Publicly, first daughter Ivanka Trump and singer Adele are among a handful of celebrities who have been vocal about their struggles with postpartum depression, which affects about one in nine women, according to the Centers for Disease Control and Prevention. However, many women suffer silently and undiagnosed with postpartum depression, which, without access to proper medical services, can be a daunting ailment that is overlooked and underestimated.

“Postpartum depression is the No. 1 complication related to pregnancy,” said Janet Abraham, a clinical social worker at VCU Health. “In pregnancy, women begin to experience a shift in their hormones thus producing, in some instances, increased stressors, depression or anxiety. It may be something that they don’t realize.”

Abraham works at VCU Medical Center’s Nelson Clinic, which caters to women with high-risk pregnancies. Because of an increased need for psychiatry services within that population, Abraham is now part of a team of clinicians and physicians who have begun collaboratively screening patients for postpartum depression. A maternal-fetal medicine faculty member, a perinatal nurse practitioner, several Virginia Commonwealth University OBGYN residents, a psychiatry fellow and a licensed psychiatrist work with Nelson Clinic patients, and patients referred from other providers throughout Richmond.

“There are lots of issues that can cause mental health problems in pregnancy like hormonal changes and body image issues,” said Ronald Ramus, M.D., director of the Division of Maternal-Fetal Medicine at VCU Health. “We use screening tools to try to assess decompensation at prenatal enrollment in our clinic, in the third trimester, at delivery, and at the postpartum visit.”

The Edinburgh Postpartum Depression Scale, a nationally recognized, 10-item psychological rating that measures the severity of postnatal depression symptoms, is used to screen patients at the Nelson Clinic. The scale probes for mental health statuses with statements like, “I have blamed myself unnecessarily when things go wrong,” and, “I have been so unhappy that I have been crying,” and asks for responses like “yes, quite a lot,” “hardly ever” or “not very often.”

Because pregnancy is age-old, it often isn’t considered a condition that would require a mental adjustment. But, it is, said Bushra Shah, a psychiatrist in the VCU Department of Psychiatry who sees prenatal and postnatal patients at the Nelson Clinic.

“It’s a change in your life, a change in your physiology,” she said.

The particulars of postpartum

As early as two to three days after the birth of a child, some mothers begin experiencing signs of postpartum depression that manifest as having trouble sleeping or eating, and feeling anxious about caring for a baby, according to the American Congress of Obstetricians and Gynecologists. Part of the organization’s mission and vision is the advancement of women’s health care and continuously improving health care for women through practice and research. Additionally, the organization advocates for routine depression screenings for all women at least once during the perinatal period.

That algorithm was integrated into services the Nelson Clinic is now offering, Abraham said.

“We’re trying to connect those gaps.”

“We noticed that, as our patients completed their prenatal care and had their babies, many of them still needed this continuity of psychiatry care as a part of their postpartum treatment plan for a healthy transition into motherhood,” she said. “Many of these women do not have an easy time getting access to psychiatry care in the community, and as a result of this we found a gap in services. We’re trying to connect those gaps. This is a continuum of care we’ve been very lucky to set up.”

The Division of Psychosomatic Medicine in the Department of Psychiatry, the Department of Psychology and VCU Women’s Health all collaborate to treat patients. The range of services patients can expect, if needed, are psychiatry assessment and evaluation, medical management of serious psychiatric conditions, medication management and emergency facilitation of inpatient psychiatric hospitalization.

One goal of the clinic is to serve as a one-stop shop, of sorts, Ramus said.

“We are in one location, and at the same time we can identify the medical and psychiatric issues that may be present in pregnant women,” he said. “It also better facilitates communication between the OBGYN and the psychiatrist working with the patient.”

Fidelma Rigby, M.D., is the maternal fetal medicine specialist who works with Nelson Clinic patients. She is present at the prenatal period of a woman’s pregnancy and works with Shah to initially communicate whether a patient needs mental health help. 

Mental health and maternity

Women with a history of depression have an increased risk of developing postpartum depression. Additionally, if a pregnancy is unplanned or if a baby is born sick, that can instigate feelings of sadness or despondency. These are all risk factors and triggers of postpartum depression, Abraham said.

“The possibility is high for women in this population to develop conditions we term as perinatal mood and anxiety disorders. These conditions present themselves as depression, postpartum depression, anxiety, post-traumatic stress disorder and, in the rare case, psychosis,” Abraham said.

Because of the gravity and unpredictability of mental illness, the VCU Department of Obstetrics and Gynecology and VCU Women’s Health partner with community agencies when it’s necessary for a patient to get additional support outside of clinic hours or closer to their community. Richmond Behavioral Health Authority and local community service boards are among the agencies where patients can get additional services and information. After a patient has received treatment at the Nelson Clinic and given birth, Abraham develops a treatment plan that may include additional counseling and facilitation of community services as needed.

Long term, the goal is to have contact with patients for at least a year after their pregnancy.

“Success would be a patient who has adjusted [to motherhood] and is doing well,” Shah said.

The multidisciplinary aspect of the clinic is what most enhances treatment planning, interdisciplinary discussion and meeting patients’ individualized needs, Abraham said. Psychiatry and OBGYN services are available at the Nelson Clinic on N. 11th St., on Tuesdays from 12:30–4:45 p.m. For more information call (804) 828-5071.

“This is a rich, collaborative arrangement that’s pretty unique,” Abraham said, “and the hope is that we could be modeled after.”

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