Psychiatric Associations Looking Beyond Webinar Series. I say good evening for those on the East Coast, but I guess good afternoon for those on the West Coast. So thank you for joining us for our closeout of our Summer Maternal Mental Health Series. My name is Dr. Regina James. I'm the Chief for our Division of Diversity and Health Equity, as well as one of the Deputy Medical Directors here at the American Psychiatric Association. So before we get started this evening, I'd like to acknowledge the land on which my home sits, which is the ancestral land of the Piscataway Indian Nation. We pay respects 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 tonight's webinar, really looking forward to it. It's gonna focus on postpartum psychosis. Are birthing people of color falling through the treatment gap? So postpartum psychosis, as you know, is a mental health emergency, and it affects around two and 1,000 postpartum birthing individuals. And it can present within the several days of giving birth up to six weeks. And because it is a mental health emergency, you can have acute and severe presentation, and unfortunately, increased risk of infanticide and maternal suicide. So tonight, our esteemed guest panel will discuss the early signs and symptoms of postpartum psychosis treatment, factors that place birthing people of color at risk for delayed diagnosis and treatment, barriers to seeking treatment, and strategies to support minoritized birthing persons that have experienced postpartum psychosis. So let's start with our guest panel. I'm gonna start with our moderator. She is Dr. Lindsey Stand-Even. Dr. Stand-Even is an assistant professor of psychiatry at Johns Hopkins and the clinical and education director of the Johns Hopkins Reproductive Mental Health Center. She is the director of resident training in women's mental health, and she's on the educational board of the National Curriculum on Reproductive Psychiatry. That is our moderator. And I'd like to introduce the other two so that Dr. Stand-Even can then just flow into her presentation as well as introducing the others. So next will be Dr. Jennifer O'Quirkoo. Dr. O'Quirkoo is a board certified adult psychiatrist specializing in women's mental health and reproductive psychiatry. Her work focuses on the management of psychiatric conditions during pregnancy and the postpartum period. She has a particular interest in reproductive justice and the intergenerational transmission of trauma. She currently provides reproductive psychiatry services via telepsychiatry in California, Illinois, Maine, and New York through private practice and works with underserved patients as an emergency psychiatrist at the Contra Costa Regional Medical Center in Martinez, California. Outside of her clinical practice, she's a columnist for a stat. Her writing is focused on social justice and exploring issues of race and motherhood and medicine. And finally, we'll have as our guest panelists a very special guest, Ms. Ayanna Laje. She is a lifestyle blogger and freelance writer based in Tampa, Florida. Let's stay safe, Ayanna. She shares content about motherhood, social justice, and everyday life on social platforms and has written extensively about pregnancy loss, awareness, and postpartum health for national publications. And so at this point, I'd like to transfer our virtual mic over to our moderator, Dr. Standeven. Welcome. Thank you very much. We actually wanted to set the stage tonight by having Ayanna start with her presentation. Laje, correct? And so I'm gonna turn it over to you and then we'll continue with some additional presentations and then we'll open up for a discussion. Thank you for being here. Awesome, thanks for having me. As Dr. James said, my name is Ayanna Laje and I experienced postpartum psychosis in August, 2020 right after giving birth to my daughter. I had a prior diagnosis of depression and journalized anxiety disorder. So I was well aware of some postpartum mental health risk but when I was preparing during my pregnancy, I was very much thinking, okay, this could lead to really bad depressive episodes. But I think that I had more resources available to me than the average person maybe. I mean, I was able to line up the help of a postpartum doula. I had a psychiatrist who I really liked and trusted. I had a therapist. I had family who were willing to come and stay and all of us, I think we're kind of just in this mindset of she could develop postpartum depression and we want to be there for her, she does. After I gave birth, I felt great. I had an emergency C-section. A lot of things did not go according to plan but I was not in any pain. I was just, I remember feeling like I was made for this. I was made to be a mother. And I'm saying these things and I think that people are so used to new parents having like all these hormonal jumps that maybe didn't raise any flags at first but I was a little bit all over the place which wasn't normal for me. But in retrospect, the thing that kind of every medical professional that I've been treated by has heard my story has noted is that I felt like I didn't need to sleep within probably after a day or two after giving birth. I just felt like endlessly energetic. When my husband would complain about sleep deprivation I would just be really like annoyed with him like thinking, okay, he's not cut out for this way that I am because I have no need to sleep anymore. Just feeling basically like superwoman. And eventually I say, but this will happen very quickly. So, I mean, let's say five days after giving birth I start to act erratically in a way that my friends start to become concerned and a couple of them actually reach out to my husband to say, hey, she just doesn't seem like herself. They couldn't really place it. And I mean, I remember even one of my friends after the fact saying, I don't know if this is like normal postpartum, this is just her body and mind processing what she just experienced, but something feels off. So he was aware, he alerted my psychiatrist and my doula and my therapist. So I kind of have all of these people on board and they weren't quite sure what was going on, but I think we all kind of thought like, okay we've got a team in place, we've got a plan. Unfortunately, I delved into paranoia a couple of days later and started to believe that the people around me were actually, so this team that I'd assembled it was actually going to hurt me and hurt my baby. And I did not want anyone to be alone with her, but me. And at this point, so this is also during the height of the pandemic. So none of these appointments or conversations other than with my doula who did come over masked are happening in person. So we're doing telehealth with my psychiatrist, telehealth with my therapist. And my psychiatrist did flag for my husband that the paranoia was a warning sign. And that if I started to act as if I did not genuinely basically if it continued, right. Did not trust anyone to be around my baby, but me that I would need to go to the hospital. And so I think my husband was kind of trying to figure that out and try to, just not wanting to take me to the hospital in the middle of the pandemic knowing that I wouldn't be able to see my baby and that there would be trauma involved there but also unsure of how things would progress. And I, the day after that began to hear detailed messages from God about my daughter being the second coming of Jesus that I was needed to rewrite the Bible. I mean, I could go on, but I mean, you get the gist. It was just very alarming and like a stark departure from my normal state. And at that point I started, I don't know how to explain it but I had just an innate sense that something was going very wrong. I knew that my husband and my parents who were there at the time did not want to take me to the hospital. They don't want to traumatize me, but I knew that I needed to go. And in my jumbled mind, I was like the only way that I can get to the hospital right now is if I tell them that I'm going to, you know attempt self-harm if I'm left at home. So I did that and I said, I need to go to the hospital right now. So obviously they rushed me to the hospital. Thankfully not by ambulance, they were able to drive me. When I got to the ER, that was when the hallucinations started. And I like, I'm so grateful even now that that did not happen at home and that it was in a place where I was able to immediately, you know, be given medication to help. But I was in the hospital for 17 days, did not see my husband or my daughter who at that point she was 10 days old when I was admitted. So I did not see them for 17 days. Most of that time was spent with me so delusional that I didn't care that I wasn't seeing them because I was still convinced of all of these delusions. You know, I had very detailed delusions about the hospital and the doctors and nurses trying to poison me to the point that I refused medication which just prolonged the whole process. But they were able to, they were starting to have conversations with my family about like long-term care because they were not sure that I was going to improve. And I think around like 13 or 14 days in, and I'm fuzzy on the timeline, but just from talking to my family that they started, they basically just adjusted my medication in a way that worked. And Haldol is actually the drug that was able to kind of snap me out of it. And the side effects were not ideal, but it brought me back to reality. So I feel like that's pretty much like my experience. And then as I mentioned, I have heard about and written about it just because I knew nothing about postpartum psychosis before any of this happened. I, before experiencing it, I thought this was something really unfortunate that makes people try to hurt or kill their children. I had no context for it. And this is something that you may experience even though you have no warning signs or no one has told you that you're at risk for psychosis. So I'm really glad that my story, although while profoundly difficult, did not end any worse. And I credit that to my family, my psychiatrists, and just having people on my side who advocated for me. My psychiatrist actually told my husband, this is the hospital that you want to take her to, because unfortunately, and I'm sure that's the case in many cities, you can't just roll up to any ER, any psych ER and get the same treatment. So yeah, having that was really helpful. Thank you so much for sharing your story. I want to continue. We really wanted to sort of start with the personal story to give context to what I'm going to talk about next, which is just really sort of a clinical overview of postpartum psychosis and sort of the illness. But having someone feel ready and able to share their experience, having gone through and recovered from the illness is both rare and very challenging for many to really relive, because it is often traumatic. I'm going to share my screen now. And I want to just, so what I'm going to do is, I mean, this could be an hour presentation all by itself, at least, but what I want to do is just sort of give us a brief clinical overview. So we're all sort of speaking the same language and have sort of the same understanding about what postpartum psychosis is and what it is not. So I just want to pause and give some credit. Some of these slides are adopted from my mentor, Dr. Lauren Osborne, and the National Curriculum on Reproductive Psychiatry, which is a free curriculum for the dissemination and training of reproductive psychiatry. And I also want to just say a caveat, which is that for fluency, I'm going to refer to pregnant and birthing individuals sometimes as female women or mothers. It's also based on, unfortunately, what the literature has looked at, but I'm acknowledging that not all individuals identify with this label. So as we heard about, postpartum psychosis is rare. It is a severe perinatal psychiatric illness, perinatal being around birth, but it is really in the postpartum. It is a true psychiatric emergency. So just as Ayanna sort of pointed out, her psychiatrist, the early intervention, I think was so key in your story, that within four to five days, the psychiatrist had contact and was already sort of aware of where this could progress because it is a psychiatric emergency, it does require hospitalization. It has rapid onset and it has three pillars of symptoms. It has affective, meaning mood symptoms, psychotic symptoms and cognitive symptoms. And that's actually what really makes it a bit different from some of the other episodes that can occur outside of the postpartum and in bipolar in general. Postpartum psychosis is a misnomer. It is not a true only psychotic episode. It is an affective disorder. And it is generally typically part of a bipolar spectrum disorder, okay? So this tends to occur in individuals who either fall into one of three categories. They have a known bipolar disorder prior to giving birth, meaning that they've experienced both a depressive, a hypomanic or a manic episode, or it can occur among individuals who have their first episode of what will be a bipolar disorder, which the first episode is a postpartum psychosis. More rarely, this episode can occur as an isolated syndrome that only occurs in the postpartum and does not go on to be bipolar disorder, as in the individual does not have psychiatric symptoms in the future. So as I mentioned before we talked, the incidence is about 0.9 to 2.6 per 1000 births. Most postpartum psychosis cases occur within the first two to four weeks after birth. It's really typically within those first two weeks as we heard, but two to four weeks is about that range. And why is that important? Well, it's critically important because women don't typically see their OBGYNs until six weeks postpartum. So birthing people are on their own sometimes for six weeks. And by then these symptoms again with rapid onset and quick severity can be very severe. I also wanna just point out this graph from a study in 2013. And essentially what it shows again is that individuals who are primiparous are at the highest risk. And overall individuals are 23 times more likely, birthing peoples are 23 times more likely to be psychiatrically hospitalized in the first month postpartum than any other time in their life. So as a psychiatrist, as psychiatric providers, knowing that this is a period of serious elevated risk for whether or not you identify as a reproductive psychiatrist or otherwise, right? If we are involved in mental health, knowing that this is this critical juncture for both postpartum depression, but tonight we're talking about postpartum psychosis is really important. What are the risk factors? I wanna divide it into these two groups that I was talking about. These two patients, there's these two sort of illness trajectories, I would say. There are individuals who have preexisting illness, right? So there are the individuals who have either had a history of depression or hypomania or mania. And sometimes some of the risk factors are that those individuals may have decided to discontinue medication. So for example, if a person is diagnosed with bipolar disorder and they decide to discontinue their medications, their risk of relapse in pregnancy is about 70% and it goes to greater than 80% by the postpartum. So the risk of a postpartum episode is much, much higher, and particularly among an individual with a history of a mood disorder and particularly if they stop medications. Premiparity, so having this be your first birth or your first pregnancy is key. And the reason there is because we don't have any information about whether or not you as an individual are sensitive to the hormonal fluctuations that occur at delivery, right, at partuition. The other thing that's really important is does the individual have a prior personal or family history of perinatal episodes? Every single patient I see, I ask whether or not their mother or their siblings had a history of postpartum depression, psychosis, anxiety, et cetera, because there's actually data suggesting that that increases an individual's risk even more than a personal history of say a mood or anxiety disorder. An unplanned pregnancy, younger age, sleep deprivation. I think one of my largest jobs as a reproductive psychiatrist is to talk about sleep and how it interfaces with all psychiatric symptoms and psychiatric disorders. Then there are the individuals who have no known prior illness, no known prior bipolar disorder, for example. What you want to be looking for that should sort of raise red flags or say, gee, this is somebody I want to be really seeing within those first two weeks is a history of bipolar disorder, a family history of postpartum psychosis, sleep deprivation, and primiparity. I mean, we heard before that one of the first symptoms that the psychiatrist recognized in your story, right, was that you were not sleeping. And whenever I hear about a patient and I hear that somebody is not sleeping, the birthing person is not sleeping when the baby's sleeping, red flags go off immediately because I have to figure it out that point. Are they sleeping because they don't need sleep? They have a decreased need for sleep. And then I'm worried about postpartum psychosis. Or are they not sleeping because they're doing things like checking on the baby? And then I worry about anxiety and obsessive compulsive disorder. So not sleeping or sleep deprivation is a key, key risk factor. Also important for things like emergency C-sections or C-sections or inductions, right? We have individuals who are up laboring for 24 to 48 hours, baby's born, they are rooming in with baby and then they are already at 72 hours with little to no sleep. What are the clinical features of postpartum psychosis? I mean, that was a beautiful description. I wanna just sort of give some other sort of clinical terms. So the earliest symptom is insomnia. And I never ask a birthing person, how are you sleeping, right? That's insensitive because no one's sleeping particularly well in the postpartum. But what I wanna know is, are you sleeping when baby sleeps? And are you able to sleep when baby sleeps? And are you tired if you're not sleeping, right? That was one of those first symptoms. Mood fluctuations, mood lability, right? The mood is up and down and irritability can be some of the earliest symptoms. Delirium like appearance. So one of the things about postpartum psychosis that makes it different from say a manic episode outside of the postpartum window and outside of your typical manic episode is that there is this additional disorientation, confusion, the sense of derealization and depersonalization. So the symptoms can actually wax and wane like a delirium. And so somebody can actually present and actually look more coherent, more together than you're hearing necessarily from the family members. This is why it's key. Anytime you're interviewing a birthing person in the postpartum that you want to get collateral and talk to the family to say, or to anybody who has observed this individual to say, how are they doing? Okay, it is critical. The stakes are high. The individual can have mood incongruent delusions. What does this mean? It's often focused on the newborn. So auditory hallucinations can occur. They're actually less common than say delusions in postpartum psychosis. So the delusions are fixed, false, idiosyncratic beliefs. So the person believes them, they lack insight and they're often focused on the newborn. So it's, you know, the baby is defective or possessed or in danger. So despite the fact that the person has lots of energy and might be feeling very elevated, they can often have these mood incongruent delusions, negative, upsetting delusions about the baby. They tend to be disorganized, right? There's a disorganization of thought, right? So this is the thought disorder that occurs here as well as it does in a typical manic episode. So these are disorganized thinking. I think we heard it referred to as, I was all over the place and that's a perfect description of it, both in thought and in metoric energy. And then the other thing are these delusions, right? Of altruistic homicide. And these are, this is where it gets very dangerous, right? So the delusions can become, you know, they are fixed false beliefs, right? That can be sort of the motivators to infanticide and suicide, right? So things like I need to save the baby from a fate worse than death. The baby's inhabited by a devil or a demon. The baby is somehow controlling my pain or the pain of the world. And so I have to save myself and my infant. And this is why this is a psychiatric emergency. Infanticide is estimated to be at 4%. So this is a rare disorder, but when it occurs, that is very high. So we need to get help and we need to get screening sooner. Mood symptoms are always present, okay? So it's usually a manic episode, but it can also be a depression or sort of a more mixed picture. What's the course or the prognosis? There's one cohort study actually showed that it's quite similar to a typical mood episode. So it's about a month for a manic episode till for recovery and about two and a half months for a mixed or depressive episode. Of those who have an incipient postpartum episode. So for example, if I personally have never had depression or mania or hypomanias and I have a postpartum psychosis episode, it's essentially a placeholder for one of two different directions and two different prognoses. One is that I would go on to have recurrent episodes and this was the first of what will become a bipolar disorder. And that's actually the majority of cases. That's about 50 to 80% of cases of individuals go on to develop another serious psychiatric episode consistent with a bipolar affective spectrum illness. A minority, about 20 to 50% of women have this isolated postpartum episode. And so those individuals, it's important to be able to distinguish it because the risks are actually a bit different. So approximately one third of individuals who have had a postpartum psychosis have an additional episode in subsequent pregnancies. The rate of recurrence among those individuals who really have that isolated postpartum psychosis, they do not have mood symptoms outside of that postpartum window is even higher. There's some estimates up to 80% likelihood of recurrence. So again, that sort of speaks to what we're learning about the biology and how these things might be a little different. What is the acute treatment? Acute inpatient hospitalization is indicated and the hardest, hardest part both for the patient and as a provider separating the birthing person from their child. This is why in places outside of the United States, we have true mother, they have true mother baby units where they are both admitted, they are both monitored and actually a key component of the treatment is the dyadic care is watching as mom recovers how they're able to interact again with baby. First line treatment is lithium. It is the gold standard. It leads to remission the quickest for acute and maintenance treatment. So the recommendation is that individuals stay on lithium if this is their first episode and they've had no other episode for at least a year and then they can be weaned off to see whether or not a recurrent episode occurs or not. And if it does recur again, that's consistent with this being the first of what will be a bipolar spectrum illness. Second generation antipsychotics or antipsychotics are also used. Benzodiazepines help stabilize initially, right? While lithium is coming on in those first sort of 72 hours. And ECT can be a electroconvulsive therapy can be a very effective and fast treatment for an individual who is an acute danger to themselves or others. So what are the key factors that you wanna be thinking about when you're thinking about is this postpartum psychosis timing? If you're seeing an individual and they're having an onset of psychotic features six to eight months postpartum and they haven't had anything prior to that, that's not postpartum psychosis. This occurs within two to four weeks. A personal or a family history of bipolar disorder makes me want, I wanna see all of my patients in the early postpartum, but I wanna see these individuals within two weeks because I'm very concerned about a postpartum psychosis. Cognitive disorientation and delirium like picture. I'm looking for whether or not the symptoms are waxing or waning. If they have a sense of depersonalization and poor attention span. And I'm asking family what they've noticed about the symptoms, the presence of mood symptoms, the presence of psychotic symptoms. I'm always asking whether or not the individual is having delusions, right? So those are the beliefs, they lack insight and those tend to be egocentronic, meaning they believe them. And so it's not upsetting that they're having those thoughts. Very different from obsessions where somebody has thoughts of what if I harm my baby? What if something happens to the baby? What if the baby stops breathing? Very different from the baby will stop breathing because they are inhabited by a demon, right? So it's the difference between belief and insight versus a fear, right? And the difference is sort of that that person's very upset. It's ecodistonic when it's an obsession or anxiety. So insight, looking to whether or not the person has insight, which is exactly what, you know, Jia Xu spoke about her psychiatrist saying if she really believes that and starts telling you that everybody really can't touch the baby, that was what was moving her from Jia Xu worried about something versus she really has these beliefs about the family members. And of course, thoughts or plans to harm oneself or an infant. Anytime you're interviewing a birthing person, you wanna ask about if they took their life, what would their plans be for their baby or their children? Because it tells you whether or not the children and the baby are gonna act as a protective factor or whether or not they are closer to suicide or infanticide because they have plans for themselves and or their children. I'm going to, this was, all this information can be found in this textbook. It's the first ever Women's Reproductive Mental Health textbook published by the APA. I'm gonna stop sharing and I'm gonna turn it over to Dr. Obegbue. Okay, so thank you for the wonderful introduction and thank you for having me. Next slide, please. So for my portion of today's talk, I'm gonna focus kind of on three objectives. First, examining the factors that might place birthing people of color at risk for delayed diagnosis and treatment. Second, to discuss the barriers to seeking emergency mental health care in marginalized populations. And third, is to explore culturally congruent strategies that providers can employ to support minoritized birthing people that have experienced postpartum psychosis. Next slide, please. Okay. So when it comes to thinking about postpartum psychosis or psychiatric illness in general, I find it useful to kind of have a model, a way of conceptualizing or thinking about these illnesses. The diaphysis stress model of illness basically helps me do that. And so I wanted to share that with you today. The term diaphysis is a Greek word, actually means disposition. And so in the diaphysis stress model of mental illness, sometimes biological vulnerabilities come into conversation with stress, a stressor, like a life stressor, and then also protective factors to kind of help us predict if somebody is going to suffer from an illness and how severe that illness may become. So Dr. Stoneman did a great job in helping us to review a lot of these vulnerabilities. So some of these biological vulnerabilities include the risk factors for postpartum psychosis. These are things like having a history of bipolar disorder or a psychotic illness, having a family history of postpartum psychosis, sometimes discontinuing your medications like during pregnancy can be a risk factor, a biological risk factor, or even having a biological sensitivity to hormonal fluctuations. And as you can imagine, pregnancy is one of the biggest times of hormonal change in a birthing person's reproductive life. In terms of the stress, the stressful life event in postpartum psychosis is childbirth. That's generally what is considered like the triggering event that precipitates the illness. And then in terms of protective factors, these are elements that can mitigate the risk of illness occurring, or if we can't prevent the illness from occurring, we try to reduce the severity of that illness episode. Next slide, please. Okay, so thinking about stress. So again, as I mentioned, childbirth is the trigger in postpartum psychosis. It's associated with these hormonal fluctuations. You know, your body no longer needs to maintain these really high levels of reproductive hormones to support a pregnancy. So there's this really precipitous drop in the early postpartum period of those hormones. And some patients are very, very sensitive to that drop. And then also there's the sleep disruption. And there's two elements to sleep disruption, right? There's the labor and delivery element and the elements of newborn care. So as you can imagine, sometimes birthing people labor for several, sometimes it's like a few days, right? And when you're laboring for a few days, you might not be sleeping comfortably or at all. So that kind of starts to snowball that state of sleep deprivation that is then worsened by actually having to care for the newborn. In terms of protective factors, these can be things like, you know, rapid recognition of your symptoms and getting an accurate diagnosis. It can be access to treatment. It can be acceptance of that treatment. Things like sleep protection and family support can be protective. So even if you do have an episode of postpartum psychosis, your course of illness can really be influenced by these protective factors. Next slide, please. Okay. So I want to take a moment to think about stress in marginalized communities. So again, precipitating stress and postpartum psychosis, childbirth is the trigger. We've already kind of discussed this, but when we're thinking about marginalized communities, I want to invite you to take a moment to think about things that might perpetuate stress. So these might be things like experiencing acute stress of racism in the setting of perinatal care, and then also the chronic stress of adverse childhood or community experiences, or what we know as ACEs. Next slide, please. So, you know, as Dr. Stoneman mentioned, any one of these specific topics can be an hour long lecture in and of themselves, so my goal here is just to kind of provide a bird's eye view and just kind of an introduction to a conversation around what some of these major stress points potentially could be. So when I'm thinking about acute on chronic stresses in marginalized communities who have postpartum psychosis, you know, I'm just thinking about the state of maternal healthcare in America, and particularly how that impacts people of color. So here's just a snippet of a couple headlines. This is from like the AMA, this one NPR, PBS, but it's talking about the black maternal health crisis, you know, black maternal mortality crisis and why it remains an issue. These are not new issues, right? These are things that are in the conversation, and these are things that are very front of mind for people of color. I think a study just came out from CDC data, I want to say mid-July, that talked about women, you know, reporting mistreatment during maternity care, and they organize this by race. And you can see here that, you know, black women report the most mistreatment, and women who have no insurance or public insurance also report a lot of mistreatment. And so thinking about the experience of interfacing with the medical system can be a very stressful experience for marginalized communities and populations of color. This has a number of repercussions, right? It may lead to symptoms like error of distrust, right? It might lead people to delay care because they're worried. It might lead people to have traumatizing experiences in these settings, which can exacerbate symptoms. So again, just thinking about the context where care is occurring can be very important. Next slide, please. Now I want to think about chronic stress in marginalized communities. And to conceptualize this, I'd really like to introduce the idea of ACEs or adverse childhood experiences. So this is talked a lot about in like the trauma literature. Initially, the initial studies focus on childhood experiences, but subsequent studies have really broadened it. And I like the term adverse community experiences because it really shows us that trauma or just negative or bad things can happen to you across the life cycle. And those events have the possibility to act synergistically, to negatively impact not only your mental health, but your physical health. And so these are just some examples of negative or adverse community experiences. This can be things like discrimination, witnessing violence, historical trauma, substandard schools, lack of jobs, structural racism, lack of social capital and mobility, poor water and air quality, food scarcity, you know, poverty. These things can exist in someone's life, like across the reproductive life cycle, right? And there are many situations in which screening people for ACEs can be of value. People who tend to have higher ACEs People who tend to have higher ACE scores have, for example, negative cardiovascular outcomes, like the American Heart Association, for example, recommends screening for ACEs. You know, we screen people for ACEs in primary care settings because folks who tend to culminate these experiences over time have more negative or worse outcomes down the line. So when we're thinking about marginalized communities, thinking about what ACEs does this person carry can kind of help you, again, contextualize the situation that that person is coming from. Next slide, please. Okay, so I wanna talk a little bit more about protective factors. So there's no validated or specific screening tool for postpartum psychosis, but there are many professional organizations like ACOG and the American Academy of Pediatrics that are starting to recognize what the burden of postpartum psychiatric illness is, and they want to increase screening to be better able to detect symptoms that may be suggestive of illness sooner. If you think about where people seek care after they have a baby, right? They go to their OB-GYN, two weeks if they're lucky, six weeks as Dr. Standingman had talked about, but then they go to the pediatrician like a bunch of times. That's why the Academy of Pediatrics is weighing in on this and they're thinking about how do we, because health of mom oftentimes impacts health of baby. So how do we impact or how do we improve the health and wellness of infants by making sure that mom is in a good place or mom, the birthing person are in a good place? So these are the most, like ACOG recommends these screenings. There's the EPDS that screens for both anxiety and affective symptoms like mood symptoms, PHQ-9 often a common screener in primary care settings for depression, MDQ that can help screen for again, affective symptoms, the generalized anxiety disorder screening, JAD-7 again for anxiety, and then this PTSD screening. Next slide, please. But unfortunately there are disparities in symptom recognition. So even though more organizations and more healthcare providers are starting to screen and relying on these tools for screening, there are disparities with how these screening tools are applied. So there's this paper from the Archives of Women's Mental Health, I think it was published in 2021, so relatively recent, but it looked at a large healthcare setting and saw that there were disparities in who got screened for postpartum psychiatric illness. So people that were less likely to be screened than white women included African-Americans, Asians, Native Americans, and multiracial individuals. They also noted that women who were insured by Medicaid or Medicare were also less likely to be screened than those who are privately insured. Next slide, please. There's also disparities in symptom recognition. So, as I mentioned, some people fall through the treatment gap because they're not screened at all. And some people do get screened, but even in the people who do get screened, there may be disparities in symptom recognition. So again, the ePDS, that's a very commonly used screening tool. That, a lot of psychiatric screening tools are validated in largely white populations. So like while they're used in the general population, they're not always the perfect way to screen in non-white populations. So here are just like a sampling of studies that start to question how we are applying these gold standard screening tools to more diverse populations. So gold standard screening tools, they may have a suboptimal performance in disadvantaged or minority populations. And that's because these screening tools oftentimes don't take into account the different ways that people from different backgrounds experience or conceptualize mental health in order to communicate that to a treatment provider. Next slide, please. Okay. So in terms of postpartum psychosis, Dr. Staneman talked a lot about treatment, but basically two buckets, right? There's like medication and there's therapy. You know, I always tell people, I tell my patients that psychiatry is the only profession where we have to negotiate with the organ that we're actually trying to treat. And so when you think about the context of medical distrust, right, that might come into the conversation when you're telling someone, here, you need to take this medication because it's going to help you with your mental health. So oftentimes thinking about that issue of distrust and how that might layer into trying to offer medication to a person who suffered with postpartum psychosis. And postpartum psychosis, in terms of medication, right, there's the acute treatment and stabilization, which oftentimes takes place in the, or does take place in the hospital setting. But then there's that long-term kind of like middle maintenance place. And then also there's like prophylaxis, right? If somebody has a history of postpartum depression or they have a history of bipolar disorder, or they have some sort of risk factor that you want to give them prophylactic treatment, there are many entry points to like having a conversation around medication. So holding it in mind that sometimes people are distrustful of medications can be helpful as you try to navigate care in these populations. Also, when people hear things like lithium, Haldol, you know, they think of these as like big time heavy duty medications. And there's a lot of stigma sometimes associated with those medications. So I think it's important to acknowledge, you know, how effective these medications are and the situations in which, you know, they are used. I kind of give patients the analogy that if you couldn't see and you went to the ophthalmologist or the optometrist and you got glasses and we gave you a really weak pair of glasses, it wouldn't fix your eyesight, right? Or if we gave you a pair of glasses that's way too strong, it still wouldn't correct the vision. I look at a medication regimen as the prescription that's just right for you. You know, it's not too, the Goldilocks, right? Not too big, not too small, but just right for you to really stabilize those symptoms and prevent over-medication. Cause that's another common fear that I think a lot of marginalized populations oftentimes experience. You know, if they've been put on psychiatric medications in the past, they may have been over-medicated. And so we're kind of undoing their experience from the past by helping them to understand that we're trying to meet them at this middle ground place. Then also therapy. Therapy, I think is a big part of the treatment of postpartum psychosis. Therapy can include psychoeducation. So psychoeducation in terms of what is postpartum psychosis? What are the signs and symptoms to look for? You know, building, engaging family members or support people to help. Cause as Dr. Stan even mentioned, like there's a lack of insight, right? The ill person doesn't always know that they're ill. So it's important for their ecosystem to be able to detect those signs of illness. Recognizing that sometimes postpartum psychosis or psychotic episodes can be very disruptive. And sometimes these are associated with really profound feelings of shame. Sometimes people use that episode as a proxy for how good of a mother or how good of a parents they are. And there can be a lot of like processing that kind of trauma that goes along with that. And that doesn't happen, you know, when someone is in the hospital, because they, again, they lack that insight, but that's kind of like shows you kind of the long tail that these illnesses can have. Next slide, please. So when we're thinking about disparities and access to care and care treatment, there are, first of all, there are a limited number of perinatal mental health providers. And then even within that low number, there's a low number of providers of color and even fewer professionals who can speak somebody's native language, right? So to provide care in a way that feels more natural and like seamless. There are many socioeconomic barriers to accessing care. You know, it might be insurance coverage and people that may need to pay out of pocket. There's opportunity costs for seeking care, like going to appointments, might even prophylactically, like preparing yourself. How do we prevent postpartum depression? I have a history of bipolar disorder. How do I prevent an episode of postpartum depression? How do I prevent an episode of postpartum psychosis, right? Going to all of those appointments is intensive. And there's an opportunity cost associated with that. Sometimes it's logistical issues like paying for a patient or setting up childcare or just having the time or space to be able to prophylactically set yourself up for success. Sometimes there are cultural barriers that get in the way. I think Ayana had like men, she used the term superwoman exactly. In a lot of communities of color, particularly, you know, black communities, there is this idea that you have to be everything for everyone at all periods of time. So to ask for help, somebody may feel like, oh, I'm weak or to ask for help, there's an opportunity cost associated with that. And so if the ill person themselves, right, may not have insight, but their community still carries that narrative, like, oh, we got this, we can take care of it. We don't need help. We don't need to involve other people in this. That can also be a barrier. And then again, there's the institutional medical distrust. And so there's one, there's like fear of welfare services. So there's a lot of fear across the board, right? In women or birthing people coming forward with their psychiatric symptoms. They weren't, you know, I hear the patient's words. I thought I was going crazy, so I just didn't say anything to anybody, right? They just keep these things to themselves. Because they're really worried what that means about their ability to parent or what that means about their ability to keep their children. This fear is heightened when it comes to communities of color. Because I'm forgetting the exact studies, but I think black families have one of the highest rates of welfare system involvement and family separation, which can be a big trauma. You know, if you think about it historically, family separation, right? Separating parents from their families has oftentimes been used as a tool of social control in marginalized populations. So if you think back to the days where African-Americans were enslaved, like family separation, that is a huge trauma, right? That's a huge trauma to the family unit. And there is that historical, cultural, collected memory of those things happen. Thinking about families being separated by deportation or, you know, even recently, you know, that is a cultural trauma. So when you think about willingly putting yourself in a situation where your family may be separated, people think twice about engaging in systems that have the power to do that. And then again, there was the fear of medication, you know, as I mentioned before. Next slide, please. So one other thing I also want to talk about is sleep and postpartum psychosis. So just like Dr. Staneman had talked about, sleep is a huge part of our job as psychiatrists in general, but specifically as reproductive psychiatrists. I always joke with my patients. I say, you know, if you take nothing away from our relationship, take away that sleep is probably one of the most important things that you could do for your health and for your wellness. Sleep is a big part of the treatment of postpartum psychosis. We need to make sure we're protecting sleep and optimizing the opportunity and capacity to sleep. But I also want to recognize and acknowledge that sleep is a privilege. I'll start with telling, you know, a personal story. So I went to a baby shower one time and I, you know, with a friend, there were a lot of physicians there sitting next to this white physician and her husband. They were very well-to-do. He was some sort of real estate mogul, I guess, in New York City. And I was asking her, I was like, oh, like, how was your postpartum period? And we were sharing kind of war stories of like what it's like to take care of a baby postpartum. And she was just like, oh, it was fine. I slept eight hours a night. And I was like, oh, like, how did you, how did you, where did you get your baby and where can I get one of those babies? But she basically was like, oh, our night nanny took care of the baby at night. So she paid for sleep. As a resident, I didn't have the means to pay a night nanny to come into my house for three to four months and take care of the baby overnight such that I could sleep eight hours every night. And that was probably one of the first times that it dawned on me that we all don't have equal access to sleep. Next slide, please. So sleep is actually a health equity issue. And so the National Sleep Foundation, there's like a whole body of research that points out the ways in which sleep is a health equity issue. There's racial discrimination. There's studies that show that people who report higher instances of racism in their life or higher instances of racial discrimination actually have poor or worse quality sleep. There's differences in access to care. So there are many things that can impact your sleep as a pregnant person, right? Depression, anxiety, GERD, restless leg syndrome, insomnia, there are many sleep disorders. People of color or marginalized communities are less likely to get treatment for sleep disorders themselves, right? So that is just like another way in which sleep is compromised in these populations. There's financial distress, or working shift work or occupational hazards. So people of lower socioeconomic status may be more likely to work shift work, like the graveyard shift, or work multiple jobs. And so their opportunity for sleep is less than people of higher socioeconomic status. Now, they might live in a neighborhood where there's a lot of noise pollution or like pollution, pollution, where you're breathing may be compromised at night due to flares of asthma or things like that. And those things also compromise your sleep. And so I think it's important for us to recognize as providers, when we are prescribing sleep for patients as treatment for illness, we have to recognize that we are recommending something that people don't always have equal access to. And I think having a conversation around the barriers to sleep is important as well. Next slide, please. So wrapping up, these are just some strategies to consider. So we wanna obviously increase our capacity as a profession and across interdisciplinary professions to screen, to screen women or birthing people for psychiatric symptoms and to do that earlier, right? I think there's a movement to start seeing more women two weeks postpartum than six weeks postpartum, but really supporting screening during these visits. And particularly if people are coming from marginalized populations, putting in that extra effort to making sure we're having these conversations and using the screening tools that are available to us. Some of the studies that showed the disparities in screening tools recommended having lower cutoffs for triggering pathways to referral. And so in terms of lowering the cutoff, some of these things may be a little bit arbitrary, but if we're able to contextualize the way that somebody scores on these screening tools with a conversation around what adverse community experiences are you experiencing, I think that might help to invite more people in the door to treatment. And then lastly, I think it's important that we start to discuss issues of sleep equity more as like a field, but then also with our patients, early on asking what are the barriers to you being able to get the sleep you need to have optimal health without even factoring in the baby? Because when we factor in the baby, we have to get even more creative. Are there community ways we can support sleep, right? Are there ways in which we can, is there a community, like for example, a church, for example, may pair moms together who are single moms, for example, that maybe one night they can tag team taking care of the baby if they're unpartnered or something like that. So there's a way in which you can bring creativity to the table if we're going to prescribe sleep as one of the mainstays of treatment for postpartum psychosis. Dr. Crick, I just want to be mindful of the time, we'll leave a few minutes. Yep, I'm all set. Thank you. Perfect. Sorry. So there've already been a number of questions coming in, some of which I've answered, but one that I thought was particularly relevant to what you're just talking about in terms of cultural sensitivity in particular. One person asked, I wonder what your thoughts are with regards to an immigrant birthing person. There is a lack of support. And if one does get support from the extended family, the difference in cultural values around that and cultural values around caring for the newborn can cause additional stress to the new mother. Are there studies which look at this specifically? I mean, I will say that not enough. I think that there is one population I think of is Chinese immigrants in particular who have different traditions around the presence of the mom and the postpartum. And that can be very helpful. It can be very stressful. I've had some patients talk about anticipatory anxiety about that. I don't know what your experience is, Dr. Kwerka. Yeah. In my culture specifically, there's something called a Mughal. I'm Nigerian and that's like an Igbo tradition. So the first 40-ish days postpartum to a couple of months, your mom or your mother-in-law or surrogate moms come into your home and basically help you become a mom. They massage you, they help you learn how to breastfeed, they cook, they clean. And it's a very kind of like cultural experience, right? As psychiatrists, we know there are complexities to being that close to your mom for that long, right? So it's a both and situation. Yes, there can be protective factors at play when you bring multi-generational kind of people into an enclosed space during a heightened time of stress, i.e. the postpartum period. But, and then also recognizing on an individual level, right, that what is your relationship with your mom? Is it going to be helpful for you if she comes into your home for a couple of months? So I think, again, just having that cultural perspective, but then also bringing that into conversation with the individual and how that individual navigates relationships in their life can be helpful in strategizing around how we manage the postpartum period. And how that conflicts with quote, unquote, American culture, right? Where you're back to work within three months. And I think many individuals who don't have specific cultural traditions are sort of saying like, where is the team? You know, like, where is the support coming in? We can go to 810 if time allows for everyone else, for our panelists. A question for Ayanna. Do you think if your psychiatrist, I love this question, provided some psychoeducation to you and your husband, specifically about postpartum psychosis before delivery, that would have been helpful? And I think that's a lovely question because it sounds like you were very prepared for postpartum depression. Yeah, I mean, I honestly, I hate to say it, but I think that I would have had some element of brushing it off as something unfortunate that happens to other people. But I think that if I'd received a pamphlet and my husband had been aware, I mean, I was textbook, you know, religious delusions, irritable, mood swings, sleep deprivation, didn't think I needed to sleep. I didn't even hear postpartum psychosis until like the end of my hospital stay, once I was lucid enough to have an idea of what was going on. And my husband, I wasn't, you know, officially diagnosed until I was in the hospital. I will say that I think if this hadn't happened during the height of the pandemic and my psychiatrist had been able to meet with me in person rather than relying on video visits, that also probably would have been really helpful. But she has told me that I've changed her approach on postpartum psychosis. I'm only the second patient that she's had in a long career who's experienced it. And I think now she's more aware of its occurrence. Yeah, wonderful. I also think, you know, I hear both sides to this also when I speak to patients. There's a lot of misrepresentation in the media about what postpartum psychosis is or what postpartum episodes are. There's a lot of assumptions made. And one thing that I will also note is that there's a huge amount of discrepancy in the way that certain races who are experiencing psychotic symptoms are portrayed. So if a minority individual is portrayed in the media because of an infanticide or a suicide, there's this assumption that there's something more, that there was a depression and that it's less permissive, it's less forgiving. Versus as soon as a Caucasian individual is portrayed, there's this assumption of like, oh, of course she was psychotic, right? So I think the media does this as an injustice. And then the other thing is that then I have huge numbers of individuals who have obsessive compulsive disorder, who are having obsessions. What if I harm my baby? What if I do this? What if this happens? Who don't come forward, just as you were saying, because they think, oh, I'm going to be these individuals portrayed so terribly in the media or I'm losing my mind. And losing my mind is just this terrible phrase. Yeah, with every one of my patients, particularly those who have like a bipolar spectrum illness, when they come for preconception consultations or treatment, during pregnancy or prior to pregnancy, I kind of lay out groundwork or framework, right? Or expectations. I'm like, okay, third trimester, this is where we got to get your village together. Like, who's going to come to your appointment with you where I'm going to teach them, teach both of you about postpartum psychosis, right? And it's not to fear monger, because again, these situations are rare and it's likely not going to happen to them because the most common mood episode postpartum is actually a depressive episode, but it's important that they understand and that they can prepare just in case that happens. And so, you know, I give all the handouts. I'm like, hey, I give like the illustrations. I tell them this is about, not about scaring you, but about empowering you to know exactly what to do. Like if a situation arrives, you guys, you've got this in terms of what to do, how to seek help, where to seek help. We have one more question that came in. So research tells us that birthing people with a history of bipolar disorder are at higher risk of developing postpartum psychosis. And it can occur among birthing individuals who also have no history, right, of a severe psychiatric illness. Are there any particular risk factors that may place a group at risk of developing postpartum psychosis? And we talked a little bit about this earlier. I mean, there are many risk factors. I think some are psychiatric and some are sociocultural. As we talked about, sort of sleep deprivation is one of the biggest risk factors. But the other is a family history of bipolar disorder or a family history of postpartum psychosis raises the risk that the individual has not just a unipolar depression, but a bipolar depression, which might present as a postpartum psychosis. Ayaan, I wonder if there's anything that in retrospect or as you've sort of gone through this journey that you would want psychiatric providers, maybe your psychiatrist did or didn't, but you would want psychiatric providers to sort of hold or that would have helped in your experience, but either in the hospitalization or the recovery or just any part of it. I feel really lucky that I had a doctor who really cares about me. I have been in psychiatric care, you know, in one way or another for about 10 years. And I've had some really bad doctors, bad doctors who when you're there for the appointment, you get the 15 minutes. And when the 15 minutes is up, you know, too bad. So I think that, again, what helps me, not only did my doctor reach out to a hospital, tell my husband the hospital, she reached out to the psychiatrist at the hospital and said, I have a patient coming in. This is the situation. Basically, like I'm sending her to you. So, I mean, I don't know how that works, but I think it's just having a doctor who I could tell during that, who my husband noted during that, deeply cared about how I was doing as a person, deeply cared about my daughter and that, you know, weeks and months after was checking in with me, asking me, how's your family doing after this? You know, how's your husband doing? Because, you know, we're out of time. But yeah, I mean, it's traumatic for everyone, anyone who's around, you know? So I just feel really lucky that I had a doctor who caught it and even, as I mentioned, said to my husband, if she continues like this, you need to take her to the hospital because had he not done that, I don't think that, had she not said that, I don't think we would have realized the severity. Yeah, thank you. One more question came in, we'll take that and then I think we'll wrap up. What are your recommendations for an OB or a family medicine providers providing OB care when you have a patient who's a minority, a non-English speaker, birthing person, potentially experiencing postpartum psychosis, but is evaluated by the psychiatrist and labeled as anxious and acting culturally appropriate, though the family members completely disagree? How does one navigate that in terms of treating the patient in the hospital setting in order to keep them and their family safe? So one of the key things here is that any medical professional can involuntarily commit an individual. So it does not need to be the psychiatrist. So if you are a provider who has concerns that an individual has postpartum psychosis and the family is concerned about their safety, or you want them evaluated by another psychiatrist, safety comes first and you can call 911, you can involuntarily commit them to, or involuntarily have them brought to an emergency room to be evaluated. I don't know if you both have other things you want to add. Yeah, I think, you know, you already have, like you've been to this seminar now, right? And so you know some of the signs and symptoms of postpartum psychosis. So you can write a note, right, that documents, these are the affective symptoms I'm concerned about. These are the cognitive symptoms I'm concerned about. These are the psychotic symptoms I'm concerned about. And nobody can fault you for writing down or putting together a clinical picture that is going to justify whatever decision that you're going to make. So if you're able to justify where your concern is coming from, I don't think anybody will ever fault you for pulling the trigger on, you know, a higher level of care, like getting someone to a psychiatric emergency room or even recommending hospitalization. Because again, in psychiatry, postpartum psychosis is one of our most catastrophic emergencies, right? And we treat that emergency as an emergency, like part of the treatment. And anything you read will always, hospitalization, it's not an outpatient, let's see what happens, it's not that. So I think getting someone to the hospital, you will never be faulted, like from a medical legal, like risk perspective, and then also just kind of doing the right thing for the patient registering your concern and then connecting them to services. I'm going to turn the virtual mic over to Madonna and our APA nurse. Thank you, Dr. Stand-Evans. Thank you. Thank you everyone for being with us this evening for another timely and important topic on maternal mental health. And as we come to a close, I would like to take a moment to thank our CEO and medical director, Dr. Saul Levin, our APA president, Dr. Petra Stavonis, the APA board of trustees, our councils, committees, caucuses, and the administration for their contributions and continuous support for this work that advances mental health equity. I would also like to take a moment to thank Dr. Regina James, our division chief, Dr. Escontrías, our managing director for their continuous support for this webinar series and to the rest of our phenomenal team for their work behind the scenes. I also want to thank our incredible panelists, Ms. Leger, thank you for sharing your story and your experience and Dr. Stand-Evans and Dr. Requiriclu for providing this much needed clinical insight into helping demystify postpartum psychosis. This was a wonderful way to close out this summer maternal mental health series. Just a reminder, our regularly scheduled Lookin' Beyond series will continue this fall. The next session will be September 28th at seven Eastern Standard Time. So please register at www.psychpietreat.org. It is free and open to everyone. Thank you again for joining us this evening and enjoy the rest of your night. ♪

postpartum psychosis

mental health emergency

early signs and symptoms

birthing people of color

barriers to treatment

screening for symptoms

culturally congruent support

education and awareness

timely recognition and intervention

medication, therapy, and support