Five Questions With: Margaret Howard

Margaret Howard, division director of the Center for Women’s Behavioral Health and director of the Day Hospital at Women & Infants Hospital, is also the recent recipient of the American Psychological Association’s Committee on Women in Psychology 2018 Leadership Award.

Howard was recognized for her evidence-based and infant-inclusive, high-quality model of delivering mental health services to women experiencing postpartum depression.

Howard’s work has become a standard of care in Rhode Island and is being replicated across the Northeast and the country. Providence Business News spoke with Howard about her work.

PBN: You were awarded the American Psychological Association’s Committee on Women in Psychology 2018 Leadership Award in part for your model of delivering mental health services to women experiencing postpartum depression. Can you explain this model?

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HOWARD: Our model, developed and implemented in 2000, is a psychiatric partial hospital, a concept that has been a cornerstone of psychiatric treatment in Providence for decades. In this model, patients attend the program daily, Monday through Friday, for six hours with a length of stay between two and three weeks. Patients who benefit most from this model are those that don’t need quite the intensity of an inpatient unit but need far more than standard weekly outpatient treatment.

Our partial hospital, or day hospital, program is unique in that we only admit pregnant or postpartum women, and it is a mother-baby unit, which means that postpartum women bring their babies to the program each day. MBUs were implemented in some Western European countries shortly after World War II, and we relied heavily on our European colleagues for guidance when we were developing our program, which became the first and only MBU in the USA until 2012, when other programs began to open.

The European MBUs are largely inpatient units. In designing our program, we felt that a partial hospital model was optimal because it would allow families to be together in the afternoons and evenings, be a more realistic gauge of treatment progress and be more cost-effective than an inpatient stay. All of our treatment providers have special expertise in treating pregnant and postpartum women and our physicians have undergone additional training relevant to prescribing psychiatric medications to pregnant and breastfeeding women.

PBN: Can you share some recent developments in the treatment of postpartum depression?

HOWARD: The most exciting development in the treatment of postpartum depression is the growing recognition of postpartum depression, both its prevalence – up to 20 percent of women who deliver will develop postpartum depression – and its adverse impact on the mother but also her developing infant.

Another change has been the formal recognition by the American Psychiatric Association that postpartum depression can actually develop before a woman delivers. This is something that clinical and scientific experts in the field have been aware of for years, but formal recognition has a further-reaching impact.

Relatedly, it has been enormously gratifying to witness the development, over the past five years, of specialized treatment programs around the country modeled wholly, or in part, after ours. Our program at WIH has been referred to as “unique” for nearly two decades and relinquishing this moniker has been a welcome change, in that it signals the expansion of programs beyond Rhode Island.

Also on the horizon are new pharmacological treatments for women with postpartum depression, an example of which was published in the Lancet last year and, if approved by the [Food and Drug Administration]. will represent an additional pharmacological treatment option for women suffering from postpartum depression.

PBN: Please tell us something about postpartum depression most people don’t realize.

HOWARD: Many people, including health care providers who treat pregnant and postpartum women, don’t realize how common it is and that it can affect any woman. Postpartum depression cuts across social, economic, geographic, racial and ethnic lines.  While there are risk factors for developing postpartum depression, the postpartum period – up to one year after delivery – is the most vulnerable time in a woman’s life to come down with a mood or anxiety disorder. This flies in the face of the socio-cultural common wisdom that new motherhood is “the happiest time in a woman’s life.”

Because of cultural conditioning, many women are reluctant to speak up about what they may be feeling and experiencing. The means to reducing stigma is wider recognition, discussion and acceptance, and we are beginning to make progress in this arena.

The other thing that people don’t realize is that other conditions frequently get labeled “postpartum depression.” For instance, conditions such as anxiety, obsessive compulsive disorder, bipolar disorder and post-traumatic stress disorder can emerge or recur during the postpartum period. Proper diagnosis is essential when instituting treatment, and women also benefit from validation of their symptoms that don’t encompass depression.

PBN: The United States Preventive Services Task Force issued recommendations calling for wider screening of pregnant and postpartum women for mental illness in 2016. What are your observations of the effect of this change since then?

HOWARD: The 2016 USPSTF recommendation was so important because this recommendation targets all health care providers, not just obstetricians and pediatricians whose organizing bodies have historically issued depression-screening guidelines. The USPSTF recommendation holds that all primary care providers, regardless of discipline, should be screening women for depression during the peripartum period – pregnancy and postpartum.

This is another example of making headway in the destigmatization of mental health conditions. Since this recommendation came out, I’ve also received many more requests from editors of primary care medical journals to submit manuscripts pertaining to postpartum depression. And there are growing numbers of articles in such journals about postpartum depression or depression during pregnancy compared to even five years ago.

PBN: Please explain your approach to leadership in your field.

HOWARD: My approach to leadership in my particular field – clinical psychology – and area of expertise – perinatal mental health – has been to never lose sight of the fact that my effectiveness as a leader has always been within a context of other leaders and a really great team of colleagues.

As an early leader in the establishment of U.S.-based MBU, I felt it was important to be willing to share both what worked and what didn’t work, in other words our successes and our failures, so that others could learn from our experience. Because I am so passionate about the field of perinatal mental health, the need for specialized programs and the ever-present need to reduce stigma, I believe this comes through in my daily work and conversations.

Another major component in my leadership style is that I have a firmly entrenched belief that all pregnant and postpartum women need and, more importantly, deserve high-quality care. It is my fervent hope that the longevity, success and replication of our model serves as an inspiration to others that “it can be done.”

Rob Borkowski is a PBN staff writer. Email him at Borkowski@PBN.com.