Five Questions With: Margaret Howard

Margaret Howard, a psychologist who treats pregnant and postpartum women suffering from depression, says that Rhode Island has a high concentration of mental health experts available to assist pregnant women and their newborns. / COURTESY WOMEN & INFANTS HOSPITAL
Margaret Howard, a psychologist who treats pregnant and postpartum women suffering from depression, says that Rhode Island has a high concentration of mental health experts available to assist pregnant women and their newborns. / COURTESY WOMEN & INFANTS HOSPITAL

Margaret Howard is director of women’s behavioral health at Women & Infants Hospital, where she also directs the Postpartum Depression Day Hospital. After the United States Preventive Services Task Force, appointed by the U.S. Department of Health and Human Services, issued recommendations calling for wider screening of pregnant and postpartum women for mental illness, Providence Business News talked with Howard to learn more about these recommendations. Howard, a resident of East Providence, is a clinical psychologist who holds clinical appointments in psychiatry and human behavior, and medicine at The Warren Alpert Medical School at Brown University.

PBN: The United States Preventive Services Task Force, which is appointed by the U.S. Department of Health and Human Services, urges wider screening of pregnant and postpartum women for mental illness. Why?

HOWARD: Increasingly, studies have shown that women are just as likely to experience psychiatric illness during pregnancy or the postpartum period as they are during other times in their lives. Moreover, there is strong evidence that the postpartum period represents a particularly vulnerable time for women to experience a first episode of psychiatric illness. Without screening, these illnesses often remain undetected and ultimately untreated.

It is well-documented that untreated maternal psychiatric illness can have an adverse impact on the mother, developing fetus and infant. For instance, studies suggest that untreated maternal depression during pregnancy is associated with preterm and/or more complicated deliveries and infants’ low birthweights. Pregnant women with depression and anxiety may be at greater risk for nutritional deficits, smoking, use of alcohol and other substances, suboptimal self-care and suicide. Untreated depression and anxiety during the postpartum period have been associated with impairments in mother-infant attachment, and infant delays in social, cognitive and behavioral development.

- Advertisement -

PBN: Do you envision medical providers in Rhode Island needing additional training or resources to fulfill these screening recommendations and, if so, how will they get them?

HOWARD: It depends. Many obstetric and pediatric practices throughout the state have initiated screening protocols based on existing recommendations from groups such as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Since screening is recommended rather than mandated, adherence to screening recommendations can vary by practice and individual provider.

The most commonly used depression screening tool is the Edinburgh Postnatal Depression Scale, a 10-item, self-reporting scale with good reliability and validity that was developed specifically for pregnant women. Published in multiple languages and self-administered, it can be downloaded at no charge; the only stipulation is that the author’s citation is included on the scale. Scores range from 0 to 30 and recommended cutoffs range from 10 to13; any woman who scores above the recommended cutoff should be referred for a more thorough evaluation. Since the EPDS is a self-reported measure rather than administered by a clinician, additional training is not necessarily required. Instead, what’s most important is having a protocol in place for scoring (which involves adding and takes less than a minute) and making a referral to the appropriate mental health setting for further evaluation.

PBN: How widespread is mental illness among this cohort of women in Rhode Island, and will additional screening reveal a significantly larger number of women needing support?

HOWARD: Major depression is the most studied psychiatric illness in perinatal women, and epidemiological data reveal that roughly 10 to15 percent of women will experience a major depression during pregnancy or the postpartum period. These rates would apply to women in Rhode Island. Risk factors associated with perinatal depression includes prior perinatal depression, prior non-perinatal depression, a family history of depression and psychosocial stresses – including poverty, domestic violence and lack of social supports, especially partner support. Routine screening would undoubtedly increase the rates of detection in perinatal women.

PBN: What programs or resources exist now to help these pregnant and postpartum women suffering from mental illness?

HOWARD: Compared to other parts of the country, Rhode Island is fortunate to have a high concentration of both perinatal mental health experts and infant mental health experts and services. For example, Women & Infants Hospital is home to the nation’s first dedicated intensive treatment program for perinatal women suffering from depression, anxiety and other psychiatric illnesses. It has been in existence for more than 16 years and serves as a model for other institutions around the country seeking to develop a similar program. For women requiring less intensive treatment, a range of outpatient services are offered, including individual, group and family therapy, as well as medication management. For women requiring the highest level of care, Butler Hospital which, like Women & Infants, is part of Care New England, offers perinatal psychiatric expertise in an inpatient setting. Because of the abundance of perinatal expertise in our area, Rhode Island practitioners can confidently screen their patients knowing that there is access to specialized mental health services for pregnant and postpartum women.

PBN: How do the task force recommendations differ from current practice? Do you think wider screening will yield more effective treatment of these women?

HOWARD: The United States Preventive Services Task Force’s treatment recommendation is that perinatal women be treated with a form of psychotherapy known as cognitive behavioral therapy. While CBT is widely held as the “gold standard” psychotherapeutic treatment for depression and many forms of anxiety disorders, interpersonal psychotherapy is an evidence-based psychotherapy that has been studied specifically in perinatal women and shown to be highly effective in this population. While I can’t speak to the current practice of all clinicians who treat this population, I can say that in our programs at Women & Infants Hospital, we utilize IPT heavily but also employ CBT and other evidence-based modalities, depending on the patient’s specific needs and which treatments will be most effective in targeting specific symptoms. In addition, our perinatal psychiatrists and nurse practitioners have particular pharmacological training and expertise with this population. We are fortunate to have three decades’ worth of research data that guide prescribing practices in pregnant and breastfeeding women. Much of the research has taught us that maternal wellness, even when it involves treatment with medication, far outweighs the risk of ongoing untreated or under-treated illness.

Perinatal women are often reluctant to reveal their psychiatric symptoms and, because some women may actually go to great lengths to “disguise” their poor mood state, it can be difficult for non-mental health providers to recognize depression or anxiety during routine medical visits. Furthermore, because symptoms of depression can sometimes masquerade as normal experiences of being pregnant or newly postpartum, true episodes of depression or anxiety can be missed. Incorporating routine depression screening during each trimester and at the six-week postpartum visit for obstetric providers and at well-baby visits for pediatric providers will result in higher levels of detection, which should lead to treatment. The good news is that these are very treatable conditions; women need not suffer in silence and we have a long track record of improving the lives of pregnant and postpartum women, their infants and families.

No posts to display