that it will come as no surprise to any of us who treat patients or people who have been perinatal at any point in their lives that mental health concerns during the perinatal period impact broadly the perinatal individual, the child, the family that are involved. Individuals with perinatal mental health concerns have more challenges in engaging in their medical care. They have higher likelihood of smoking or exposing the pregnancy and themselves to substance use. They are at higher risk for preeclampsia, preterm delivery, lower birth weight, NICU admissions, obstetrical complications, essentially. As the pregnancy advances into the postpartum period, lactation challenges, bonding issues, adverse partner relationships, and IPV, maternal suicide most catastrophically are all potential outcomes of maternal mental health challenges. Then for the child, cognitive delays, motor and growth problems, behavioral problems, and mental health diagnoses of their own. This is not a benign exposure. This is why we want to think carefully about what we can do to impact and intervene as early as possible. Also, just to scope, perinatal depression is the most common complication of pregnancy. One in seven in the general population will be impacted by perinatal depression, but this number increases with increased psychosocial concerns, increased risk factors, increased stressors. This is really an underestimate. This is really for the general population. As we've more recently started to learn more about the narrative and the story around maternal mortality in our country, which is in fact abysmal, mental health conditions are rising to the top of leading causes of pregnancy-related deaths. Part of the reason this is a new story is because we are only now starting to really look at mental health conditions as contributors to maternal mortality. This is a relatively new area of study in the past decade. The other piece that's really important to acknowledge here is that people of color are more likely to experience perinatal emotional complications like postpartum depression and less likely to receive adequate care. This is just one piece of data that illustrates this. In one study, 44% of African-American women and 48% of Hispanic women showed symptoms of perinatal emotional concerns as compared to 31% of white women. Additional data demonstrates that of those who screen positive with screening evaluations and during the course of their perinatal care for emotional concerns, there are disproportionately fewer women of color referred to care and even fewer than that who ultimately engage in care. There's really significant health inequities here that we can talk more about as our discussion evolves. The other piece about perinatal mental health that I think is really important and one of the things that drives me at the edge of collaborative care is that the perinatal period is really an optimal time for the detection, engagement, and treatment around mental health and substance use concerns. We know in general health care, primary care providers are largely treating depression, much more in fact than psychiatric providers, 80% of depression is treated by primary care providers. The perinatal period itself presents regular opportunities to screen and engage individuals in treatment. Especially in this age group of reproductive age, potentially birthing people, we're really seeing at least 10 visits across the course of a pregnancy and postpartum, which can be opportunities each time to discuss mental health concerns, to discuss barriers to engaging in treatment and frontline providers, meaning the obstetricians, the midwives, the folks who are primary care providers, pediatricians who are interfacing with these individuals really have a pivotal role in engaging and providing care. You'll notice I'm talking about perinatal emotional concerns, not just postpartum. We used to really primarily screen for emotional concerns in the postpartum period, though this study by Kathy Wisner and her group nearly a decade ago at this point really demonstrated that of a group of about 10,000 birthing individuals who were screened postpartum at the six-week postpartum point, of those who screened positive, only 40% of them had the initiation of their symptoms occur in the postpartum period. Fully almost two-thirds of them had the beginning of their symptoms either prior to pregnancy or during pregnancy, really highlighting this kind of long period of opportunity to engage in intervention and assessment and treatment. Now there are a number of professional bodies that recommend screening for depression and anxiety during the course of the perinatal period. The CDC, ACOG, the USPSTF, the Council on Patient Safety in Women's Healthcare all recommend screening for perinatal emotional concerns at least once during the perinatal period, but even more frequently than that in some cases. What are we talking about with screening? We're talking about the utilization of validated screening tools that have validity in the context of the perinatal period. The most common tool that we talk about is the Edinburgh Postnatal Depression Scale. While the title is postnatal, it is in fact validated as a screening tool in many populations for use during pregnancy and in the postpartum period. It's been translated into at least 40 languages, it's been validated in a number of populations, it's freely available, and it's only 10 items easily taken as a self-report tool. There's a lot of versatility and utility in using this tool. We tend to prefer it in the perinatal population because as compared to the tools like PHQ-9, it really focuses on cognitions associated with mood and anxiety and less on somatic symptoms and so helps to distinguish some of the challenges of pregnancy itself, which are normative experiences. The GAD-7 is also a validated tool that can be used in perinatal populations for anxiety. The PCPTSD is also another tool that can, in its shorter form, can be used to screen for trauma-related symptoms in the perinatal population. The nice thing about all of these tools is that they can be used not only as a binary tool for screening and detection, but also a scale of severity too. That really helps to direct treatment, treatment interventions, different types of stratification and stepped care. When we're thinking about screening, really, that's just the beginning. Once a screening has taken place and there has to be a response to screening, the next steps are assessing severity and comorbidities, considering all treatment options and support that includes the whole range of pharmacologic and non-pharmacologic treatments, talking with the patient about their preferences and desires around treatment, and then, in particular, ruling out bipolar disorder, which can have really, really important consequences in terms of risk and treatment decisions in the perinatal period, and then considering the risks and benefits of treatment. This is really just the beginning of a conversation around screening. I'm really pleased to be able to introduce my colleagues here on this panel. I would like to introduce Dr. Alexis Wesley, who is a double board certified child and adolescent and adult psychiatrist who specializes in reproductive psychiatry and women's mental health. She completed her child and adolescent psychiatric training at Children's National Hospital and her adult psychiatry training at George Washington University, her medical training at University of Connecticut, and her undergraduate studies at Yale University. After training, Dr. Wesley worked as a perinatal psychiatrist at Children's National Hospital and has since moved to full-time private practice, providing care to women who are struggling with a range of challenges. Our next panelist is Dr. Sarah Kornfield, who is a licensed clinical psychologist, the clinical director of Penn Center for Women's Behavioral Wellness, and leads the Maternal Wellness Initiative. Dr. Kornfield's research focuses on post-traumatic stress disorder during pregnancy, the development of a brief psychotherapeutic treatment that can be delivered in primary care or prenatal settings, and improving access to perinatal mental health care. And our third panelist is Javeena Coleman, who is a licensed clinical social worker and international board certified lactation consultant who has dedicated over a decade of her life to serving women, children, and families in Philadelphia. Javeena received her Bachelor of Science in biobehavioral health from Pennsylvania State University and a master's degree in social work from the University of Pennsylvania. She is now the owner of Life House Lactation and Perinatal Services, where she provides lactation consultation services and psychotherapy with a concentration on perinatal mood and anxiety disorders. In addition, Javeena is the co-founder of the Perinatal Mental Health Alliance for People of Color, providing resources and support to professionals and communities of color who are treating and dealing with complications of perinatal mood disorders. So, please, I'd like to introduce or begin our discussion with a couple of general questions. I'm hoping that all of you can each sort of begin to address this first question. Firthing people may express emotional distress as somatic complaints in some cultures. However, validated screening tools like the Edinburgh Postnatal Depression Scale and the PHQ, for example, do not contain questions that assess the physical presence of psychological distress. How can clinicians work around this shortcoming to ensure accurate screenings and limit missed opportunities to diagnose and treat? So, maybe we can start with Dr. Wesley and then go around. Can you guys hear me okay? Awesome. Great. Thank you so much for having me and thank you for the introduction, Dr. Mattel. So I think, as Dr. Mattel spoke about, for African American women specifically, their higher likelihood of experiencing postpartum depression or anxiety, but less likely to be identified. And so I do think that there are some good tools that we have like the EPDS and the GAD-7 like Dr. Mattel talked about, but we are missing some things. And so my goal is to try to incorporate some of the strategies that we're looking for into the screening. So we know African American women, for instance, have higher likelihood of somatic complaints. Their presentation might present with a little bit more irritability as opposed to saying the word depression or sadness. Some of the language could be different. So a lot of the women that I've worked with might say, like, I don't feel like myself or I'm feeling off. And so those are my top three things that I try to incorporate in screening. Somatic complaints, irritability, and then feeling different from your baseline. A lot of those things can be hard to assess, so it does take time. But even if you ask someone, like, are you feeling different? It might be hard to articulate, but that can be huge in trying to identify more women that might be experiencing depression, because the language that we use might be different for different cultures. Dr. Mattel, you're unmuted. Dr. Kornfield, do you want to respond as well? Sure. Thanks again for having me. It's lovely to be here with you all tonight. I completely agree, Dr. Wesley, with what you pointed out about, like, making sure that we can add questions to some of these screening tools that really get at, I think, the issues that don't come across in these validated measures. And to your points about, you know, what else to assess for, I always think about anger, because I find that that comes up a lot, and I find that a lot of times my patients who live in under-resourced environments, you know, have a lot more interpersonal issues that contribute to depression or that show up in ways that we would consider to be depression, but maybe they don't. And so I tend to ask a lot about relationships and people who support you, especially as it relates to somatic concerns, because I think that a lot of times patients that I see kind of notice that they tend to feel more tired, more achy, more cranky when relationships aren't going well. So I always ask about anger, and I always ask about relationships. One of the things that I've noticed about women who have more somatic complaints, especially in the setting of perinatal or postpartum timing, is that sometimes when they present for care reporting somatic complaints, they're actually told that these things may be related to postpartum depression or anxiety, and then their actual physical health complaints may go unaddressed. So I think this is a really delicate balance that we have to be aware of on both sides. I know that we're all coming to this from the perspective of mental health, right? So we all want to make sure that the mental health is addressed, and so it's probably great, you know, when we get referrals for patients who come in with somatic complaints and they can identify a mental health contributor to that issue. But I think we also want to be really careful to make sure that we're making the right referrals in the other direction to make sure that some of those true physical health complaints can be addressed accurately and adequately. Shabina, do you have thoughts? Yeah, I think I don't have much to add to both what Dr. Wesley and Dr. Kornfeld mentioned. I think really also giving room and space for like this, the qualitative piece of like asking me questions around like how someone responds, like when you're sad or angry or upset, like what, you know, really getting that story for people to, for us also as providers to understand the language, because there are certain terms that folks are going to use in your community, whether they're snapping out, and that's one of the, you know, if someone says I've been snapping out, then that's my cue, right? And so we also have to be mindful of the language that's being used in the community and in different cultures around how they're feeling, because it doesn't always equate to I'm feeling depressed. And so, you know, around that culturally responsive care, it's really important that we get the stories from our, from the patients and the women and families that we're working with to help inform, you know, some of the language. So to pick up on that thread, and we also have some questions from the audience too, but just to pick up on that thread, Javeena, I guess I'm wondering if you can say a little bit more about how patients' culture can define their or inform help-seeking behaviors in general, especially in the context of when a perinatal emotional concern is identified. Are there things that you've, in your practice, kind of incorporated into thinking about culture informing help-seeking behavior? Absolutely. I think that some of the questions that I may ask my clients around, one, tell me your family history and stories around, you know, pregnancy and birth. What does it look like? What are some of the challenges you've witnessed? And sometimes the challenges go unnoticed because many people aren't talking about it. And so that's where I begin the part of, like, educating on what things can look like in the perinatal period. And so just really thinking about, like, how to engage in the conversation to give tips and tools and just be able to help support with language around whether it's somatic symptoms that folks are experiencing and or giving some examples of like when folks are feeling depressed, what could potentially happen? If you're feeling anxious or you're experiencing, you know, postpartum panic, like what could be happening to you and how that can translate, but also making sure that these are conversations that just doesn't stop with the parent or the birthing person, but it really extends out to their community and their family, those closest to them, because they are the ones that are also being able to see and witness the behavior changes. We have a question from the audience, specifically, it's a high risk of morbidity postpartum, but screening is most of the time limited for the one to two months after delivery. What are each of your recommendations about how to engage in detection and screening beyond that one to two months post-delivery? Maybe we can start with Dr. Wesley again. Yeah, so I think that's a great question. You know, there has been a push to define that postpartum period for longer. You know, some people say up to two to three years postpartum, I, you know, that first year for me is what's the most critical. And this will come up a little bit later, but one of the primary things that I feel is most important is to try to meet women where they are. Oftentimes we can't expect people to come to us because if you're struggling, you know, you don't know what to do, you don't know where to go. And so one of the pieces of work that I've done is incorporate my work into pediatrician offices, for instance. And so where are women going to be? And so, you know, if there's a perinatal psychiatrist who's going to be providing education there or a clinician, therapist, anyone who has that background, you know, we can incorporate screening for longer. And so for me, at least a year postpartum is critical and sometimes up to two to three years. How about in your experience, Dr. Kornfield, how are, what are some practices to sort of engage in detection beyond those early postpartum days? Yeah, well, I love the suggestion of being in pediatrician's offices because that is where moms are. Another option that we have developed at my institution is a text message chat bot for support in the postpartum. So this is a way also to, I think, meet moms a little bit closer to where they are. They don't have to even leave their home to send a quick message to, you know, to a chat bot, which is powered by artificial intelligence, but monitored on the backend by clinicians. And so we would get alerts about any concerning content that people are typing into that support chat, but it also gives people 24 seven access to information about what's normal, what's not normal in terms of their mood, in terms of their feelings, and also around, you know, typical new mom baby care, right, which can be a source of a lot of perinatal anxiety as well. So that's something that we have developed that has been going really well and allowed us to then develop relationships with people in a less formal way. And in a way that sometimes because of its anonymity feels a little more comfortable for people to reach out and say, hey, you know what? I think I really need to move this up a little bit. I need to see someone in person, or I need to talk to someone on the phone. And so that's been a way that we've had some success in screening beyond one to two months postpartum. Javeena, do you have thoughts about sort of extending the period of detection and how we can do more beyond those early months postpartum? I think just making sure that everyone that's in contact with the new birthing person within the first year to two years postpartum. So I think like Dr. Wesley mentioned, pediatricians, we're talking about your PCP, making sure that everyone is connecting and asking the question and having the discussion because we know how prevalent it is. And so, you know, the pediatrician, I think, you know, and we definitely are seeing more push and the recommendation is that they're, I think they're screened up to six months postpartum. And so it's really important that we're all having the conversation and then being able to speak with one another about what we're seeing overall. Sort of like integrating across the disciplines. Absolutely. There's another question from the audience, which I think really ties into the fact that we're a really multidisciplinary panel here. There's a question about the role of doulas and especially the role of doulas for black Americans, which the question asker says doulas seem to be the most culturally appropriate resource, but it is not often covered by insurance. Is there more kind of that we can all say about the advantages of using doulas and the work that is necessary to have those services covered? And then I think it would be great if we could also just think a little bit about the disciplines that we're bringing to this work and if there are unique aspects to the work that you do based on your training and backgrounds. So maybe we can start with Dr. Kornfield this time. Sure. So I think this is great to acknowledge the role of doulas because they are such an important advocate for patients in the birthing suite, essentially, and then as well into the postpartum as well. I know in Philadelphia at my institution, I'm at UPenn, we actually have a free community doula service that's available to patients who give birth at our hospital. And that has been an amazing resource and I refer all my patients to connect with them. They can connect with a doula before they give birth to develop an early relationship or if a patient walks in in labor, they can ask for a doula and if there's someone available on call, they will attend their birth. So that is a really nice service. I think it will probably take a lot of work to have that added to insurance panels as a covered service, but I think those of us who do advocacy work certainly can look at it as a preventative measure. And I think that anything that we can do to think about how to prevent later use of services in an emergency way is something that I think insurance companies really like in terms of cost-effectiveness. Of course, it's not my area of expertise, but I don't know if anyone else in this panel does advocacy work or in the audience, but I think it's such an important and necessary avenue to pursue. I can say in Massachusetts, we're certainly seeing currently some pieces of legislation around advocacy for including doula services and payment. So that's certainly true. Jebita, I see that you're unmuted. I'm wondering if you have some thoughts. Yeah, I work very closely with doulas in my work. We're currently working on a corey funded study looking at cardiovascular disease and birth outcomes in black birthing people. And one of the arms of the study is really put, working with the doulas and having doulas support birthing people during the pregnancy up until one year postpartum. I think when we're thinking, and a lot of my work is around educating doulas around perinatal mood disorders. And although they're not diagnosing, they can know what to look for, what signs and symptoms to look out for, and then who to connect with in the community. And so making sure again, that we're all connected and not just to put the onus on doulas too. Like I think doulas are a great resource in the community to be able to first identify because oftentimes they're the first ones in the homes, especially in the early postpartum period and they can provide resources for new birthing people and then make referrals. But it really is again, important that we're all having that conversation. I think sometimes we're very much siloed. And so as much as our doulas are really important to the birthing experience and provide a lot of the resources and support, it's important that one, when we're talking about mental health specifically, that our doulas are educated. And that's one thing that I try to do is make sure that our doulas know pretty the basics. So that, because it is the information can sometimes be misconstrued or you just don't know what you're looking at and looking for. Kimina, I'm curious, cause you're a IBCLC in addition to a social worker. I'm curious about your, how you incorporate those aspects of your training into working with birthing individuals. Yeah, absolutely. So they're not mutually exclusive, right? If you're looking at laxation, you're also looking at mental health. And I think for me, that's one thing that I really like and about the niche of my work is being able to, sometimes it's the chicken or the egg, which one came first? Was it the lactation issue or was it the mental health issue? And so being able to have the conversation and support folks, and sometimes it's the anxiety that shows up. And after you work through some of that, lactation is no longer an issue, but we know that they're not mutually exclusive. And so it's really important that all of our lactation consultants alike, right? Are very much aware of perinatal mood disorders and signs and symptoms. Dr. Wesley, I wonder if you wanna speak a little bit to the question around doulas and also to your role as a psychiatrist. Yeah. Yeah, well, I think that the role of doulas is huge. As a psychiatrist, I think it's all important that we all play a role, especially as we talk about maternal mortality for black women. So a lot of the work that I do is also helping women learn to self-advocate. And I think a doula is huge in supplementing that ability to advocate for women in the hospital, postpartum. And so self-advocacy is important for our physical health and our mental health as well. So I think that we all can have a role in helping women to be able to communicate their needs, just like Dr. Kornfeld, you were saying, sometimes things are dismissed. Sometimes you're experiencing a physical symptom and it's not taken seriously. So learning who you can talk to, where you can go, what advocacy for yourself looks like is huge. So self-advocacy, but also the doulas can take on a big part of that role and that's why they're so important. So we have another question from the audience. I love all of these questions. It's really getting to the meat of the topic. I'm curious what each of you do in terms of talking with folks prior to delivery so they can learn how to recognize symptoms that might require support or distinguish between what is normal and what might require additional attention. Do you wanna take that one, Dr. Wesley, to start and then we'll go back around? Yeah, yeah. I mean, that's huge. Before delivery, I often talk with my patients about things to expect. What's the difference between postpartum blues and postpartum depression? What's the timeframe? What's the severity of symptoms? What to look out for? I think often just having that connection with someone who knows what to look out for is reassuring and it's comforting. So sometimes it's just being connected and I think that's why it's so important to make sure women have access to care because having that conversation, what to look for postpartum, what is the range of normal, what's not, it's hard to tease out, but having a doctor who can watch you closely, a therapist that can watch you closely can make the difference. Dr. Kornfield, do you wanna pipe in? What do you do for folks as they prepare for delivery? Yeah, absolutely. So I think that we're probably all biased as mental health practitioners because we see women that have already identified a need for mental health care. And so I think that they sometimes can be at an advantage because of their connection with us as providers and because of the knowledge of their own mental health or mental illness before they deliver or before they get pregnant even. And so I do a lot of education around what relapse looks like, what recovery looks like, what triggers that they can be aware of, especially when I think you had pointed out before that bipolar disorder can be an especially concerning risk in the perinatal period, right? So women with bipolar disorder, we wanna especially counsel them about the importance of sleep and the importance of regular routines and really sort of watch very carefully to make sure that we don't see big shifts in relapse to depression or mania or psychosis in the postpartum. So our patients are really lucky. I think the challenge is then getting that education to women who aren't already engaged in care. And I think that's where we can be really good partners with obstetricians, gynecologists, and doulas and other providers who see women who are pregnant who may not be seeking out mental health care before they deliver. Yeah, I will say that in our context in Massachusetts and anywhere where there's a perinatal psychiatric access program, we also do a fair amount just to support those providers, multidisciplinary providers, even prior to identifying mental health care issues. I think you're right, like we are in the field. So we're already like seeing people who've been identified. Jameena, what are your thoughts about working with folks prior to delivery and how we can best support their own recognition of symptoms? Yeah, I think it's important for them to understand their baseline ahead of time and their risk factors, right? And then destigmatizing mental health overall in the prenatal period or before pregnancy. And again, building the confidence to want to talk about it, want to talk about the changes that are happening. And I think like Dr. Wesley and Dr. Kornfeld mentioned, really giving people information on signs and symptoms, things to look out for, what the differences are between baby boos and postpartum depression. And then giving folks language because I think it's important as providers to know here in Philly, we hear a lot that folks will say, I have postpartum and not correcting folks. I think that's important. And so recognizing like what folks are saying, like if I say I have post, if a patient says they have postpartum, it's not that moment to like correct the language to say like postpartum is the time after giving birth, but also recognize, so tell me what that looks like. You know, like what are you feeling? What's coming up for you? And so really giving folks some language in the prenatal period as well, or before pregnancy around what signs and symptoms look like. How does postpartum depression differ from postpartum anxiety or postpartum panic, you know? And so, and even speaking to OCD, which we typically don't often talk about and intrusive thoughts. And so building some, you know, just some language around that for folks is what I try to do. Dr. Kornfeld, I feel like this next question from the audience is sort of just for you. I'm wondering, it's really referencing the use of technology and taking into consideration technology evolution and what your thoughts are on the use of AI to do some of the screening and pregnancy education, thinking that screening is less judgmental, 24 seven access, as you mentioned with your study. Curious if you have thoughts about using this kind of technology for screening and education. Yeah, it's a really good question. I will say as a researcher who's invested in this area, I want to believe that it is really terrific and can give us so many options, but also as like a human in our world, I do see the concerns and the risks. And so I try to build that in, you know, in both directions. I think that, you know, making sure that any technology that you're using to do screening is backed up with actual clinical, clinically trained humans behind the scenes is really important. And making sure that you have specific flags in your, we call it like natural language processing, right? So that the program can sort of recognize the content that people are typing into the chat to know when there's a concern that needs a human to actually reach out and connect with this person. So I think that there are a lot of benefits. I think that texting has the benefits of being asynchronous. So you can send a message to someone, they can look at it in the moment, they can look at it two hours later, right? Whether compared to like a phone call or a therapy session that's at a specific time, you might not catch someone, right? But the text messages can be sitting there waiting for them. Also, it has the benefit of that anonymity, right? So you don't have to be like looking someone in the eye as you tell them your deepest, darkest concerns or things that you might feel ashamed or stigmatized about. It can sort of open up people to be a little bit more forthcoming with some of the things that they worry about. So I do think that there are a lot of benefits, but we have to be very careful. Jameena, are you using other modalities than sort of direct interaction? Are you using technology in your practice? So, actually on the study that we're doing, we do use texting and even just with doulas, right? Just being able to, I think there's one thing to have a session and just virtually, like my practice is all virtual, and so just when people don't have the energy to show up, to get on the bus or go to your clinic, for me, that has been really helpful, especially for a lot of my new moms, but for texting, I think our doulas have been even more recently been able to communicate with new birthing people around changes in mood, especially very early on in the postpartum period. And so just having that person, and I think to Dr. Cornfield's point, whether it's AI or person, like a live person, I think just really being able to have someone available has seemed so far to be very useful and helpful for a lot of our new moms. Dr. Wesley, have you been incorporating technology into your practice in any kind of way? Both at my time at Children's and private practice, we have incorporated texting, but it's mostly for coordinating, making sure people remember their appointments, things like that, just because it's easier because people prefer texting. So we incorporate it just for reminders and if there's a question about scheduling, things like that. I mean, it has been really helpful, but not in terms of screening, we've just more appointments. In our program at the Brigham, we have a parent mental health program that's embedded in our neonatal intensive care unit. And so, and even in some of our ambulatory psychiatry practices, we'll send out screens through the patient portal and there's the patient reported outcome measures, they can answer the screens. And so we do use it, but it requires that folks are engaged in the portal that they're comfortable answering on a device. I would say I've had mixed results in terms of getting people to engage. One of the things we've talked a bit about already is the very clear health inequity for individuals of color in the BIPOC community. Do you have thoughts about how we can work on closing that gap in the mental health space? Maybe I'll start with you, Trebina. Yeah, I think de-stigmatizing, one, but then also culturally responsive care and providers. We recognize that when we think about the number of black and brown social workers, therapists, I imagine psychologists, psychiatrists, that oftentimes folks want a provider that looks like them and that may share the same lived experiences. Really making sure that we're diversifying the field is, I think, one way specifically. Yeah, absolutely. Dr. Kirkfield, do you have thoughts about closing the equity gap? Yeah, I think increasing access to care is really the root of it. Certainly providing culturally informed care is a huge piece of that, but where we may lack in having providers who look like our patients, I think we can also just show up where the patients are. To that end, at Penn, where I met Trebina years ago, was when we were working in the same clinic. We had created a co-located embedded psychology, psychiatry clinic within the hospital-based perinatal women's health center that mostly served underserved women and Medicaid recipients. We were able to provide care there to women who might not otherwise have access to care, who mostly tended to be black and brown women. So I think that that's another really important piece of closing that equity gap is just our presence there. I think our goal was that we destigmatized mental health care for black and brown women by being just part of the team. Then we were there to see those patients when they were already coming for their prenatal care. So they didn't have to make an extra trip. They didn't have to go to a different place. We were just there, part of the team. We could see the patients the same day as their regular prenatal appointments. Dr. Wesley, what are your thoughts? Yeah, well, I agree with what's been said. I think the burden is on the professionals. We should be meeting people where they are. We should be diversifying our field. So I really do think that's our responsibility. But on the patient end, I think that there could be more conversation. We could lead more conversations about mental health to try to destigmatize it. I think oftentimes, I have patients where they're like, after we meet and we talk, they're like, that wasn't that bad. The face of what a psychiatrist looks like or what a therapist looks like, there's a lot of stigma. I think historically, it was older white men that were leading the field. Having a base to the name and the field that we're actually in and making it a little bit less scary, a little bit more accessible, I think is helpful on the patient end. But really, the burden's on us as clinicians and physicians. We have another question, which I think all of us probably have different perspectives on, but it's a really important one about the risk of suicide postpartum, and especially in communities of color. The questioner asks, in your practices and clinical experiences, what has been done to address this elevated risk, and also, in general, addressing issues of social determinants of health? Maybe we can start, Dr. Wesley, with you. Yeah. Well, I found that the people that tend to struggle the most are the people that aren't getting support. We've said this, but I really think I'm just going to hone in on the point, is that we really have to reach people. The people that are connected tend to have the most support. We're screening for suicide constantly. We're thinking about what things they might need, especially postpartum. These are all things that we're doing to support women on a day-to-day, but the women that are suffering in silence are the ones that I worry about the most, in terms of suicide. Access is making sure people are connected and not suffering alone. Jabina, what are your thoughts? Yeah. I think I agree with Dr. Wesley. Yeah. Meeting people where they are. As she mentioned, we are seeing the folks who are coming into care, and so what about those who are not? How do we reach that population? How do we reach that community? Oftentimes, sometimes we're only seeing them when they deliver, when they give birth. How do we, at that point as well, create a safe environment that patients are able to trust us to be able to support them through those immediate postpartum times? Building trust is incredibly important, especially when we're thinking about suicide. Dr. Kornfield, what are your thoughts about impacting the risk of postpartum suicide? Well, I think Dr. Wesley's point is such a good one, that these are the patients that we probably aren't seeing, that probably aren't engaged in care. This is where I think that community education can be really important, so that family members, people who do have access to these individuals, who are seeing them potentially on a daily basis, are able to identify the risk factors or identify the symptoms and triggers that their loved one may be suffering from. Sorry, my dog is jangling all of a sudden. This is where I feel like beyond just the perinatal patient themselves, the community education would be really important to make sure that everyone is aware. We're all told, look out for your perinatal people, keep an eye on them, ask them how they're doing. Even if you're not a mental health provider, you could be a friend, a neighbor, a cousin, call them up, check in, how are they doing? Because those are the people that are close to them when they're not engaged in care. Yeah, and I want to point out that a lot of the screening tools that are used do have a safety question, so both the PHQ-9 and the Edinburgh Postnatal Depression Scale ask about safety, but I know when I go talk to OB providers and midwives out in the community, they are just sometimes really hoping nobody answers yes, because what are we going to do if they do? I think just to all of your points, lowering the barriers to being able to ask those questions, to have some capacity building around how do you respond if someone says yes to that scary question? What do you do? What do you think about? How do you stratify risk? All of that's really challenging, but a lot of people just are like, I don't want to ask because I don't want to know the answer, and that's the worst outcome, I think. One of the questions in the audience has come up about where do these issues sit? Increasingly, we're talking about OB-GYNs asking more and engaging more about mental health. What's the future going to look like in terms of who is going to be the primary treaters of mental health concerns? Maybe we can start with Dr. Wesley. Yeah, well, I really do think that it is something that we have to work together to address. When I worked at a children's hospital, I found that people really take co-ownership of patients when it comes to kids. Everyone cares about that well-being of that child, and so everyone takes some ownership in supporting that child. That same thing has not been, well, in my experience, I have not seen that same level of collaboration in adults. I think if we can treat women the way that we would treat a child, and we can all be invested in the care of birthing people, pregnant people, and supporting the family, I think that we'd be in a better place. I really think it has to be co-ownership. What are your thoughts, Shabina? Yeah, I agree. I think the onus shouldn't be on one specific provider. We're all caring for the birthing person at some point in their care, and if we all take ownership, and if we all also break those silos and just barriers of communication and collaboration, then we can all be speaking the same language to make sure that birthing people are heard, and that their signs and symptoms and experiences are validated and taken seriously. Dr. Kornfield, I'm curious your thoughts about this, because you practice in an embedded setting, yes, amongst a sort of elbow-to-elbow with OBGYNs. Yeah. I think both of the other panelists are right, that we are a team, and we need to work together. I think I'm in a unique situation where I'm able to work side-by-side with those providers and clinicians. Our setting allows us to have warm handoffs between providers. They can walk right by our offices and say, hey, I'd like to introduce you to Ms. Smith. She's struggling. Can you talk to her? That, I think, really helps make the patients feel that we're part of the team, that we're on their side, that we are working together. I think we are able to have that medical home model that is promoted in integrated care settings. I think that's a really nice way to share the ownership of these patients and their care. Yeah. In the substance use world, we sometimes talk about no wrong door, so just increasing all the different doors and windows and cracks for people to find help. Jimena, you had another thought. Yeah. One reason why I think that's a great question, because sometimes the onus is on the therapist or the psychologist to be able to answer the question and provide resources and treatment. What I do find, I think you mentioned earlier, is that some providers don't feel equipped to even ask the question or respond to the safety question out of fear. I think that really educating and supporting other providers as well to be able to ask the question and not just punt it. Folks want to feel comfortable in understanding PMADS, understanding the continuum, and then have resources in the community. I think that is the other part that makes it hard, too, as we're thinking about who should be diagnosing, how do you make referrals. Referrals oftentimes are really hard to get someone into care. Really just opening up that dialogue. Any other thoughts around this from anybody? Dr. Wesley, do you have any other thoughts? No. I agree with Jimena what you were saying. Education, collaboration, that's the way that we are going to surround our patients, our birthing people, and try to create success for the parent and for the family. We have a really interesting question, actually, that I would love to hear all of your thoughts on. Is postpartum depression preventable? I imagine that we may have some different thoughts about that. I wonder, what are some strategies to prevention? Dr. Kornfield, do you want to start? Sure. I think I mentioned before that in my role, I'm seeing people who are coming in that already have identified mental health concerns before they get to the postpartum, for the most part. We know that these are the patients that are most likely to be at risk. I think in some ways, postpartum depression can be preventable if you're getting treatment beforehand. If we know what to look out for, we can prevent worsening symptoms in the postpartum period. In terms of totally preventable from the beginning, I think a lot of that depends on someone's potential hormonal sensitivity to the major changes that are experienced in the aftermath of childbirth, with the way that hormones have this precipitous drop afterwards that can put some particular women at an increased vulnerability. I'm not too sure. Maybe other panelists can speak more to the preventability of that particular type of postpartum depression. I do think that some postpartum depression is certainly situational, as we see that some people just don't have the type of emotional or practical instrumental support that is really important for women at this stage, for parents at this stage. Having people to help you take care of the baby, or come into your home and make meals for you, and just hold you up, hold you together during that time. I think there's lots of ways we can think about prevention. It's a great question. I think in some ways, you're referring to that reproductive phenotype, Dr. Kornfield. I wonder if you have thoughts about that, the component that's biologically based versus the component that's circumstantially driven. Yeah. I wouldn't say preventable, but I do know that the women that are connected tend to do better in ways, because even if we are seeing signs, we're catching it so early that we can adjust. From a medication perspective, if I'm seeing someone every couple of weeks, or if I'm watching them very closely in the postpartum period, it's never getting to that severe level, because we're able to intervene, we're able to support. I wouldn't say preventable, but I would say that we have resources, and we have treatment options to help support women such that we can support early on. Shabina, what are your thoughts about the preventability of postpartum depression? Yeah. I think I agree with both Dr. Wesley and Dr. Kornfield. I would say manageable. I think once newbirthing people have support spaces, one group that I have created here in Philly is our BAE group, BAE Breastfeeding Awareness and Empowerment. However, it really focuses not just on breastfeeding, but also on mental health, reproductive justice, and trauma, and trauma-informed care. Really creating spaces for people to be able to show up, to just talk about their experiences collectively. I don't necessarily say preventable, because I think it's manageable when you have resources, when you are connected, whether it's to a provider specifically or to just community care where others are sharing and experiencing very similar changes in mood, and then you can normalize those behaviors. We're reaching the end of our time. I wonder if each of you might have some final words for things that folks, we hope, will take away from this panel. Dr. Kornfield, do you want to start? Sure. I just want to, first of all, thank you all for being here tonight, and thanks for inviting me to be on this panel. I think when we started this conversation, we were talking a lot about screening. I just want to get back to, I think, where we started a little bit, thinking about, obviously, the screening tools are not perfect, and we really just want to think about the individuals that are in front of us. I think my favorite question that I always tell my students to ask is just say to someone, how are you really feeling? What's really going on? I think, honestly, that might just be the best screening question you can ask if you're in the position of meeting one-on-one with individuals. Dr. Wesley, any final thoughts? Any last words for the audience? Yeah. Well, I'll just say, from a psychiatrist perspective, a clinician perspective, the take-home things that I would say in supporting birthing people in their mental health, what we've talked about, physically being in the same spaces, pediatricians, OB-GYNs, helping to educate doulas and people at the front lines. I've worked with pastors and churches, specifically for Black women, to help support that. Thinking about education, things like this, forums like this, panels, talking about mental health to help destigmatize it. Sometimes that even means, for me, bringing family members into the conversation so that I can help educate that way. Then lastly, pre-pregnancy planning. Sometimes we wait until postpartum to react, but if we can start talking to birthing people about mental health before they're pregnant, I think we can help, not prevent, but try to get ahead of it. That's where I'll end it. Thank you guys for having me. Any final thoughts, Jabina, before we hand it over to our organizer? Yeah. I think Dr. Weston and Dr. Brunfield said it. Really, building trust, building relationships, destigmatizing mental health, and continuing to be comfortable as providers, be comfortable with the discussion and the conversation. Really, I think another take-home for me would be to make sure you know your community and you know, be able to use their language when you're speaking to them. I think that's, for me, has been really important in my care as we also talk about screening tools and so being able to diversify that language as well. This has been so much fun. I feel like I could talk to all of you for so much longer, but we do have to hand it over to our wonderful organizers from the APA. I would hand it back to Madonna, who is organizing us. Can you hear me? Yes. Okay. I just wanted to thank you all for joining us this evening and a very special thank you to our esteemed panel. You've shared some extremely invaluable insights on the cultural considerations that we hope our clinicians would keep in mind when they're working with culturally diverse birthing people. Thank you so much to our attendees and to you again for having this conversation with us this evening. Our next Looking Beyond webinar is scheduled for June 15, so those of us who are still on the line, if you are interested in attending, please visit psychiatry.org to register and we look forward to seeing you all at the next webinar. Thank you so much. Have a great evening.

maternal mental health

postpartum depression

webinar recording

perinatal mental health

screening for perinatal emotional concerns

closing the equity gap

role of doulas

technology in screening

early intervention