Punting in Medical Care
Most of us are familiar with the term doctor referral in reference to being sent by your physician to a specialist for treatment. There is a similar situation which is not really a referral. Recently the term punting has been used to describe the medical situation in which a patient is passed on to another doctor for treatment, but the patient’s condition isn’t treated by the second doctor and the second doctor sends the patient to yet another doctor.
Unlike a medical referral, punting has taken a more negative tone meaning passing responsibility to another doctor or abandoning a patient without diagnosing and treating the patient. Punting is very common in women seeking help with postpartum depression. Pregnancy-related depression or psychosis doesn’t fit into any physician’s purview or specialty. These patients can be punted from the obstetrician to the psychologist to the pediatrician and to other behavioral health providers and back again.
What is now termed punting with postpartum care I have always called a medical vacuum. Although the patient will probably not understand or know, in postpartum care, they have just stepped into a medical black hole. How can this happen?
Obstetricians are not trained in psychiatry. Psychiatrists are not trained in obstetrics. Pediatricians are trained in neither obstetrics nor psychiatry. So the patient is sent to one specialist after the other without getting a diagnosis. To make matters more complicated, physicians are more territorial than cats. If obstetricians spend too much time dealing with psychiatric issues, they can be accused of practicing outside of their scope. Likewise, if pediatricians or psychiatrists begin to practice obstetrics, they could also be accused of practicing outside of their scope.
On the other hand, a family practice doctor could at least in theory treat patients in all three of these areas. They would still, however, be threatened for practicing outside of their scope. This political stew is something that most patients don’t recognize and probably find hard to understand.
I don’t see this problem being solved any time soon.
My suggestion would be that obstetricians take another six months of residency to learn about behavioral health related issues in pregnancy, and how to manage them, and that psychiatrists do the same thing. It is not fair for mothers, fathers and children to simply not have a treatment option and to wind up by default in the deadliest of maternity-related illness, an illness which should be 100% preventable according to the CDC.
Although postpartum depression (PPD) and postpartum psychosis (PPP) can end in death, PPD is more likely to terminate in suicide while PPP is more likely to end in infanticide or filicide. Either can also be associated with suicide. Although PPD requires and responds to prevention or treatment, there is most often a little bit of time, of wiggle room with PPD. However, PPP is recognized as a medical emergency because nobody knows when the condition can lead to homicide or suicide.
Doctors and spouses are sometimes fortunate enough to get a warning about thoughts of filicide, but sometimes there are no warnings. When there is a warning, children should be immediately removed from the care of the filicidal parent until thei return of the children can be considered safe. PPP must be taken seriously.
Some parents will have enough self-awareness to know whether they are depressed or psychotic. In such cases, they will reach out to behavioral health specialists for assistance. In my experience, PPD responds poorly to the usual anti-depressant medications. Those treating PPD need to be careful and choose any medications wisely. I have found only two medication’s helpful for the treatment of postpartum depression: Ativan and Effexor.
Ativan is good for dealing with anxiety and promoting much needed sleep and rest. Addiction should not be considered an issue since taking Ativan and being alive is much better than not taking it and winding up dead. In my experience, Effexor is a good postpartum antidepressant which offers important postpartum motivation because somebody has to take care of the baby. There is no point in being content to sit on the couch, eat potato chips, watch TV, and listen to the baby cry, which has been my observation with other selective serotonin reuptake inhibitors (SSRIs) or the other norepinephrine reuptake inhibitors (SNRIs) besides Effexor.
If you are a healthcare provider or a family member and your spouse has not said one way or the other that they are depressed or homicidal, you may rely on erratic actions, such not sleeping or a knowledge of previous abusive traumatic events which may be triggered and return during the postpartum time.
Finally, most important, is establishing the correct diagnosis. Recently, Lindsay Clancy obviously had postpartum psychosis (PPP) for four months, was probably seen by more than one psychiatrist, and was given 12 different antidepressants over previous four months. After her last visit she was given the diagnosis of generalized anxiety disorder (GAD) rather than postpartum psychosis, (PPP). Three weeks after she was discharged from the hospital she strangled her three children. So, it is extremely important to give all postpartum patients the correct diagnosis and the correct treatment.
It's time to stop punting PPD and PPP patients from doctor to doctor and treat these postpartum problems effectively by learning what works, diagnosing accurately, and treating effectively. The CDC says these deaths are preventable.
While the general public is becoming more aware of mental illness associated with pregnancy, we are still waiting for mental health to be introduced into prenatal and postpartum care.
Providers of prenatal care have a golden opportunity to get in front of the pregnancy-related mental health issues. Whether they do or don’t feel responsible for preventing deaths from suicide, homicide, or drug overdose, they can still choose to prevent illness and death.