Hello, everyone, and welcome. My name is Diana Clark, and I'm the Managing Director of Research and Senior Epidemiologist and Research Statistician here at the APA. I'm pleased that you're joining us for today's Striving for Excellence series, Black Perinatal Mental Health, Current Evidence, Gaps, and Road to Equity. Next slide, please. On this slide, you will find the funding and disclaimer statement. Next slide. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians. Captioning for participating in today's webinar will be available for 60 days. Next slide. Okay. Okay. The PDF of the slides will be available in the chat tab designated here. Next slide. Okay. So captioning for today's presentation is available. To enable the captions, click Show Captions indicated here at the bottom of the screen. Click the arrow and select View for full transcript to open the caption in the side window. Next slide, please. Please feel free to submit your questions throughout the presentation by typing them in the question in the Q&A area indicated here. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide, please. So we have a very exciting talk today, and I really want to introduce our speaker, Dr. Crystal Clark. Dr. Clark is an Associate Professor in the Department of Psychiatry at the University of Toronto. Hey, hey. I'm an alum. She's also a scientist at the Women's College Research Institute and serves as the Associate Head of Research at Women's College Hospital. As an adult psychiatrist, Dr. Clark specializes in mood and anxiety disorders and is internationally recognized for her expertise in the treatment of women's mental health across the reproductive lifespan. Dr. Clark's research aims to develop identification and prevention strategies to optimize perinatal mental health care for populations who are marginalized and or have severe mental illness. Her novel research in psychopharmacology aims to establish personalized dosing algorithms that account for metabolic and genetic differences for pregnant and postpartum persons with bipolar disorder. In her efforts to increase equity in perinatal mental health care, she's committed to studies aimed at characterizing, developing, and increasing prevention and intervention strategies that address perinatal mental health in Blacks. Dr. Clark is a past president of the Marseilles of North America and serves on the Board of Directors of Marseilles International. Dr. Clark received her Bachelor of Arts in Psychology from Northwestern University and her Master's of Science and Medical Doctorate from the University of Louisville, Kentucky in 2006. She completed her adult psychiatry training and served as Chief Resident at Johns Hopkins in Baltimore, Maryland in 2010. And I also did my postdoc at Hopkins, so we've kind of followed that path. Prior to her completing her Master's of Science in Clinical Investigative Sciences in 2012, Dr. Clark completed her fellowship training in clinical research and reproductive psychiatry. During her tenure at Northwestern Feinberg School of Medicine, she served as the Associate Training Director and Co-Founder of the Women's and Perinatal Psychiatry Fellowship. Dr. Clark, welcome. I'm excited to hear your presentation on this important topic. Right. Thank you so much for having me, Dr. Clark, and I'm looking forward to talking about perinatal mental health and Black birthing people today and where we need to, what we know, what we don't know, and where I'm hoping we will go in the future to achieve equitable care. So again, my disclosures. And I just want to kind of level set today and give us some key terms of what, you know, for those of who are not perinatal psychiatrists or don't live in this space like I do. Perinatal means any time during pregnancy and the first year postpartum, that's how it will be referred to today. Antenatal is referring to during pregnancy and prior to childbirth. Fourth trimester is the time between birth and 12 weeks postpartum. For some people, that definition is birth to six weeks postpartum. And postpartum is the period after delivery up into 12 months postbirth. That's really how we think of it in perinatal psychiatry. So it's not just that people can have postpartum depression just in the first few months. It can be any time within that first year postbirth. And I also want to just highlight that my language today in terms of being gender inclusive, I'll be saying birthing people, but I'll also be referring to women specifically. And the reason I'll be referring to women specifically is because unfortunately, so many of the studies have only been done in people who identified as women or it was assumed that they identified as women. So much of the reports, the research is framed that way. And that's yet another gap that we are desperately in need of closing in this particular area of study. So with that said, the objectives today are really to describe the prevalence of mental illness among Black birthing people and as it relates to the disparities in our society, particularly in the U.S., describe the evidence of characteristic differences in symptom presentation and identification of illness through screening, explain known risk factors and how the impact of structural and social determinants of health may influence the experience of perinatal mental illness, and then understanding perinatal mental illness as it relates to obstetrical and neonatal outcomes, as well as how we might think to optimize care for a mother and infant pair in the future. So with that said, perinatal mental illness is an area in which I got very interested in when I was in training at Johns Hopkins. And it was actually began before I even became a resident in psychiatry, in which I was grappling in medical school with how to bridge the gap that I saw then. I would be on my OB rotations and appreciating the mental health concerns that the patients were bringing into the room and feeling that I would be on my psychiatry rotations and appreciating how pregnancy and postpartum was complicating the mental health picture that I was observing and evaluating. And so I ultimately decided to pursue psychiatry and bridge the gap as a psychiatrist in this field, trying to optimize wellness and birthing people. So we know that perinatal mental illness is a major public health issue, particularly in the United States, but definitely globally. This is something I'm always speaking to my international colleagues about. And it is one of the most complications, most common complications of pregnancy. It increases the risk of poor pregnancy, neonatal and infant outcomes. So when we're thinking about preeclampsia that impacts so many black birthing people or preterm birth or having low birth weight babies, these are the complications that we know have been linked to the to the internal things going on, such as inflammation, cytokine formation and things like that that are internally impacting the pregnancy. And we know that the the interactions of a person who is depressed or anxious or has mental illness with their child postpartum increases disruptions in infant cognition, emotional and social development. So it's not without risk, which is why perinatal mental illness is such an important topic, because it's so often it's like, oh, well, especially I see this in the black community. Well, if I just if I just hold on, if I just get through it, if I just, you know, can can fight my way through. But there is actually repercussions, consequences, poor outcomes for not getting the help that we need during this very vulnerable time of the perinatal period. So the problems of perinatal mental illness, it affects broadly one in five birthing people in developed countries, so throughout the world. In the U.S. specifically, we know that depression occurs in about 18.4 percent of those who are pregnant. And what we're thinking about postpartum up to three months postpartum numbers are as high as 19 to 20 percent. We know that 14.5 percent of people will have a new episode in pregnancy or postpartum. So we're thinking one in seven about we'll have a new onset episode. These are people who may have never had any symptoms or or episodes before. Anxiety occurs in about one in five people during pregnancy, at least one anxiety disorder, and five percent will present with two anxiety disorders. Postpartum psychosis, thankfully very rare, but occurs in one to two of every thousand deliveries. And then one out of every hundred people will have will complete suicide, the highest incidence being between nine and 12 months postpartum. A bipolar disorder is a very important, it is very important to consider during this period, period as well, mainly because of the high risk of having a recurrence of an episode during pregnancy or postpartum for this patient population. But it's an area that we don't know enough about, to be honest, in terms of just how often is it newly onset in pregnancy or newly triggered in pregnancy for those who are treated. We continue to need more data about this. But we know that bipolar disorder in general affects four million women in the U.S., 2.6 women or those of childbearing age. And we know that the exact prevalence is not quite known, but about 20 percent of positive depression screens are actually people who have bipolar disorder. And our best data that's available, 60 to 71 percent will have a recurrence. Those who already have bipolar disorder have been diagnosed prior to pregnancy. They will have a recurrence during pregnancy, with the most common episode being depression. And we know that, in fact, they are actually at much more increased risk postpartum as well, about 50 percent increased risk for having a postpartum episode. And again, that episode being depression. So with all of the prevalence, with this high risk of having an episode of depression, anxiety, bipolar disorder, there has been a lot of movement and initiatives to increase screening and identification during this period so that there can be interventions and treatment. So the American Psychiatric Association in 2018 came out with a position statement stating that all perinatal patients should be evaluated for depressive anxiety and psychotic disorders throughout the perinatal period. The American College of Obstetricians and Gynecologists and Human and Health Services came out with their most recent update just a few months ago, which is stating that patients must be screened at the initial visit, later in pregnancy and postpartum, ideally at well-child visits. And this is an initiative that ACOG is nationally implementing in OB offices and gynecology offices, screening for bipolar disorder before initiating treatment and assessing for social drivers or social determinants of health. And then the United States Pregnancy Service Task Force has also been very much focused on increasing depression screening for adults, including pregnant and postpartum adults. So what does this mean for the Black perinatal patients with mental illness? How does this illness impact Black perinatal people? But also, what is the characteristics? What's the prevalence? What do we understand about it? So we know that depressive symptoms in Black perinatal people are that definitely they're experienced. The range is quite broad in the research, unfortunately. So the estimates are a little confusing. It's like, do we experience it more than others? What drives the likelihood of that, of experiencing depressive symptoms? Now, what do we understand? But in the literature, 11.4 to 56.6 percent of Black perinatal people mostly study in low income and urban samples will experience an increased amount of depressive symptoms in the postpartum period. Now, these estimates vary so much that some studies, when they control for social economic status, there is no difference, whereas other studies have suggested that the difference is actually double to triple that of White perinatal people. So we're a little torn as to, OK, what is the exact prevalence and what's the and how often is this experienced, particularly in the U.S.? So I'm going to highlight here some studies just to help appreciate the range here and what's so different and how different assessments are used to assess for depressive symptoms. So one study of low income women, well over a thousand who participated, who were 16 years of age, seeking care in North Carolina, 49 percent of the Black women in this study endorsed elevated depressive symptoms. And they used the Center for Epidemiologic Studies for Depression Scale. So anyone who had a score over 16 was considered to have a positive screen. And it was 49 percent of Black women who scored a screen positive compared to 33.5 percent of White women. So just in this study, you can see that these averages are actually higher than what we have determined to be the prevalence of postpartum depression, for example. And another study, 30 percent of low income Black women, around 95 women with a singleton pregnancy in a clinic in Chicago, endorsed elevated symptoms in the second trimester without a particular scale being used. An ongoing study by the CDC, the Pregnancy Risk Assessment Monitoring System, which is being adopted increasingly by more and more states, they look at self-reported depressive symptoms and found that it declined in Black women from 21.5 percent across 17 states in 2004 to 10.8 percent across 27 states in 2012. And then you have a chart review in the South Bronx that looked at Black women and found that 22.8 percent of African-Americans and 23.8 percent of Black immigrants endorsed depressive symptoms that resulted in a positive EPDS screen of greater than nine. EPDS screen score greater than nine was considered positive, that is. And finally, in a study of English-speaking women who gave birth in Iowa's maternity hospitals between 2001, 2002, 25, about 25 percent of these patients endorsed depressive symptoms on a questionnaire called Barriers, compared to 15, about 15.5 percent in white women and 15.3 percent in Hispanic women, so almost double. With that said, you can kind of see just kind of the range in terms of what types of screens are used, what the cutoff scores for like, for instance, the PDS score is commonly cut off at 10, different populations, often low income. And this doesn't really get at the gamut of how these these studies differ and how hard it is to, you know, maybe do a meta analysis and compare the results or put the results together to come up with one estimate. And studies with positive screens are followed by clinician administered diagnostic assessments, which is really what we need to better understand, like, okay, well, but what's the rate of the disorder, not just depressive symptoms. The rate of postpartum depression amongst those who were diagnosed with the diagnostic assessment ranges from 24.2% to 56%. So, higher again than the max of 20% that's seen globally at the low at the lowest end, but double to almost triple if we're thinking about the higher end of that range. These studies included SCIDS, MINI, or CIDI assessments, which are all, you know, structured clinician administered diagnostic assessments. And some studies only included positive screens on EPDS of greater than 10 or 11. And so there's a range of where the cutoff is. The interview timing may have ranged between early postpartum, during pregnancy, or three to six months postpartum. So, again, some differences that may add to this, this wide range that we see in the literature. And although findings from several studies suggest that, overall, black perinatal people have higher rates of perinatal depression and anxiety, we need more data that is not confounded in terms of low socioeconomic status and other risk factors. It needs to be more assessments for social determinants of health. We need larger sample sizes. And the use of different self-reports and lack of diagnostic assessment makes it also challenging to aggregate the data and come up with a more consistent estimate. With that said, there has been some more recent work coming out of North Carolina looking at the Kaiser Permanente database. And this population-based data on racial and ethnic differences I'm showing you here has…what's been great about it is that not only were they able to look at their large database of insured patients who are commercially and publicly insured, although they did not tease out who had which, but everyone has access to the clinics under the Kaiser Permanente insurance to all their clinics. And so that helps to at least level the playing field a little bit. And they looked at this patient population where they have mandated screening across pregnancy and at different time points postpartum, as well as the electronic records, like where they actually diagnosed with depression. And so what you see here is that compared to other populations, such as Hispanic, white, Asian, or other, Black birthing people experienced depression more commonly than their other counterpart, other racial counterparts. So, you can see the blue representing pre-pregnancy experience of major depression, the green representing pregnancy experience of major depression, and this somewhat teal turquoise bar representing postpartum experience of major depression. Similarly, we see with anxiety that there is high rates of occurrence with anxiety among Black birthing people, but not that different, actually, from their white counterparts, but greater than that experienced or reported by Hispanic, Asian, and other, those who identify as other. There was an interesting note in this study about the willingness to report also. So, you know, when we think about the numbers as well and these estimates, you know, how often are people underwriting their scores because of stigma, because of fear of consequences toward their children or something like that. And they notably mentioned this as related to the Asian population in these studies, who we know in other reports, for example, have had much higher rates of mental illness experience. So, we know that that also happens in the Black community, and it's not clear how often the symptoms are underreported, and might we actually not be seeing the actual prevalence, even in studies that try to account for this in more structured, systematic ways. Finally, what has been consistent in the literature, not just in this study, but in other studies, is that when Black birthing people do experience depression or anxiety during pregnancy or postpartum, they tend to have more severe symptoms. And like I said, this has been a consistent finding amongst many studies, whether the rates are equal or not, that the symptoms, the symptom severity reported is greater than that of their Hispanic, White, Asian, or other racial counterparts. So, a recent study reported that between 2008 and 2018, rates of antenatal depression among Black perinatal people with commercial insurance in the U.S. has had the greatest rise in rates of antenatal depression and suicidal ideation, increasing by 66% and 700% respectively. This just came out this year, and I personally found that quite alarming. And, of course, there's not clear understanding as to why. You know, is that, are we capturing it more? Are, you know, is this any relation to the pandemic and some of the things we saw happen socially? But the rates have definitely gone up, which is definitely alarming and becoming, and highlighting this public health issue. So, suicide rates in Black perinatal people. We know that death by suicide the year after birth tripled in 2020 compared to 2017 to 2019, according to United Kingdom Confidential Inquiry into Maternal Deaths. They have a great surveillance system. And what they noticed in their surveillance of this is that the greatest increase was among those of low socioeconomic status and those of younger age. And we see this in our U.S. population as well, although not captured as well as their data in the U.K. Younger age, meaning in some studies less than 25 or less than 22, seem to have a greater risk of mental illness in the perinatal period. Mental illness, interpersonal violence, and substance use were also associated with increased rates in this particular analysis. According to the CDC, in the U.S., approximately 23 percent of pregnancy-related deaths among non-Hispanic Black women have been related to mental health disorder, making mental health-related death a leading preventable cause in this population. Finally, the National Survey on Drug Use and Health found that racial ethnic groups of women in the third trimester were less likely to be suicidal relative to non-Hispanic, to Black non-Hispanic women. So basically every other racial group is more likely not to report suicide compared to Black non-Hispanic women, which given, as we know culturally, the potential not to report, I find that statistic alarming as well. So regardless of whether or not we know the exact estimate, we know that there are many risk factors that make it more likely that Black birthing people will be disproportionately impacted by perinatal mental illnesses. And some of these risk factors that have been more broadly determined, and we still need more data to appreciate which ones are drivers for the Black community in particular, but we know that the Black community disproportionately has less social support. More perceived stress is more likely to be racially discriminated day-to-day and the weathering of that discrimination and racism, but also discriminated when they're trying to seek care for perinatal, for obstetrical care or perinatal mental health. More likely to have more physical symptoms, which increase the risk for perinatal mental illness, dealing with infant colic, having less access to health care, less self-efficacy, feeling like they don't have control of what's going on with them or control of their circumstances. Less access to education, so not attaining as much education, and that being a risk factor. History of sexual and physical trauma, which has been directly associated with the risk for perinatal mental illness, and history of mental illness prior to pregnancy that often has gone undiagnosed or untreated and increases the risk for worsening or recurrence during pregnancy or postpartum. Again, I highlight that trauma, including sexual and physical abuse, is disproportionately occurring in the Black community, and this is highly associated with the increased risk of perinatal mental illness. We see that association in other populations as well, but because of the disproportionate degree of trauma, not just sexual and physical for that matter, we know that people are experiencing trauma in their neighborhoods. Trauma from seeing George Floyd's video, I mean, so many ways in which trauma occurs on a day-to-day basis that has not been well characterized but is impacting the perinatal experience. Black perinatal people are disproportionately exposed to trauma, as I mentioned, in the living environment, so living in a violent neighborhood, for example, or a heavily policed neighborhood. And then the lack of screening and treatment for trauma, sorry, my screen just kept going there, lack of screening and treatment for trauma is likely to result in exacerbation in the perinatal period, so it's a lot of people who experience trauma, may not even recognize that they have been traumatized, or even if they do know, they don't know where to seek help, how to seek help, or may not have access to help, and that can become a more significant issue in the perinatal period. When we think about risk factors, though, we also have to consider the social determinants of health that thankfully is becoming more and more talked about and considered in research and in medical care today, but we've got a long way to go. We know that social determinants of health are non-medical factors, including those conditions in which people are born, live, learn, work, and age. And when they're suboptimal, you know, such as living in a neighborhood where it's a food desert or there is no major health facility, we know that that can be a significant driver of inequitable health outcomes. We know that social determinants of health are directly linked to current and historical systemic structures, such as there being neighborhoods, again, that are food deserts or lacking in quality schools or red lines so that they're segregated, which comes with all of the things I just mentioned, less healthy, nutritious food options, there being more fast food, more liquor stores, all of those things can be impactful towards health. And we know that these structural systems are rooted in anti-Black racism, which results in less opportunities, resources, and power among Black people, power to change these structures and to change these outcomes. As such, social determinants of health may influence perinatal mental health outcomes and must be accounted for in our research so that we can better understand how to develop preventative and intervention strategies and also advocate and change policy. So, I highlight this structure and the white areas here you're seeing kind of definitely not a comprehensive list of the structural determinants of health that have been rooted in racism, but just highlighting a few slavery, segregation, redlining. And here you're seeing anti-Black racism and sexism. These two particular things can function as both social determinants of health and structural determinants of health. And then in the middle here, you're seeing kind of the trickle-down effect. So, slavery and segregation and other factors have led to these social determinants such as income, living environment, health care access, education, and all of that impacts Black perinatal mental health. That then impacts obstetrical and neonatal outcomes. And there might be some bi-direction here too, because poor outcomes can then further impact mental health. And we really need to study both sides of this equation. I meant to say social segregation here, which is also a major factor in structural racism. So, poor birth outcomes. We know, again, that perinatal mental illness increases the risk for preeclampsia and low birth weight and preterm birth and other postpartum hemorrhage. There are many, many adverse outcomes associated. But in particular, psychiatric disorders can increase perinatal mortality and death of the fetus and death of the neonate. And the most common causes of perinatal mortality are preterm birth and low birth weight, which is interesting because that is disproportionately the poor outcomes that Black working people face. So, the perinatal mortality, including preterm birth and low birth weight, is believed to result from the disruption of normal physiologic processes, including placental function, as well as increases in cortisol and inflammatory cytokines. So, again, there are some actual biological basis for what we're seeing, particularly as it relates to mental health and that biological impact on the birthing person. Black perinatal people in the U.S. compared to White perinatal people are more likely to have a pregnancy that results in infant mortality. They're 2.35 times more likely, approximately three times more likely, to have a pregnancy-related death. And they're more likely, about double, twice as likely to give birth to a child that is low birth weight and almost twice as likely to give birth to a child that is preterm, this being compared to White counterparts. So, how do we identify those who are experiencing a perinatal mental illness, depression in particular? So, the peer health or the patient health questionnaire, some people call it peer health questionnaire nine, has looked at racial and ethnic differences. In a study in 2005, they looked at how the assessment compared across the racial backgrounds, specifically African American, Latino, non-Hispanic White, and Chinese American. They found that the performance was similar across all backgrounds. And this is a depression questionnaire, a depression screen that has been well validated in the perinatal population as well. So, I highlighted it because, as you'll see, we'll talk about the EPDS and others that have not been as well validated or as well studied. This is just one study. We need more. But at least there was a look at how does it compare across races? Does it capture depression like it should? And the Annenberg Postnatal Depression Scale, which is widely used, widely translated in many different languages, actually has not been validated in the Black population. And not many studies have really looked at how well it performs in the Black population and how well it just lets someone know if they have depression, anxiety, or what have you. And unfortunately, that's not good because it's so widely used. And I have patients, for example, that come to me all the time and say, well, you know, I handed them the assessment, and they're like, well, what does question five mean? Or what do you mean by question six? And we'll discuss one of the questions in more detail. But to me, that says, okay, if my patient is asking me, you know, what does this mean? Or, you know, clarify, how often are we not capturing the symptom? Or how often is someone not understanding this particular assessment? And how well does it capture what we want to know about their experience with depressive symptoms? So there was a study that looked at factor structure. And historically, this EPDS was really created to be a unidimensional structured assessment, just looking at depression. There have been some studies that suggest that maybe the EPDS should be used as a two-factor, two-dimensional assessment, really looking at depression and anxiety based on different answers to questions. And then a more recent study looked at three factors. And by looking at three factors, they determined that actually, three factors may be better for those who are from the black community. And it allowed them to look at depression, anxiety, and anhedonia. And anxiety, depression, and anhedonia seem to be reflected in different questions, depending on racial background. So for instance, question number six, things have been getting on top of me. I have so many people ask me questions about this particular question. Like, what does that mean? Does that, what does it mean for something to be on top of me? And it's not just in the black community either. My Hispanic patients, Asian patients are always asking about what does that mean? So item six is intended to address being overwhelmed. And for some populations, it did help identify depression, such as in black perinatal people, whereas it identifies anxiety in non-white Hispanic perinatal people. So this is just an example of how we have to really make sure we understand how questions are translated to the patients, reading them, and whether or not they're getting at what we're hoping that they get at. And if they're not, okay, as we see in Hispanic people, okay, if they answer yes to number six, that might mean anxiety. And we haven't done enough of that in dealing with the black perinatal population. We also know that optimal cutoffs are not the same across all racial backgrounds. So for instance, there have been studies to show that the EPDS screens may be lower than 10 or greater, which is the standard cutoff amongst the black community. They might be seven or eight. There's actually a positive screen for them. And so we need to adjust accordingly when we're screening this patient population. So in a study in 2011, comparing three screening tools for perinatal depression, it was actually found that the CESD, the EPDS, and the BDI2, the depression inventory scale, were equal in a low-income black perinatal population of about 100 women. So, you know, there, again, there's some variation depending on geographical location, it seems, and how the study is designed as to whether or not, you know, the assessments are capturing what we hope they will. But the great thing about this study is that the positive screens were confirmed by diagnostic assessment. Those are, again, a structured clinician diagnostic assessment. So we can feel pretty confident about those results. In terms of experiences, a recent literature review by Beck just this past year found that black perinatal people with mental illness experience the typical mood and anxiety symptoms, including crying, guilt, loneliness, sadness, irritability, and suicidal ideation. And that many prefer as first step to seek help from family, friends, and church. They find that more acceptable. So not as quick to go to a mental health provider, whether that's a social worker, psychologist, a psychiatrist, or even a primary care provider, their OB, their midwife, or their family practitioner. They often don't recognize the symptoms as abnormal, which I can definitely say I experienced in my clinical practice, there's a lot of rationalizing disproportionately amongst my black perinatal patients, although I see this across the board. And there's this idea of, oh, well, this just must be the pregnancy, or I'm just exhausted because I'm pregnant. I'm just sad because I'm pregnant. I'm crying because I'm hormonal. I'm irritable because I'm uncomfortable. And some of those things could be true. It's not totally out of the realm of possibility. But when those symptoms are persistent, ongoing, as I explained to my patients, and there's not even a, you know, sometimes they have stressors, and other times they don't. But either way, it's usually out of proportion to how they would normally respond. I have to remind them that this is something more than their pregnancy experience. We know that the treatments include psychotherapy, whether that's individual or group therapy, pharmacotherapy, including medications such as antidepressants, mood stabilizers, or atypical antipsychotics, and neuromodulation, such as TMS and ECT. And I actually did not put one of the most recent, which I said, give an eye to pharmacotherapy agents, that being our neuroactive steroids that have more recently been brought to the market. But we don't have access to them yet, which is partly why I should have left them off. Treatment acceptability is a huge issue in the black community, where black people are less likely to seek care or initiate treatment, part of that being, you know, due to mistrust, stigma, fears of being, having their children taken away, concerns about medication being addictive or changing their, I've had patients say to me, I don't want to change who I am as a person. And, you know, so we get into this dialogue about, well, is it, I don't want to change who you are as a person either, but I wanted to change who, I wanted to change how you're feeling today. And if that's changing who you are, meaning that you'll feel better, then yeah, that's the goal. So we, there's a lot of education needed to make patients feel comfortable. And that's understandable, considering the historical nature of medical care in the U.S. and how it has impacted the black community. Black perinatal people are more likely to initiate psychotherapy compared to medication treatments, but often want that psychotherapy to be provided by someone who looks like them, who represents them. And that's a challenge in our U.S. community because there are not many who are black that are providing this care. Behavioral focus and educational interventions delivered in the obstetric setting may improve outcomes, though, because we see that patient-centered models where the mental health provider is implanted right in the OB office has been very effective for patients who are worried about stigma, are concerned about what does what this person, this mental health person is saying align with what my OB says, and just a lot of factors there. So combining the two and providing that care kind of in a one-stop shop has been very, very helpful in some models. We know that treatment barriers, though, continue to be structural racism. So having lack of maternity leave or discrimination by clinicians or being underinsured, so not even being able to access the care or pay for the care. Postpartum being such a significant vulnerability or vulnerable time for onset of mental illness, but you only have a month off and must go back to work, these are significant issues that don't allow for a person to not only recover, but not allow them to get the help they need. There's medical mistrust. There's cultural barriers. There's stigma and the need to be the strong black woman. And there's the lack of time and resources. So some people needing to take two modes of transportation, bus and a train or something to get to an appointment, and having to leave work to achieve that is a barrier in itself. And so we're very thankful for telehealth, which has been increased since the pandemic and has become an option to reduce that barrier. But still, many places require that you at least need to get to that first appointment in person, or maybe several appointments before you can have a virtual appointment. So structures where we have, that are more accessible, continue to be needed. Pathways toward equitable care include education and training, integrated care and decision making. So having that collaborative care, whether it's between pediatricians and psychiatry or psychology, mental health providers embedded in primary care clinics, whether it's OB, pediatrics, family medicine. Black community representation is so important. So often we're seeing models that don't include people that look like the patient population they're trying to serve. We see this in the research as well. We see this in publications, black representation from the community as well as amongst professionals is so needed. Investment in community programs, research and outreach, and patient-centered treatment and approaches that are culturally aligned and trauma-informed given the disproportionate levels of trauma, but also appreciating that what this patient population want may not be the evidence that's based on the majority of the society. We have to meet people, meet the community where they are and what is acceptable, feasible, and reasonable to them. And then just increasing our systematic and rigorous research approaches is so important. So that brings me to gaps in future research. I personally, when I look at the literature, when I look at my patients, when I give talks like this, I find myself challenged trying to just even state the prevalence. We have got to better understand the trajectories of mental illness in this patient population, not just looking at one-time snapshots, but how does it develop over time. If there is an increased likelihood of having depressive or anxiety symptoms, or does that become depression or anxiety three months into postpartum or six months into postpartum? We know that the first year postpartum, the entire year is a vulnerable time. So what's the trajectory for Black perinatal people? Rates of mental illness for those with sexual, physical, and other sources of trauma. How is, what is the interplay between trauma and perinatal mental illness, and how can we intervene there and prevent? The prevalence of perinatal bipolar disorder is completely lacking in the literature. Very, very few studies that have looked at this in the Black perinatal population. And the studies that are out there, if there were any Black perinatal people involved, there was not a stratification for us to understand. Addressing the heterogeneity of the Black community, so often the literature speaks of the Black community as a monolith, as if there is a, just, it's homogeneous, and it's not. Black, the Black community is not all low income. It's quite a spectrum. And unfortunately, the literature typically talks about low income urban samples, one social demographic kind of set of characteristics, and there's a lack of accounting for social determinants of health. Needs consistent, rigorous, culturally informed systematic study approaches that we can actually compare and actually use to do larger meta-analyses and not these studies from Medicaid databases, for instance. Studies that include intersectional identities. We know that it's not just being, it's not just race. We're also thinking about sexual orientation and gender identity. And the development of optimal and effective patient-centered protocols. So, really meeting the patient where they're at and providing care that is acceptable to the patient so that we can provide preventative and intervention strategies that are optimal. And of course, policies that increase insurance coverage and perinatal supports, like doulas, for example. I think it'd be awesome to see more community outreach in spaces such as beauty salons, which I believe is being done in New Jersey, and in, you know, other places where Black perinatal people or birthing people come together. With that said, here are the references, and we will end with Q&A. Thank you so much, Dr. Clark. I know we only have a few minutes. So, I just want to remind people that you can actually submit your questions via the Q&A area. But while we're waiting, I have, you know, I was really excited to see that you talked about the doulas and how, you know, having coverage for them and how that might be useful for the Black perinatal persons. And because that's something I, and I just completed a project funded by CDC Foundation that did a needs assessment for perinatal mental and substance use disorders. And it was really quite interesting to hear pregnant persons talk about, and this is across the board, but specifically in the Black population, talk about lack of access and feeling uncomfortable. And, but not only in reaching out and thinking about the doulas, but I think part of it has to do with the history of mistrust. Do you have any suggestions on how to rebuild that trust? Because I think we can do the research that we want to do. We're continuing to get by a sample, right? Because not a lot of Blacks will want to, some of them don't want to participate because they just don't trust it. They don't necessarily show up for care when they have mental health problems, even prior to pregnancy. So, then they have worse and more severe when they show up and they do experience it. You know, it gets exacerbated during pregnancy. How do we go about rebuilding that trust? What would you suggest? I have a couple of suggestions, actually, and this is something I do in my own practice. I encourage my colleagues to do, especially those who are not persons of color, are not Black. And one thing is being, developing a rapport through patient's repeated visits. And what I mean by that is that I think there's still some paternalistic approaches out there by some colleagues. And, you know, we're like, okay, I know what you need to do. This is what you need to do. Done. And when the patient's like, I don't know about that. We're like, well, good luck, you know, it's like, you know, I wish you well. And come back if you change your mind. My approach is more like, okay, I understand that. Let's keep talking about it. Come back in a couple of weeks. We'll keep that conversation. I'll keep monitoring you. Well, you keep, I keep educating you. You keep looking within and deciding and talking with your family or those who you trust and observing your own self to determine whether or not you are seeing what I'm sharing or not. Because it is their body, their experience. But I think so, I think it's so easy to dismiss. Not appreciating that there's a lack of trust that is heavily rooted in history. And it doesn't fit with our paternalistic medical model. We really need to kind of just continue to use that as an opportunity to educate, be patient. And I often find that my patients end up saying, you know what, I see what you're saying. I need help. And many of them go on to have treatment, whether that's therapy or medication. And they do well. Not everybody is 100% full safe. Yeah, yeah. But many do. Thanks for watching!

perinatal mental health

black birthing people

mental illness prevalence

disparities in society

symptom presentation

identification of illness

risk factors

structural determinants of health

social determinants of health