Earlier this year a national message of hope was announced for all pregnant and postpartum women, their children, their families, and our larger society – perinatal depression can be prevented.
Perinatal depression, depression in pregnancy or the year following birth, affects 1 in 7 women making it the most common complication of pregnancy. It is associated with negative short and long-term outcomes for mothers, babies, and families. Despite how common it is, its association with significant negative consequences, because despite its inherent treatability, it often goes unrecognized and untreated. Thus, women with perinatal depression often suffer needlessly, stigmatized, and in silence.
Over the past few years national attention has been brought to this issue. Professional societies and governmental organization now recommend that women be screened for perinatal depression and treated when identified, with the goal of symptom improvement and improved maternal and child outcomes. Earlier this week, the conversation has advanced even further with a focus on prevention in addition to treatment.
To simplify, if you know 7 woman who have been pregnant, you likely know at least one that has suffered from an emotional complication of pregnancy. Yes – we want her to get treatment once diagnosed with the condition. But better yet...what if we could prevent her from ever having it?
The US Preventive Services Task Force (USPSTF) has now said that this is possible. They recommend that clinicians provide, or refer, counseling interventions for pregnant and postpartum persons who are at increased risk of perinatal depression for counseling interventions (B recommendation). This recommendation is based on a systematic review of 50 studies, concluding in which they conclude “with moderate certainty that providing or referring pregnant or postpartum women at increased risk to counseling interventions has moderate net benefit in preventing perinatal depression.” Specifically, they note a nearly 40% reduction in risk and a number needed to treat of 13.5 – meaning 13.5 women would need to receive treatment for 1 case of perinatal depression to be prevented. Pragmatically speaking, women at ‘high risk’ are suggested to be those with one or more risk factors. This includes including a history of depression, current depressive symptoms, and socioeconomic risk factors including adolescence, single parenting, recent intimate partner violence, or other mental health related factors.
The interventions specifically cited as being effective in preventing perinatal depression are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). These are traditionally interventions that require significant education and training with 1:1 delivery. Given the current state and availability of behavioral health professionals and resources in general, most providers currently struggle to get timely referrals for women with known mental health diagnoses. Furthermore, access to therapists specializing in perinatal mental health is even more markedly limited. Increasing the number of women needing to utilize these services will further limit access if resource and referral options are not significantly increased. There is however hope for how we can increase needed access to care.
Evidence supporting the recommendation included therapy recommendations that varied in setting, intensity, format including individual and group, and intervention staff – this is fortuitous as it gives flexibility and increased options for providing recommended care.
In the USPSTF recommendations, the CBT-based “Mothers and Babies” program was cited as an effective therapy. It is notable that this program is delivered on a large scale through the Healthy Start Home Visiting Program in Florida. As more than 750,000 women across the 50 states and District of Colombia receive in-person home visits during pregnancy and after delivery, there is potential to partner with these, and other programs, to create synergy around common goals and novel approaches to care delivery through existing programs.
The IPT-based Reach Out, Stand Strong, Essentials for New Mothers (ROSE) program was also cited as an effective therapy. In fact, five randomized clinical trials have shown that ROSE reduces risk of postpartum depression in low-income women by half. That being said, its creator and collaborators recognize that clinical studies do not always translate into real-world care. Thus, they are currently funded by the National Institutes of Health to partner with 90 clinics/programs providing prenatal services to low-income women in all 50 US States. This study will help determine what is needed to help prenatal clinics/programs implement and sustain ROSE over time.
This later point is worth reflection. . . a critical aspect of getting women the care they need and deserve is by partnering with prenatal care providers to deliver this care. as They are pivotal in recognizing risk for perinatal depression, addressing it when it is present, and connecting women with care, whether its preventative or therapeutic. Along those lines, it is important to recognize that the vast majority of prenatal care providers are obstetrician/gynecologists. and Historically, they have not received training in mental health and thus, in many cases lack knowledge, comfort, and resources. Through the work of the Council on Patient Safety in Women’s Health Care , the American College of Obstetricians and Gynecologists, and other stakeholder organizations, recommendations are now clear. Clinicians caring for pregnant and postpartum women need to screen patients. and They must provide appropriate follow-up and treatment when indicated, including initiation of medical therapy and referral to behavioral health resources, like therapy or counselling.
Programs that increase the capacity of front-line obstetric providers to address perinatal mental health conditions now exist. The Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, was the first-in nation, state-wide, population-based, perinatal psychiatry access program designed to do this through provider trainings, telephone consultation with perinatal psychiatrists, and resources and referral services. MCPAP for Moms has been recognized as a sustainable and reproducible innovative service delivery model that has impacted state and national policy. It has already been replicated in two states (Washington and Wisconsin) and one health care system (Dignity Health, CA). Additionally, seven states (Florida, Kansas, Louisiana, Montana, North Carolina, Rhode Island, and Vermont) were recently awarded federal funds through the Health Resources & Services Administration (HRSA) to develop perinatal psychiatry access programs. Now, with funding from the Perigee Fund, the University of Massachusetts Medical School’s Lifeline4Momsprogram is actively creating a national network of these existing and emerging perinatal psychiatry access programs to conduct innovative research and outcomes evaluation. This is designed to inform the implementation of sustainable systems that integrate maternal and mental health care and improve individual, health systems, and societal outcomes.
Since women have been having babies, women have experienced perinatal depression. Innumerable women have suffered and have experienced the negative consequences affecting themselves, their babies, and their families. Recent years have provided hope for changing the future... hope for decreasing stigma... hope for improved recognition... and hope for increased access to treatment, as national conversations have catapulted efforts to address this issue. Now, hope is ignited further as we embark on conversations of prevention. To keep this hope alive, and more so, to transition the potential of hope into the reality of positive change, we need to continue to work together to make purposeful investments in large-scale programs and policies. Policies designed to holistically integrate perinatal and mental health care and thus improve the outcomes of our mothers, babies, and families.
