Know Science No Stigma: Antidepressants During Pregnancy and Risk of Autism

Coming out of a blogging break to step onto my soapbox for one of my favorite reasons….to point out inaccurate information being published, in this case by JAMA Pediatrics in its report titled “Antidepressant Use During Pregnancy and the Risk of Autism Spectrum Disorder in Children.”  Now, mind you, JAMA is a publication on which pediatricians from all over the world depend for the latest research.

Over the past few days, several responses were published, including ones from Postpartum Support International (PSI), Slate, and Huffington Post.

The sub-title or header to the PSI article says “Less Fear, More Science.”  That’s what EVERYONE needs to focus more on.  It’s one of my main mantras.  In fact, one of my most popular Pinterest pins (pinned 629 times as of 2/11/18) says KNOW SCIENCE. NO STIGMA.  Four words with significant meaning.  It’s posted on the Brain & Behaviour Research Foundation website.

JAMA needs to acknowledge this and pull the study, and if they can’t pull it, then they need to read the response from PSI, discuss it with other subject matter experts and decide how to handle it properly so the pediatricians all over the world can know the truth.  So that pediatricians don’t feed the flames of ignorance and fear among the public unnecessarily!

American Academy of Pediatrics on the Importance of Screening New Moms for PPD

According to the latest American Academy of Pediatrics report published on November 1st in the journal, Pediatrics, with the over 400,000 infants born to moms with depression each year, perinatal (both antenatal and postpartum) depression is “the most underdiagnosed obstetric complication in America [which untreated and improperly treated] leads to increased costs of medical care,….child abuse and neglect,….family dysfunction and [adverse] affects [on] early brain development.” [1]

As I have said in prior posts, depression in new moms impacts the entire family.  Not only do fathers have an increased risk for developing depression themselves, but babies are at increased risk for insecure attachment, which can lead to developmental (cognitive) delays and behavioral (social, emotional) problems as they grow older.  Children exposed to maternal and/or paternal depression are at much greater risk of developing mood disorders, such as depression.  Hence, to ensure the health and wellbeing of the baby, it is important to ensure the health and wellbeing of the baby’s mother, which is why pediatricians are in a good position to screen new moms for postpartum depression (PPD), as well as help provide referrals for treatment and community resources/support services.

Between the American College of Obstetricians and Gynecologists recommending similar screening earlier this year and now the AAP, I truly hope that this will mean more new moms with perinatal depression being properly diagnosed and treated!  According to this report, although most pediatricians agree that screening for perinatal depression is something that should be included in well-child visits during baby’s first year, they also felt that they didn’t have adequate training to diagnose and treat PPD.  The report also states that the “perceived barriers to implementation [include] lack of time, incomplete training to diagnose/counsel, lack of adequate mental health referral sources, fear that screening means ownership of the problem, and lack of reimbursement.”[2]

There are indications, based on the report, that there have been efforts to move toward inclusion of women’s perinatal health in pediatric practices as demonstrated by programs like the one set up between Dartmouth Medical School and 6 pediatric practices in New Hampshire and Vermont, which show that pediatricians have the ability to effectively screen for PPD.  There is also the ABCD (Assuring Better Child Health and Development) Project, which is comprised of 28 states and their AAP chapters.  It’s wonderful that in Illinois, one of the ABCD states and one of the only states with a postpartum depression law, pediatricians who use the Edinburgh Postpartum Depression Scale to screen new moms for PMDs are actually paid (yes, paid!) by Medicaid for doing so.   Once again, Illinois is setting a positive example for the rest of the country when it comes to looking after new mothers and babies.  For more information on the initiatives going on in the various ABCD states, visit www.abcdresources.org and www.nashp.org.

What we need to do is mandate pediatrician (and OB/GYN) training to recognize PPD symptoms and provide proper referrals to medical/mental health practitioners trained in treating PPD.  The ideal goal would be the establishment of a multi-disciplinary approach (like I mentioned in my last post) wherein doctors–be it OB/GYNs whose patients are the new mom or pediatricians whose patients are the babies of the new mom suffering with PPD—would collaborate with each other and mental health providers in their communities to ensure new moms suffering from a PMD does not fall through the cracks.

I’d like to end this post by pointing out the difference between the AAP’s view of PPD timeframes of occurrence and peak prevalence versus the proposed guidelines I wrote about in my last post with respect to the DSM-5.   The AAP indicates that the peak for a PMD is 6 weeks postpartum, with another peak occurring 6 months postpartum.  It goes on to state in the report:  “Given the peak times for postpartum depression specifically, the Edinburgh scale would be appropriately integrated at the 1-, 2-, 4-, and 6-month visits.” [3]  Hey, American Psychiatric Association, the AAP gets it more than you do!  Please get with the program!

In Conclusion:

From the mere fact that it’s the primary care pediatrician that sees the new mother and her interactions with her baby within the first six weeks (before the postnatal follow-up visit with her OB/GYN at 6 weeks), the pediatrician is in the best position to detect maternal depression early and help prevent adverse outcomes for the baby and the family. “In addition, it is the [pediatrician] who has continuity with the infant and family, and by the nature of this relationship, the [pediatrician] practices with a family perspective [since a healthy functioning family means the healthy development of the child].”[4]  Screening can [and should be] be integrated into the well-child care schedule, as it “has proven successful in practice in several initiatives and locations and is a best practice for [pediatricians] caring for infants and their families.”[5]  The report further clarifies that, since the infant is the pediatrician’s patient, just because the pediatrician screens for PPD does not mean that the pediatrician must treat the mother. It just means that if a PMD is detected during the screening process, the pediatrician would provide information for family support and referrals for therapy and/or medical treatment, as needed.


[1] Earls, Marian F. and The Committee on Psychosocial Aspects of Child and Family. Incorporating Recognition and Management of Perinatal and Postpartum. Pediatrics 2010;126;1032-1039; p. 1032.

[2] Ibid., p. 1034.

[3] Ibid., p. 1035.

[4] Ibid., p. 1035.

[5] Ibid., p. 1037.

Current Dilemmas, Barriers to Progress When it Comes to Diagnosis and Treatment of PPD

Continuing from previous post titled “Recent News on Screening Expectant and Postpartum Moms,” the following scenarios are the current dilemmas/barriers to progress when it comes to detection, diagnosis and treatment of postpartum depression (PPD).

One of the contributing factors to the numbers of undiagnosed and untreated cases of PPD is that the responsibility for detection, diagnosis and treatment falls between two specialties—obstetrics and psychiatry—that are currently not set up to cooperate with each other in the treatment of PPD.  Unfortunately, the “norm” in the United States—which has created a disjointed system that leaves perinatal families at a tremendous disadvantage—consists of:

  • Lack of training on perinatal mood disorders (recognition of symptoms and treatment)
  • Lack of cooperation between the segments of professional care

The problem with the healthcare industry when it comes to treating women postnatally is that, once a woman has given birth—with the exception of the standard, six-week follow-up visit—it’s almost like the OB/GYN is washing his hands of her.  Aside from the doula who fills this gap in care for the new mother, there is no medical professional who fulfills such a need.  This is why the role of the doula has evolved and become more commonplace in this country.  She is there to provide the family with support for as long as she is needed.  It is not uncommon that she stays with a family for six weeks or longer.  She can work any schedule that you require.  She could work a typical 9 to 5 day, or she can do mornings, afternoons or overnight.

One thing I’ve personally witnessed through the years at my company is the unfortunate tendency for groups to work in silos, which is seldom associated with achieving good results.  Similarly, health professionals ranging from OB/GYNs to pediatricians, general practitioners, psychiatrists to social workers work in silos too.  They do not work as a team.  Not enough doctors out there care enough to cross their areas of expertise and perform the extra step to show that they truly care for their patients–e.g., following up even when not asked to, making sure the mom gets treatment, etc.   Ideally, there would be a collaboration between medical healthcare providers (GP, OB/GYN, pediatricians), mental healthcare providers (psychiatrists, psychologists), and others who come in contact with the new mother (lactation consultants, midwives) to proactively coordinate care of the new mother and communicate with each other about her status, treatment and progress.  In most cases, the woman cannot muster energy and/or willpower to do this herself.

It’s time for women to stop falling through the cracks once and for all!  OB/GYNs, pediatricians, lactation consultants and primary care providers–basically, everyone who would come into contact with a new mother after she has a baby–should know the basics about PPD and be sensitive enough to at least inquire about the well-being of the mom in the first 3 postpartum months.  In fact, hospital nursing staff should proactively call each and every mother 1-2 weeks postpartum to see how they are doing.  As the new mother checks out of the hospital, the OB/GYN (or hospital staff) should talk to her about the mood changes (i.e, baby blues) that are considered normal and experienced by most new mothers, and why this happens.  They should provide a pamphlet about PPD that says right up front (like the Postpartum Support International poster) that the #1 complication of childbirth is PPD, with an occurrence rate of about one out of eight new mothers.  That would be more likely to catch attention, as most new moms are likely to wave it off, thinking they would never let themselves fall victim to such a thing as PPD (like me).  The OB/GYN should also explain how PPD is different from the blues and offer the patient to call whenever they need to, particularly if their mood changes last longer than 2-3 weeks and seem to be getting worse.  Knowing that a professional is just a phone call away can make a big difference. 

Significant changes would need to be made at the legislative level first—which is why I believe the passing of the long overdue Melanie Blocker Stokes MOTHERS Act is so important—to drive the changes needed to ensure healthcare professionals are trained in screening and treating PPD, to require healthcare professionals to screen and treat PPD, and to ensure medical insurance covers screening and treatment.  More realistically, and in the nearer-term, the ideal approach to treating PPD would be via an extensive referral network or multidisciplinary team of professionals consisting of:

  • Obstetricians, pediatricians, family physicians/general practitioners
  • Nurses, physicians assistants
  • Midwives, doulas, social workers, lactation consultants
  • Psychologists, psychiatrists

Why pediatricians, you wonder?  Well, pediatricians are the ones who typically see the mother first, and it’s their office that would get the phone calls from the mother with concerns about the baby.  It’s the pediatrician’s office that would come into contact with the mother the most, not the OB/GYN’s office.  High anxiety can result in an increase in frequency in phone calls—with many even being mundane in nature—to the doctor, nurses or other staff members, particularly if reassurance from anyone on the staff doesn’t do anything to help the mother’s concerns.  It’s a shame pediatricians don’t work together with the OB/GYN.  If they did, pediatricians can give the woman’s OB/GYN a heads up about the possibility that she could have PPD.  Rather than the pediatrician telling the mom that she should be assessed for PPD, which can be taken the wrong way by the mother who thinks it’s the baby that’s their business, not her.  Fear of bringing up the topic would merely open up a can of worms, resulting in spending a lot of time—which they lack in the first place—talking about something that is not their specialty.

The pediatrician would normally see both infant and mother right after childbirth and regularly for a period thereafter.  However, they do not have en established relationship with the mother.  To complicate matters, the mother may feel too embarrassed to admit what she’s going through to a doctor because the focus is the well-being of the baby.  It’s only natural for the mother to avoid wanting to be perceived by the doctor as being a failure at properly caring for her own baby.  People must realize that the well-being of the baby is dependent on the well-being of the mother.  The pediatrician (whose patient is the baby) and even the lactation consultant (whose goal is to ensure the baby can successfully access his/her mother’s breast milk) should be concerned about the postpartum mom because it’s her mental health that has a huge impact on the baby’s development.  The least they can do is provide a pamphlet to all new moms, regardless of their current state.  In the ideal situation, the pediatrician’s standard protocol should be to ask the new mother during each visit how she is doing, especially if she is a first-time mother and/or a mother who had complications during childbirth. 

Actually, I will give my daughter’s first pediatrician credit.  Knowing the complications I experienced during childbirth and our extended hospital stay, the first question she always asked me—while looking straight into my eyes—whenever I brought my daughter in during the first few months was “How’s mom doing?”  Realizing it was “out of her jurisdiction” to help me, I never went into any details of how I was really feeling.