Title:

Non-drug PPD Interventions
Purpose: The purpose of this activity is to educate healthcare providers on how to assess, screen, diagnose, treat, and refer patients with postpartum depression.
Target Audience: This activity is intended for healthcare providers (pediatricians, obstetrics-gynecology, psychiatry, nursing, social workers) who provide care to patients of childbearing age and/or pregnant patients.
Presenter: June A. Horowitz, PhD, APRN, BC, FAAN
Panel: Cindy-Lee Dennis, RN, PhD; Jeanne Watson Driscoll, PhD, APRN, BC; Katherine L. Wisner, MD, MS
Reviewer(s): Caroline Hewitt, RNC, MSN, WHNP, ANP; Cheryl Smith, MD; Melanie Steilen, BSN, RN, ACRN
Description: Dr. Horowitz discusses the available nonpharmacologic options for the treatment of postpartum depression. Pharmacologic and nonpharmacologic approaches are discussed, as well as barriers to their use from both patients and physicians.
Credits: 1 CME credit(s)
Learning Objectives: Upon completion of this activity, participants will be able to:
1. Recognize the crucial role of the infant in considering treatment choices for postpartum depression.
2. Identify the specific roles of partners, friends, and family in recovery from postpartum depression.
3. Define the effectiveness of interpersonal psychotherapy (IPT) and other forms of psychotherapy as primary or adjunctive therapies to pharmacotherapy.
4. Discuss the evidence base for bright light therapy, which has a strong evidence base for efficacy in seasonal and nonseasonal major depression.
5. Discuss the evidence base regarding complementary and alternative medicine, including acupuncture, essential fatty acids, aromatherapy, herbal and Chinese medicine, and maternal and infant massage therapy.
Accreditation(s):
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CAI designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Nursing Contact Hours: CAI is an approved provider of continuing nursing education by the New York State Nurses Association Council on Continuing Education, which is accredited as an approver of continuing education in nursing by the American Nurses Credential Commission on Accreditation. It has been assigned code: 653NHU-PRV-04-153 -- 1.5 Nursing Contact Hours will be awarded.

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Disclosure(s): The "Faculty Disclosure Policy" of the ACCME requires that faculty participating in a CME activity disclose to the audience any relationship with a pharmaceutical or equipment company which might pose a potential, apparent, or real conflict of interest in regard to their contribution to the activity, and any discussions of unlabeled or investigational use of any commercial product or device not yet approved in the United States.

June A. Horowitz, PhD, APRN, BC, FAAN has no relationships to disclose. Cindy-Lee Dennis, RN, PHD has no relationships to disclose. Jeanne Watson Driscoll, PhD, APRN, BC has no relationships to disclose. Katherine L. Wisner, MD, MS is on the speaker?s bureaus of Pfizer and Glaxo Smith Kline.

There are no commercial supporters of this activity.
 
Release Date: November 1, 2006; Valid for credit through October 31, 2008

Copyright 2006 Cicatelli Associates Inc. Provider Number: 0007155

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NASW Credit
(Social Workers):
This program was approved by the National Association of Social Workers (provider #886471152) for 1 contact hour.




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Non-drug PPD Interventions

Presenter & Moderator: June Andrews Horowitz, PhD, APRN, BC, FAAN
Panel: Cindy-Lee Dennis, RN, PhD; Jeanne Watson Driscoll, PhD, APRN, BC; Katherine L. Wisner, MD, MS






Slide 1. Iím June Andrews Horowitz and I want to introduce the three discussants who will be engaging in discussion with me along with you about non-drug postpartum depression interventions: Drs. Cindy-Lee Dennis, Jeanne Watson Driscoll, and Kathie Wisner.




Slide 2. The objectives that we have for this session include recognizing the important role of the infant when we consider treatment choices for postpartum depression (PPD). We also want to identify the specific role of partners, friends, family, and others in helping a woman recover from postpartum depression. Weíll define the effectiveness of IPT (or interpersonal psychotherapy), along with other forms of therapy as a primary and/or adjunctive treatment in relation to medication use. Weíll also discuss the evidence base for bright light therapy, which has a strong evidence base for efficacy in seasonal and nonseasonal major depression, and weíre just beginning to look at it a bit more with postpartum depression. And to discuss the evidence base regarding complementary or alternative types of approaches.




Slide 3. The infant role is really important when weíre considering treatment for postpartum depression -- not just psychopharmacological treatment, but also other kinds of therapies. The treatment options for PPD really are the same in many ways as for depression and other life stages, as weíve talked about in other sessions. However, there is a need to consider the effect of postpartum depression on the baby; not just medication use, but the effect of PPD on the baby, and the maternal-child relationship. Will our treatments also target any negative effects on the infant because the mother's depressed? We also talked earlier about the fact that all medications are secreted into breast milk, and that is something to consider; it's certainly important for women when selecting a particular kind of treatment.




Slide 4. Other treatment considerations include the immediate post-delivery period and the long-term effects on the infant. The literature has demonstrated at this point that postpartum depression has a variety of negative effects on the mother-infant relationship, and through the effects on the relationship, has an effect on infant development. Treatment of the mother should begin early. There are negative effects for the mother, obviously, but there are accruing effects on the infant as well. Remember that during these early weeks and months, the infant is undergoing neurobiological changes and learning how to relate to another human. If there's a problem in that process, there may be ongoing effects to the baby, even through childhood. Lastly, on that point, is that even when treatment reduces postpartum depression symptoms, we canít assume that the mother-child relationship is going to be improved automatically.




Slide 5. An earlier discussion focused on decisions about bottle feeding and breastfeeding. If a woman chooses to bottle feed when sheís experiencing postpartum depression, that does mean that the benefits of breastfeeding will not be available to the baby. On the other hand, breastfeeding while being depressed also means that the baby could be exposed to medications through breast milk and/or be exposed to maternal depression if other treatments are not instituted to help the mother cope with the depression and reduce symptoms. And we know also in terms of effects on the baby that PPD is associated with extra crying among infants, and that there are long-term effects on cognitive and emotional development. Even brief (1-2 months) exposure to major, severe depression has had negative effects on babies' development. We also have mounting evidence that shows effects throughout early childhood and even into the early school years.




Slide 6. So because of these concerns, women often will seek complementary and alternative treatments because theyíre worried about the effects of taking medication when theyíre breastfeeding.




Slide 7. What are some other reasons that women choose different treatments? From a womanís point of view, she may want to try every option available rather than medication; she may want a treatment with fewer adverse effects, because medications are not totally benign. Besides the possible effects on the infant through breast milk, there are side effects that some women experience. Women also wonder: How long will I need to take this; is this something I have to take for the rest of my life? They also view alternative and complementary treatments as less authoritarian and more empowering than traditional treatments. Thereís a good amount of qualitative research data to indicate that women want treatment that is contextual; that makes sense for them as mothers and women, and also empowers them. Changes that happen through psychotherapy involve the motherís ability to make changes and to decrease her own distressing symptoms, and thatís different when itís all coming from a medication; so I think thereís certainly an advantage to considering psychotherapy. And then many women see other providers who are not prescribing medications as being more involved and holistic. I donít think that has to be the case by any means, but it can be a perception.




Slide 8. When making treatment choices, I would advocate that it should be an interaction; a discussion, a negotiation, a supportive relationship that allows a woman, along with her primary care provider, to pick the best treatment for her. It wonít be the same treatment for every woman. You need to consider her preferences, the availability and coverage of services, as well as the primary care providerís sense from his or her expertise about what might be best for this particular woman.




Slide 9. When we talk about therapy and recovery from PPD, we also want to consider social support and its role. Social support can be understood as a well-intentioned action that is given willingly to a person with whom there is a personal relationship, and that produces a positive response in the recipient. Social support has been shown to play a mediating role in decreasing perceived stress in women, and thereís a strong research base besides the reference thatís cited here; thereís a lot of evidence to show that social support can improve health outcomes. However, there is a dark side of social support, or a cost thatís sometimes involved. There are people who would not acknowledge a negative side to social support, but I think in its easiest sense, we should consider that there can be pressures to conform to family or cultural norms; there can be paybacks, there can be family or relationship dynamics that are not always benign for many women. We also know that women who do feel well supported in their networks tend to have better outcomes.




Slide 10. Postpartum women can vary in terms of what support is important to them, and how much support they desire. And I think we should underline the word "desire" because we often make assumptions that more is better, and that we should increase social support; but it really is up to the woman to tell us whatís going to be helpful to her. There can be payback expectations that lead to some people being reluctant to ask for needed support; in other words, costs and benefits. For example, in a study that I was involved in -- a cross-cultural study -- we had 9 cohorts of women from around the world, and from many traditional societies. Some women told us that there was a serious cost sometimes to having a traditional practice, be it a postpartum ritual. One woman in a qualitative component of the study said: My mother told me I have to sit in this bath for so long, but I donít know why, and I donít want to do it. No one asked her if she wanted to do it. And other women valued some of those rituals, but again wanted to have a voice. The other piece that they said so strongly to us was that the ďmother-in-lawĒ or partnerís mother, paternal grandmother or partner grandmother -- in this case they were male partners -- that she owned the baby in many ways and took over sometimes, and that was problematic and stressful for many women. Again, they felt that they werenít asked and didnít have a voice, including coming out of the hospital and having the nurse hand the baby to the mother-in-law rather than to her. So communication is key and we need to ask -- we canít assume Ė that women want certain kinds of support and not others. And thatís true for clinicians as well.




Slide 11. Letís talk about psychotherapy. Itís effective in the treatment of postpartum depression, and I think we need to get the word out that thereís good evidence to show that psychopharmacology and good psychotherapy -- particularly interpersonal therapy (IPT), and cognitive-behavioral therapy (CBT), have demonstrated efficacy in reducing depression. Furthermore, if psychotherapy is started and the womanís symptoms are not remitting, theyíre not getting better, or theyíre not coming to full recovery, psychopharmacology can be added as another treatment; it does not have to be either/or. And many breastfeeding women, as weíve already discussed, do prefer psychotherapy because they are worried about taking medications even though there are many that they could take safely.




Slide 12. So letís talk a little bit about IPT, because itís the approach that has had the most evidence to date. Michael OíHara, along with his team, has done some extensive work to test the efficacy of IPT in treating postpartum depression. In one study, he and his team assigned 120 postpartum women who met criteria for major depression to either 12 weeks of 1-hour/week IPT, or to a control group. He and his team found clearly that the IPT group did much better in terms of depression symptoms, but also in terms of improved relationships and postpartum adjustment. And those are parts that arenít always targeted by medication; medication should improve depression symptoms. Secondarily, we hope that relationships and adjustment will improve, but therapy, particularly interpersonal therapy, targets those aspects of postpartum depression directly so itís an ideal treatment with or without medications.




Slide 13. Meg Spinelli also conducted a study with antepartum women and had good outcomes. And from this and other work, we can say that IPT is an effective form of treatment for depression; we have good efficacy data at this point for use during pregnancy and also postpartum. Again, it targets interpersonal distress and has a good effect on mood.




Slide 14. Letís turn our attention for a minute to another promising treatment: bright light therapy. We know that itís very effective for seasonal depression, and thereís some data now to support that nonseasonal depression can benefit from use of bright light therapy as well. Letís think about what happens with postpartum depression, and whether this nonpharmacologic somatic therapy is an option.




Slide 15. Hereís a picture that shows you what that looks like; with a very special kind of light that this woman is receiving. It doesnít work with just regular lights; it has to be special.




Slide 16. In this graph, you can see that on the left-hand side, there are symptom measures at baseline and then the light treatment begins with that first vertical line. Look what happens to the symptom measures. They all go down, indicating that women are receiving benefit from the bright light therapy. On the other side of the graph where it says withdrawal, youíll notice that when the treatment is stopped, the symptoms begin to increase again.




Slide 17. One of the things that we do want to pay attention to is how we can improve the quality of mother-infant interaction in the presence of postpartum depression. As we said earlier, postpartum depression has demonstrated negative effects on the relationship between the mother and her baby, subsequently on infant development, and even later child development. Even when postpartum depression symptoms decrease over time, you canít assume that maternal-infant interaction will automatically improve. And data from a study I conducted was rather remarkable, showing that even when depression improved, the relationship didnít. Treatment of the relationship did make a difference, but decrease in depression alone made no difference whatsoever. So we might think about behavioral coaching interventions that have demonstrated positive effects on the quality of the interaction between mothers with PPD and their infants; Iím conducting a clinical trial now as a follow-up to my previous study. Part of the intervention (it's very safe, so people could try some of this out even as work is going on), involves teaching mothers about what babiesí behaviors and cues mean. They donít come with instructions, right? I think every mother could use this, and dads, too. But teaching moms who are depressed in particular is helpful because moms who are depressed have more difficulty focusing, tuning in, paying attention; because depression mitigates that ability, and has cognitive implications for the mother. Then coaching the mother in a gentle, supportive, praising way about how she can respond to her infantís cues in a timely, contingent, sensitive, responsive way.




Slide 18. Letís look at some alternatives, as well as complementary approaches. Herbal medicine is a category that many women use -- over-the-counter (OTC), available at health food stores, and a prescriber, a clinician, physician, nurse practitioner, doesnít need to write a script. So what do we have? Herbs and dietary supplements, and some have demonstrated effects on mood, anxiety, and insomnia. St. Johnís wort has shown some efficacy in ameliorating symptoms of mild depression, but we donít have any studies yet to examine what happens with breast milk, and really what happens with postpartum depression. And I think we also must be cautious about anything thatís over-the-counter because we donít know how to control the dose; we donít really know how much a woman is taking, so I think we should be cautious. Kava has also been found to be an effective treatment for moderately severe and nonpsychotic anxiety, and it does affect neurotransmitter activity. And at this point, I would say we should not be using it in women who are breastfeeding, and Iíd welcome comments from others as we have a discussion.




Slide 19. Chinese medicine involves treatment with a mix of various herbs and, again, now we donít know the exact proportions; what has been mixed, how much, how powerful. Given that, and that we have no studies documenting the efficacy of the use of these kinds of herbs on depression, or the safety of usage, it needs to be put on hold in the treatment of postpartum depression; particularly when women are breastfeeding. We do need to pay attention to womenís perspectives when it comes to use of herbs and over-the-counter medicines, because often if itís over-the-counter, they assume itís safe; and if itís herbal, many women say itís natural. We know that thatís not the case because many of these herbs, as well as OTC medications, have psychoactive properties.




Slide 20. Omega-3 dietary supplements: thereís some evidence of beneficial effects on major depression; we do need more studies to decide how we might use those for the treatment of postpartum depression. You can see some of the sources here on this slide. There was one comparison across 12 countries, and the outcome indicated that those countries that have greater seafood consumption had a lower prevalence of bipolar disorder, which is interesting. More studies are needed. The recommended starting dose (a safe level), is 1 g per day.




Slide 21. Iíll comment briefly on massage therapy because youíll see it in the literature, and there has been some work done. Field has done the most work on massage therapy. In one study of maternal massage, 32 depressed adolescent moms were randomly assigned to relaxation and massage therapy. She found that the massage group had lower anxiety; less anxious behavior, and lower stress hormones. Massage therapy could offer short-term improvements in mood and stress in the postpartum period. Iím not sure Iíd recommend it as a major treatment, but I think as an adjunct or a complement, it could be nice. And I think many women would love it! They may not have the resources to pay for it, but if itís available, itís safe and might be very helpful.




Slide 22. Infant massage therapy: Field and her team has also looked at the effects of rocking and massage in several studies. Just to highlight one, 40 full-term infants between the ages of 1 and 3 months who were born to depressed moms were randomized, and the infants received either 15 minutes of rocking or 15 minutes of massage twice a week for 6 weeks. And what they found were infants in the massage group had more organized sleep patterns (that could certainly be helpful), and more positive interaction behaviors. I think thatís really important because one of the problems is not only the quality of the interaction, but then how the babies begin to have what we might call depressed, fussy, anxious, irritable behavior in response to the momís interaction and her behaviors. They showed a significantly greater improvement in emotionality, sociability, and soothability, and so itís possible that these changes in the infant could also have a positive effect on the motherís depression; but that remains to be seen.




Slide 23. Now acupuncture is another alternative to consider, and in one study by Tao, 68 participants with chronic illness experiencing anxiety and depression were evaluated, and the treatment was individualized to each personís condition for the appropriate acupuncture points. The result showed a statistically significant reduction in anxiety and depression a month after the acupuncture treatment. So thereís no contraindication at this point to treatment; it doesnít interfere with breastfeeding. I think we need more tests with postpartum depression, but at least itís something that shows promise as well.




Slide 24. In conclusion, postpartum depression is a common postpartum complication; we all know that. If the same 10%-15% of women who experience postpartum depression also had another major complication, like post-delivery hemorrhage, what would we be doing? We would have the hugest initiatives to change healthcare practice. We'd have screening and referral networks set up, and we would have available treatment because it would be considered a huge epidemic. But because PPD is an emotional, mental health, psychiatric kind of problem, it has remained covert, hidden, and been silenced, and we donít have good treatment plans set up yet. But change can come; this is a first step!

We do know that medications and psychotherapy, particularly IPT and CBT, can ameliorate postpartum depression. Complementary treatments show some promise; bright light therapy as perhaps a stand-alone treatment, or in conjunction with psychotherapy and/or medications. All 3 are possibilities. We also need to be weighing the treatment benefits and risks, the severity of the postpartum depression symptoms, and the motherís preferences. Those are essential things to consider when weíre determining the best plan. The evidence to date shows that interventions to treat PPD do not target or affect the mother-infant interrelational problems specifically, so that's something that we do need to attend to in the future. Specialized mother-infant interventions do show promise, and may be necessary to complement postpartum depression treatments, particularly when an observable problem in the maternal-child relationship is apparent to clinicians.




Slide 25. Weigh the severity of depression symptoms with potential adverse effects of medication treatment. Iíd be more likely to suggest starting without medication, and psychotherapy for more mild-to-moderate depression, and then consider over the next few weeks if medications need to be added. On the other hand, if a woman presents with very severe symptoms, we need to start with medications instantly as well as bring in psychotherapy. The longer sheís on medications and symptoms decrease, the more effectively sheís going to be able to use psychotherapy as well. They really can work together beautifully. Consider the evidence of efficacy and psychotherapy when planning treatments. Attend to the effects of postpartum depression on the mother-child relationship, and on the babyís development. Plan to make postpartum screening part of standard practice -- thatís been our mantra -- and develop a referral network, which is the next step after screening.




Slide 26. Now what Iím going to do is just offer some brief questions. Weíre going to do it the old-fashioned way, and you can wave if you think you like a particular answer. So, what information should I give to a woman about postpartum depression treatment options, if Iím coming from the perspective of a primary care provider?




Slide 27. "B." You bet! Youíve been listening! You also came knowing quite a bit of this as well!




Slide 28. Which of the following complementary treatments do not have demonstrated positive benefits or not adequate positive benefits at this point or may not be safe to recommend?




Slide 29. "A," herbal medicines. Thereís some evidence of efficacy, but there are a lot of concerns, and there may be some safety issues.




Slide 30. Which of the following statements about the effects of postpartum depression on infants is wrong?




Slide 31. "C." Excellent!




Slide 32. And last, family members and friends can assist a woman who has postpartum depression in all of the following ways, except:




Slide 33. "D." Excellent!




Slide 34.


Now we can turn our attention to a discussion about the challenges for innovative practice and using non-drug interventions for PPD, and Iíd like to offer the panel a chance to respond. Dr. Dennis, would you like to start?




Slide 35. Cindy-Lee Dennis, RN, PhD: Iím from the University of Toronto, and Iím a researcher and an academic. Iím not a practitioner, so I donít see patients or anything of the sort, so Iím coming to this from a research perspective. This sessionís called ďNon-drug Interventions for Postpartum Depression,Ē and when I think of interventions -- weíve been talking a lot about treatment -- thereís also preventative interventions that are available. And in fact a review of the literature suggests that there are over 30 randomized, controlled trials looking at interventions to try to prevent postpartum depression. I completed a systematic review and meta-analysis of psychosocial and psychological interventions looking at preventing postpartum depression, and of these 30 trials, 15 were rigorous enough to be included in the meta-analysis; this included 8,000 women.

Most of these preventative interventions were completely ineffective in preventing postpartum depression. Some showed a little bit of promise, looking at professional home visits. A study by MacArthur was conducted in the United Kingdom with midwives providing intensive home visits up to 28 weeks postpartum. The other study was conducted in Australia by Armstrong in families where the child was at risk for an adverse home environment. They received intensive weekly home visits by public health nurses. As soon as those home visits stopped, the mothers developed depressive symptomatology. So we really donít have any clue about how to prevent postpartum depression when we look specifically at psychosocial or psychological interventions.




Slide 36. Included in this meta-analysis was the types of interventions and how they were provided, and this meta-analysis demonstrated that interventions that were initiated in the postpartum period, rather than initiated antenatally and carried into the postpartum period, tend to be more beneficial. Interventions that targeted at-risk mothers, however they conceptualized at-risk mothers, were more beneficial than these universal preventative interventions applied to all mothers. And interventions that were individually-based rather than group-based tend to have more of a preventative effect. So when we think about trying to prevent postpartum depression and evaluating interventions, this meta-analysis provides some clues as to how we can actually evaluate an intervention that may have a preventative effect. So I just wanted to briefly mention that there is a whole body of literature looking at preventing postpartum depression. I think one of the challenges with preventative research is that we all have these different types of risk factors, but translating risk factor research into effective preventative interventions is very challenging, because what may be a risk factor for one mother might not be a risk factor for another mother.




Slide 37. In relation to treatment, Iím currently conducting a systematic review and meta-analysis of psychosocial and psychological interventions, and again, there are over 30 studies (not all randomized, controlled trials), that have looked at treatment interventions. In fact, thereís more interventions evaluating preventative studies than there are treatment studies for postpartum depression. And the types of studies that Iím seeing that are nonpharmacological are looking at support groups, peer support, cognitive behavior therapy, IPT, relaxation, massage, and exercise. So those are the types of interventions that fall into psychosocial and psychological.

Right now, when we look at treatment interventions, they are mostly generalized from non-postpartum depression literature, not postpartum depression literature. Weíve talked about OíHaraís trial, and thatís the only really good IPT trial for postpartum depression. Spinelli has done some studies in antenatal depression, but when we think about IPT for postpartum depression or cognitive behavioral therapy, it mostly comes from the general non-postpartum literature, and we then generalize that to postpartum depression.




Slide 38. When we think about treatment for postpartum depression, we also have to think about the 50% of women who do not seek treatment, or if they are referred, they donít go to treatment. The big question is: Why aren't these women accepting help; why aren't the help-seeking behaviors there, even if they do identify that they have depression?




Slide 39. Iíve just completed a qualitative systematic review of the literature of help-seeking barriers and treatment preferences. The barriers can be classified into 3 different categories -- some of them being maternal, which weíve talked about, where women donít know about what treatment options are available, or they deny that they are actually having postpartum depression. They think that theyíre just having a normal response to an adverse situation. Often women talk about fear: fear of the child being taken away from them; fear of being labeled mentally unwell; or fear of being a failure as a mother. And another barrier that Iíve encountered in the literature is family barriers, where the family members donít want mothers to seek treatment. This has more of a cultural component, but they want to keep this in the family and not bring in outsiders to address this emotional issue, or the family members just do not identify the symptoms of postpartum depression with the mothers. This indicates that we should be educating family members about postpartum depression, particularly the partner, if the mother does have a partner. And then of course weíve talked about healthcare professionals, and how there can be some barriers to help-seeking; one of them being not having enough time in their practice, and minimizing symptoms. Youíll see that in the literature often, where they say: This is a normal reaction that all mothers experience, and youíll get better. So mothers then arenít referred on to treatment.




Slide 40. In relation to treatment preferences, weíve already talked about how mothers are not very receptive to antidepressant medication at times, and this becomes very clear in the literature when you review it. What they do prefer is talking therapies. There is a study that was published in the British Journal of Psychiatry (first author Oates), and itís a cross-cultural study across 11 different countries, and the #1 treatment preference from these mothers was talking therapies with someone who was nonjudgmental. Also, having services that were not labeled related to the treatment of postpartum depression, because that has a stigma associated with it; so you would have exercise programs like pram [baby carriage] groups (we know that exercise can be beneficial for mood), so mothers would go to these pram groups and get the exercise, but not have pram groups for postpartum depression -- they felt that that would be very stigmatizing and that they wouldnít attend these.




Slide 41. And then the final thing I just want to say is that I think we should be creative in the mode of delivery of the treatment options, especially for mothers who are in rural and remote areas. When we talk about treatment, itís often a face-to-face type of interaction, but mothers in rural, remote areas often do not have access to mental health specialists for cognitive-behavioral therapy or IPT or even support groups. Sometimes itís very challenging for them to have access to these types of treatment options. Often you'll see in the literature that mothers don't want to leave their homes, or they find that leaving their homes is challenging, especially when they're really depressed. Arranging childcare, or even the notion of getting to the treatment are also concerns. Traveling is definitely a barrier that you see in the literature. I just want to throw out there the notion of telepsychiatry and exploring that with postpartum depression. Iíve just submitted another trial for funding; itís going to go across Canada and is looking at providing interpersonal psychotherapy over the phone to mothers in rural remote areas to see if this might be an effective treatment option. We know IPT is an effective treatment for postpartum depression, but maybe providing it over the phone might be a really good treatment option. Maybe we should be thinking about providing treatment in different ways other than face to face; although that is desirable, it might be just as well delivered via the telephone or video or something of the sort.




Slide 42. Jeanne Watson Driscoll, PhD, APRN, BC: Well, Iím the clinical person here practicing very eclectic psychotherapy care, I guess. I come as a childbirth educator, retired lactation consultant, parents' group leader, psychotherapist, and a psychopharmacologist! I became involved with this very personally 30 years ago, but whatís interesting to me is when we look at nonpharmaceuticals or look at any treatment, the relationship is critical with this woman and her family. And I truly believe in having the mother/baby and partners, in-laws and outlaws, and everyone come to the first meeting so that we get everybody on the same page. We talk about HIPAA regulations; about who can call and who canít call, because very often, the partner is a greater observer of behavior than the woman can be. So setting up the relationship is critical; to know that theyíre not coming into my office to have me open their mouth and insert a pill. the relationship begins first. I was the advisor to the postpartum depression support groups in Massachusetts where these women had been recovered, and would run groups, and they would call me with any question or problems, and I could see the patient if there was anybody who came up and caused some concerns. We also, in Massachusetts, have a really great program with Jewish Family Services where they do visiting mom programs for a year; have early relational development programs put together with some lactation consultants. Peggy Kaufman has done a wonderful job of pulling that together.

Referring people for IPT and CBT groups: there are no specific groups in the Boston area that are just for postpartum except in the research centers at Mass General with Lee Cohen and colleagues, and theyíre not easy to get into. Trying to set up support groups: I agree on the clinical side itís very hard if you call it postpartum depression groups because of the stigma attached to that. Regarding building the relationships, helping all the women do the nutrition, Deborah Sichel and I wrote a book called Womenís Moods, and we have the nurse plan in that, which is: nourishment -- food for the brain and food for the body; understanding rest, relaxation, spirituality, and exercise. I will base my assessment using a dynamic accumulation of your life experiences, genetic background, and reproductive hormonal life, and then pull together this nurse plan. And the nurse plan is then re-evaluated at every visit. Also, babies have to come to my office because we do mother/baby assessments; most of the practice is teaching moms about their babiesí cues and watching the breastfeeding or the infant feeding.




Slide 43. Dr. Driscoll: So I think using as many nonpharmaceutical treatments is wonderful; however, I do feel strongly that there are too many women who are not being referred soon enough for psychopharmacology. And we know from the research that if their symptoms go on for a long time, it takes us longer to manage their biochemistry. You want to empower the woman. The goal for me in therapy with my patients is that postpartum depression will be a gift that ultimately they will be glad they had, which sounds like a horrible thing, but if we pull together this holistic plan, she leaves as an authentic, voiced, empowered woman. And I really see that thatís an important part of this, because rather than pathologizing this, how do we keep the dynamic of womenís development, the cultural oppression, the issues of social/cultural aspects and economic aspects in womenís lives?

And so I always get concerned when weíre just talking about drugs, or just talking about psychiatric treatment, that there are so many multivariants that we canít lose sight of in the whole care of this woman. My biggest comment is to create interdisciplinary collaborative relationships, and I think that everyone has to sit at the round table, and we need to be talking. I think sometimes postpartum depression is a niche market, and all of a sudden it gets very popular, and we have a lot of people who are ďexpertsĒ in the field; people Iíve never met, and I think Iíve been around a long time! But itís important that we do come up with a curriculum; that we do have perinatal psychiatric mental health providers who are indeed experts in this field, so that women arenít being sloughed from provider to provider, and depending on what the theoretical model of that provider is, thatís what that woman gets. And if that therapist doesnít believe in psychopharmacology, that womanís not going to get it. I kind of think thatís malpractice because then if she gets my name from somebody, and comes to see me and we do a couple of visits and then she starts her medication and she says: Why didnít anyone help me do this sooner? -- now we have that whole therapeutic issue of impotent rage. So I think that we need to look much more holistically; look at women antenatally, even in primary care, do an assessment. I think that the flags are always there, and if we can pull them through and set up preventive care plans, women donít fall through the dark cracks of postpartum.




Slide 44. Katherine L. Wisner, MD, MS: Since Iím somebody whoís made my entire career doing fairly biological studies and drug studies, why am I on this panel? I think my colleagues have really said very well why Iím here; which is, when you treat patients with postpartum depression, you run very rapidly into the issues that have been discussed. And the fact that youíre using medications in childbearing-related situations -- pregnancy and breast feeding -- if there are great treatments that you can use, why not study them, offer them? My feeling is that we need a much broader base of tools to offer patients with depression; particularly female patients with childbearing-related depressions. My residents sometimes look at me and theyíll say: Whatís the right drug, what dose should I use, how do you treat this? And Iíll say: No treatment occurs outside of a therapeutic relationship. And they say: Oh no, Iíve just given her drugs. And I say: No. No treatment occurs outside of a therapeutic relationship, and if you think you can hand her a box of pills and tell her what to do with them and sheís going to take them, forget it. My colleagues are exactly right; these treatments all occur in this context of a therapeutic relationship, and Iíve had to think very carefully recently about medications and what they mean to certain populations. In my work with Cheryl Squire Flint, in her indigent, predominantly African-American population, when you say you have depression -- that is, an illness that then is existing in them, and you say: Here is a medicine that I am going to give you, that is only available by prescription, and itís regulated, and Iím going to give that to you and it will make you better -- the entire way thatís conceptualized is problematic. Cheryl has taught me so much about what ďnamesĒ mean. So that for example, when weíre talking about depression now, what we talk about is not that word, but we talk about it exactly the same way: but the expression they gave for us for this illness is ďstress distress.Ē And in the group of Cherylís front-line caseworkers, weíve developed an adapted dialectical behavior therapy set of modules that are really based on skill-building for women in this childbearing-related situation. It really takes out a lot of the disempowering verbiage and dynamics of this situation with medicines.




Slide 45. Dr. Wisner: The other issue is weíve talked so much about how these things are so importantly contextual: how a woman feels about being a mom; how a woman interacts with her baby; it isnít just a disease is in her -- to give it something and fix it. The ramifications of the illness, and to some extent its etiology, are really due to the context with the baby, with the family, with the community, with all kinds of layers, so that weíre not set with one biological explanation; hereís a medicine to fix it.




Slide 46. Dr. Wisner: There is IPT, thereís CBT; there are ways to think about how these incoming life event stressors interact with the coping skills network, and then looking at how one can restabilize oneís self through the use of those wonderful skills that we call psychotherapy. Thereís light in the world. So many years ago, our group began to work with colleagues at Columbia including Meg Spinelli; it was actually Meg who got me into light therapy for depression in childbearing women, and we focused primarily on light therapy for depression and pregnancy. A Cochrane Review and an APA (American Psychiatric Association) review that we did, both of which were meta-analyses, showed that the effect of bright light morning treatment for depression (the effect size), was similar to that of medication. And one of the big issues now is, why is it that we canít disseminate this treatment (which has decades of research and known efficacy) into more settings? certainly, a $250 light box is a significant up-front expense, but thatís a couple monthsí worth of medications for some people, and it can go to rural Pennsylvania, or Iowa, or wherever. Theyíre fairly simple to use, and theyíre empowering; the woman can adjust doses with input from knowledgeable folks. We think it works by normalizing circadian rhythms, so that there are even these environmental treatments.




Slide 47. The nutritional treatments I think are also fascinating. We have clinical trials now for EPA (eicosapentaenoic acid), an essential fatty acid for the treatment of depression, which is effective. My colleague in Tucson, Arizona, Marlene Freeman, is doing several studies of mixed fish oils (which are high-potency essential fatty acids) for depression during pregnancy and in the postpartum period. Alternatively, itís possible that nutritional deficiencies may play a role in psychiatric illness. I think this is an interesting area of study, looking at the contextual picture. We have a nutritional epidemiologist working in our group who has found almost a perfect correlation between the levels of essential fatty acids and depression score. Sheís done 2 studies looking at antioxidants and nutrients that our bodies use for healing; vitamin C and omega-3 fatty acids; essential fatty acids. Sheís also absolutely fascinated with vitamin D; I think thatís her next assay. She has collected nutritional data on all of our depressed and control patients to look at both things.

And finally, just to pull it together, so many of us cringe when we hear about things we donít know. I certainly hear from patients: Oh, I mentioned light therapy to the psychiatrist and they said, ďOh, come on,Ē or to my OB/GYN. Thereís this tendency to downplay anything weíre not familiar with. And my approach to that is always, no matter what it is: Whatís the patientís interest in it? How can I engage her in a way thatís going to be therapeutic, even if I think sucking on lime peels is the most bizarre thing ever? But if I can engage her in a way where we monitor sucking on lime peels and if that doesnít get her where she needs to go, then perhaps she can feel prepared to move to the next step in the therapeutic armamentariums. So itís those kinds of issues that I think are very important; not saying ďthis is the right treatment for your postpartum depression,Ē but engaging the patient in moving somewhere, even if itís, ďletís monitor you together.Ē And sometimes itís all you can get; theyíll agree to monitoring, but thatís it. Anyway, tool boxes with more tools is what I think we critically need.




Slide 48. Irene Frederick, MD: I really just resonated to that; to the belief system model. If a woman comes into your office, what is her belief system? What can we do to support that belief system? Iíll try anything. You want to try this? Weíll try it. But if she wants to do herbology, then I have some colleagues who are herbologists that Iíll refer to. My concern is that she sees somebody who knows what theyíre doing. Or homeopathy; we have two psychiatrists who are also homeopathists. So again, itís that collaborative relationship; sending them for body work, going for Reiki and going for other forms of chakra healing. If we support that, it embeds the relationship as trusting; because I think that so many women give off cues that somethingís going wrong, but we donít always acknowledge the cue. And the more she cues and the less we hear, the less sheís going to cue anymore; so itís that sensitivity as an obstetrician, pediatrician, family practice, nurse practitioner. Anytime you get two women together, youíve got a group!

So itís always trying to listen for that hidden language. If youíre sitting in a group with women, you can say: You know, you sound like youíre having a hard time; did you ever think about seeing someone, or trying this? I think that a lot of case-finding comes from that relational cue listening, because theyíll say: Well, I told them I didnít feel good, but they didnít really listen. Again, it goes back to womenís relational connection. The biggest paradox in womenís relationships is putting others ahead of herself: Iím not going to risk the relationship with my doctor, thinking that he might not like me if Iím crazy (or she might not), so Iíll just, Iíll go somewhere else. The privilege of being a nurse is that theyíll often come talk to you; youíre not the doctor. And thatís great because then you can say: Well, Iím colleagues with the doctor, so we have to talk about this. You kind of segueway in based on the respect of the patient and the relationship.

Dr. Dennis: An important point that you were talking about is listening to the motherís cues. I think another important aspect is just asking her what she thinks is the cause of her depression, and then offering treatment options that are related to the cause of her depression. Itís called the matching hypothesis, and I think that thatís one way to increase compliance, because often you see, even if mothers do go for treatment, they often are not compliant; so to enhance treatment compliance, you need the matching hypothesis; matching the treatment with what the mother thinks is the etiology of her depression, which means looking at the cues and communication, and asking the mother what her preferences are.

Dr. Wisner: Something thatís very humbling for me: our antidepressants generally in intent-to-treat samples, you get about a 50%-60% response, right? Well, you get about a 33% placebo response in control groups, so our ďsuper medsĒ are about twice as good as placebo. Placeboís pretty darn good, if you get a third of people better. So damning these other treatments before theyíre studied is a little premature.

June Andrews Horowitz, PhD, APRN, BC, FAAN: I want to pick up on a couple of themes that I heard. One point that came across is: Do women find a particular treatment contextual? Does it make sense to her? Is it matching how she understands whatís going on with her in her depression? So itís really important for us to ask, because we know thereís enough evidence to say that thereís no one cause of depression, period; but certainly of postpartum depression. Therefore, thereís not going to be just one magic bullet kind of treatment that we should always jump to. Letís be multifaceted in how we think about treatment, given that we know that itís caused in a multifaceted way; there might be 6 risk factors that for a woman at one point in time, add up to be the tipping factor that caused her to be depressed now. Maybe she wasnít the last time she had a baby; maybe she hasnít been at another time in her life -- itís not always a new incidence of depression postpartum. It can be, but it also can be a rare occurrence, or a second or third, and it varies. So why is it happening now? We need to talk with women about that, regardless of whatever clinical role we might be in.

Also, the context involves relationships; the woman as well as partners, her baby, other children. Jeanne so beautifully described what she does in treatment as an expert over 30 years. Few providers I think, at this point in time, hit that ďgold standardĒ kind of level. Iím doing sort of the research side of what Jeanne does in practice every day; trying to test if we do an interactive intervention with mother and baby. Does it make a difference? Intuitively, should it? Sure. But we have to test these things and get the evidence; otherwise, they wonít get paid for, and they also wonít get disseminated, and they wonít become the standard practice that Jeanne provides. Many other clinicians just donít, and may not even think about bringing the baby into the office: Oh, my goodness! Thatís not something that I would do in psychiatry! So we really have to open our minds and think outside the box as well.




Slide 49. Catherine Cerulli, JD, PhD: Iím not here as a postpartum expert, but as a domestic violence expert. Iím repeatedly struck by the parallels between the fields, and in the work that we do assessing readiness for victim-empowered steps: not necessarily to leave the partner but to get safer; not necessarily to get a divorce, but to get a protection order. One of the things that I think is an issue for our field, and Iím hearing with postpartum depression, is overcoming stigmatization of the label. The second really big thing is this concept of what does it mean to be a mother or a wife or a woman; the cultural burden of being the perfect mother or the perfect wife. I think that some of the work that youíre doing in looking at people as a whole maybe letís them express that theyíre not meeting the images that are being projected on them. So I think this is pushing the envelope so much further to say: How do you assess people to have a better life? -- as you were saying earlier, Judy, holistically. But the parallels are striking and I think that the fields are just on this exact same track.

Dr. Horowitz: If we donít do that kind of work to understand what this means to the woman, and what kinds of treatments or approaches, supports, etc., would be acceptable to her and make sense, weíre never going to increase the treatment rate. As we said, only about half of the women are evaluated, and fewer than those even get into treatment. I just did a secondary analysis of some data that was part of a mother-baby interaction trial. We had nurses seeing these mothers, on the phone first and then face to face up to 4 months postpartum, actively encouraging all the moms who had scores in the moderate-to-high range to call their primary care provider; offering to assist even to do it, to get into treatment. Well, how many women actually got there? About 19%. So Iím looking at it more actively in the current study; itís a huge need. We were also doing home visits; we were going to them. They were all nurses, and we lost almost nobody from the study for our intervention -- less than 5% attrition. Wouldnít I love that if it were therapy! But I think itís because we went to them, they connected with the nurses; we didnít even lose control group people, and I had to get the nurses not to intervene in the control group; it would ruin the whole study! But it was still a presence, and it was still an offer of referral as needed; so, a small intervention. But I think we have to be user-friendly and also figure out, as you said, Cindy, different ways to deliver the care.




Slide 50. Laura Miller, MD: To re-emphasize the role of the interpersonal context and connection, some of the nonpharmacologic therapies that you have talked about really call for that as an integral part of the treatment. For example, bright light therapy: What new mother has 20-30 minutes every morning to sit in front of a bright light unless somebody else steps in to help her have that available time? So intrinsically, that is a therapy that engages support as part of the treatment package; even more so, interpersonal psychotherapy, in which a case a woman is learning how to examine, renegotiate the roles in her life, which requires other people to change as well as her. Optimally, medication treatment also engages other people, but often enough, that part of the treatment is neglected if medication is the only treatment modality, and the implicit assumption that some people can make is that thereís something wrong in the brain of the mother; itís being fixed by this chemical and now everybody else is off the hook and nobody else has to be involved.

Dr. Driscoll: And thatís unfortunately when youíll get the suicidal ideation; 4-6 weeks postmedication, you get the call from the ER, and then sheíll say: Well, if my husband just cared if I took my happy pills, Iíd be happy. And thatís where the familyís not involved in understanding what the potential ideologies are for and how this is a holistic care plan. And then youíve got to look at the partners, whether theyíre male or female, because then they get depressed after this depression is healed. So youíre looking at this dynamic thatís constantly changing. It's important to be aware of all these changeable factors, and trying to put together this multivariant care plan that includes all the support, the nutrition, the vitamins, trying to get everybody on the same page. The frustration I have is trying to get people to call you back; when youíre trying to get on that collaborative page with other people. But women are very smart, and theyíll figure out ways to do a lot of things. They teach me an awful lot when I just sit and listen to what they have to tell me; about how they needed to get what they needed to get. But I often help them fire their healthcare providers, too! Sadly, if theyíre not getting what they need -- this is a consumer market -- they have every option to get a second and third and fourth opinion, and I would encourage them myself when Iím hitting my head against the wall; we need to get a consult, we need to go find somebody else to look at you through different eyes because our perceptive realities get blurred when trying to do so much for so long.




Slide 51. Seth Rubin, MD, MSCP: Just coming from the standpoint of primary care practitioner (family medicine), Iíve listened very intently and with a lot of interest about the nonpharmacologic treatments, because my experience with the patients in the population that I take care of, which is a predominantly disadvantaged patient population, many people are very reluctant to either spend the money or trust that a medicineís going to help them, or not cause them side effects, so itís often very difficult to get people to start a medication. But on the same token, itís very difficult to sometimes consider having folks take part in some of these nonpharmacologic treatments that were suggested, which all sound very promising, but again, from the point of view of folks that I generally take care of, thinking about coming in and talking to yet another stranger about their problems is very rarely accepted as a good idea. Even if they agree to take the phone number of the person that Iím suggesting, they still usually donít follow up. Thinking about things like body work and massage and herbal things, these things can be extremely expensive, and thinking about again the population that I take care of, itís hard to imagine them really taking part in a lot of them. What I think probably needs to be investigated more closely are ways that primary care physicians -- whether itís OB/GYNs, pediatricians, family physicians, etc. -- ways that they can be effective during those few encounters that these women are actually making with a clinician; thatís when theyíre coming for help. It was pointed out that if I come for this purpose and Iíve taken 3 buses and Iíve arranged child care, why canít we do it all in that one session? I think thereís a sore lack of direction for people like me about what I can do when that personís there to really help them thatíll have a long-lasting effect? I think we all know being supportive and doing some good listening is helpful, but is there something else that I can do? The patientís coming to see me; she will not see anybody else. She cannot afford or doesnít want to take a medicine, but she still wants me to do something.

Dr. Driscoll: Itís important to be connected to your community groups; your church connections. Depending on the community of women that you serve, women and families, some of the cultural, religious groups are so supportive to women; like the quilting groups, the cooking groups. Itís saying: In your community, this church has this, this parish has this; let me give you the name of Mrs. Jones who runs this. I think it was Zachary Stowe who had a mother-to-mother buddy system at Emory University, trying to hook them up, not with healthcare providers so much, but to the powerful women in the community who might be running a mother-baby hang-out time, or letís play with our kids, cook with our kids. It decreases the marginalization; stigmatization. Letís get them in a place where women are empowering and caring and connected; women do help each other a lot, which is a nonpharmaceutical treatment methodology! In the United States, we have this promotion of individualization, separation, rather than community and connection. So we need to be helping women and men set up more community connection, because there are a lot of stay-at-home dads who are very depressed hanging out at the playground because they feel like none of the women want to talk to them. Then we have a lot of gay, lesbian, and transgender couples that weíre ignoring as far as postpartum depression. So everybody has their culture community. That can be the gift of your listening and saying: I know about this cooking group; and thatís not so scary. And then also the relationship you have with your patients to say: I know this is hard for you; come back in a month and letís see whatís gone on -- so that they know that you want to follow up; Iím sure you do that. That relationship is so critical, even though they might be there for that little bit.




Slide 52. Dr. Rubin: It strikes me that that sort of community assistance between different people -- your neighbor and someone else who seems to have a similar background or experiences -- has a kind of currency that people are freely willing to spend, and it gets back to them as well.

Dr. Dennis: I completed a peer support trial; mothers helping mothers. We identified moms with depressive symptomatology -- the EPDS greater than 12 at the 8-week immunization clinics. We screened all moms, and moms that had depressive symptomatology were put into a clinical trial. The mothers that received just telephone-based support from another mother -- just to talk to validate their experiences, to tell them that theyíre doing a great job -- these moms had significantly less depressive symptomatology. Iíve taken that model, and thatís now my prevention trial. Mothers in the immediate postpartum period get matched up with other mothers in their communities -- their peers -- just to have someone there to provide support where itís proactive, where the new mother doesnít have to call the experienced mother. The experienced mother, I call the peer volunteer, telephones the new mother on a regular basis just to see how sheís doing, to show that someone cares about her in the community. And we train these peer volunteers to be mediating links between mothers in the community and healthcare professionals, so then they can refer them to any types of professional health services in the community. That can treat depressive symptomatology, and now Iím looking at that to try and prevent the development of postpartum depression; creating support networks, because lack of social support is one of the biggest risk factors.

Dr. Wisner: Sethís touching on something that we spent a lot of time talking about, which is this fantasy that you identify depression, they go to a mental health professional over here, and itís as if something magical is going to happen in the magic appointment. But what we began to wonder was, if we have this holistic view -- there are a whole set of things around self-care, community engagement, education -- how could we operationalize that so there's not so much emphasis on the magic appointment; youíve got to wait 6 weeks for the magic appointment. There are things that havenít been very well articulated that I think youíre touching on, that I think are critical to define.

Dr. Dennis: There are things that we can do with mothers antenatally that can have a preventative effect that haven't been rigorously evaluated. Self-care strategies: encouraging the mother to eat properly, to make sure that every day she gets a break, and to educate the father or the partner antenatally that indeed the postpartum periodís going to be a stressful time period. And based on the literature, this is what mothers say that they want in the postpartum period from their partners. Educate partners because partners say: I donít know what to do. The biggest risk factor for partners is that approximately 8% of partners will develop postpartum depression. The mother has postpartum depression, then the dad gets depression.

To try and prevent all this as a primary practitioner is to really encourage self-care so the mother starts off in a very healthy environment: to say that you need a break; make sure that you set up supportive resources; make sure that dad knows what your expectations are, so that the relationship doesnít deteriorate. Thereís a lot of scrapping in the postpartum period; you can try and prevent some of the stuff. We havenít even talked about sleep deprivation. Thatís a real big thing as well. My research shows that if a mother gets less than 6 hours of sleep within a 24-hour time period, sheís 4 times more likely to develop depressive symptomatology; so she needs breaks.

Dr. Horowitz: What it underscores, too, is the need to bring mental health care -- and I donít mean just treatment, but care in the broad sense and in the specific sense -- into primary care, and also through VNAs (Visiting Nurse Associations), and home visiting and other approaches.




Slide 53. Linda H. Chaudron, MD, MS: Can I just make a comment because I think itís a theme actually for a lot of us: weíre often talking about very different populations. The population that Cindy was just talking about with partners and husbands Ė that's not my population. My moms have no one, and there is no one to give them a break so that they can sleep. I think this is the population youíre seeing, and I think as we develop tools, we really have to think about the populations that weíre talking about, because the tools are going to be very different.

Iíve just been floored: when you ask my moms whoís their support, there is no one. And what do they do with their time? They tend to their children the best that they can, which is wrought with amazing amounts of chaos and difficulty. And you ask about the partner: 3 fathers, all in prison. When we hear about one father that provides financial support: great! So we have to be careful about the interventions weíre talking about, and which population, and how we can help providers with different populations. I think your questions are critical about how do we help our primary care providers who are it. They really are it, and they donít see them all that often either. And I think we have to think about different levels of interventions, as well as asking the moms that you see, what they are willing to do. Nobody asks them what theyíre willing to do. What are you willing to do? Youíre not willing to take medicine; youíre willing to come see me. Okay, how often are you willing to come see me? What can I do for you in that, how can I talk with you? But there are so many levels, and I worry about how we talk about the interventions, because we have to think about them in context.

Dr. Driscoll: I think thatís so important, because we had a perinatal advisory committee in Massachusetts; we had a grant looking at that, and the great thing was bringing together all the people across the state of Massachusetts who were in the trenches doing the work with the different cultures of women and saying: Weíve got to be careful that weíre not moving into this kind of classed-care model, or that weíre talking about everything that works with middle class Caucasians and forgetting that we live in a community of diversity. That gets lost sometimes if only 2 people are talking, forgetting the Northeast or the Northwest corridor; to bring them in. I was called to give a talk in Maine to the public health nurses -- 60 public health nurses in the state of Maine do all the healthcare for the whole state, and they have an issue for mental health! Iím thinking I should probably run the group for the nurses, forget the patients!

Dr. Horowitz: Well, I think thatís a good place for us to wrap. Thank you very much.



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