March 23, 2017
Over the last decade, appreciation of the prevalence of perinatal depression – depression during pregnancy and/or the postpartum period – along with interest and willingness to diagnose and to treat these disorders across primary care, obstetric, and psychiatric clinical settings – has grown.
The passage of the Affordable Care Act in 2010 included the Melanie Blocker Stokes MOTHERS Act, which provides federal funding for programs to enhance awareness of postpartum depression and conduct research into its causes and treatment. At the same time, there has been increasing destigmatization associated with perinatal mood and anxiety disorders across many communities, and enhanced knowledge among clinicians and the public regarding evidence-based treatments, which mitigate suffering from untreated perinatal psychiatric illness.
There also has been a wave of interest around the country in establishing consistent screening for postpartum depression across a range of clinical settings. Approximately 40 states have instituted guidelines and recommendations regarding screening for postpartum depression. These positive developments, in part, follow recommendations from both the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists to move toward routine screening for depression, particularly among vulnerable populations such as pregnant and postpartum women. Both groups coupled their screening recommendations with a call for adequate systems to ensure treatment and follow-up but neither suggested how to implement it (, ).
The importance of identification of perinatal depression cannot be overestimated given the impact of untreated perinatal mood and anxiety disorders on women and families. Unfortunately, data describing the outcomes of these screening initiatives have been profoundly lacking.
There are many unanswered questions. What proportion of women get screened from state to state? What are the obstacles to screening across different sociodemographic populations? If screened, what proportion of women are referred for treatment and receive appropriate treatment? Of those who receive treatment, how many recover emotional well-being? These are all critically relevant questions and one has to wonder if they would be the same from other nonpsychiatric disease states. For example, would one screen for HIV or cervical cancer and not know the number of women who screened positive but failed to go on to receive referral or frank treatment?
This knowledge gap with respect to outcome of screening for perinatal depression was highlighted in one of the few studies that addresses this specific question. Published in 2016, the systematic review describes the so-called “perinatal depression treatment cascade” – the cumulative shortfalls in clinical recognition, initiation of treatment, adequacy of treatment, and treatment response among women with either depression during pregnancy or postpartum depression ().
The investigators included 32 studies where they were able to look specifically at this question of what happens to women who are identified as having either antenatal depression or postpartum depression. In total, six studies examined the rate of treatment of women who had been diagnosed with antenatal depression, resulting in a weighted mean treatment rate of 13.6%. For women identified as having postpartum depression, four studies examined showed a weighted mean treatment rate of 15.8%. What that means is that even if we have a sensitive and specific screening tool and we look only at women who have screened positive, we still have just 14% and 16% of women receiving treatment of any kind.
Drilling down to the issue of treatment adequacy – defined in the review as at least 6 weeks of daily use of antidepressants or at least 6 weeks of psychotherapy – the picture is unfortunately worse. Among the entire population of women with diagnosed antenatal depression, 8.6% received an adequate trial of treatment. Similarly, 6.3% of women with diagnosed postpartum depression received an adequate trial of treatment.
Continuing down the treatment cascade, remission rates also were extremely low. The overall weighted mean remission rate – reflecting the percentage of women who actually ended up getting well – was just 4.8% for women with antenatal depression and 3.2% for women with postpartum depression. These are striking, although perhaps not surprising, data. It suggests, at least in part, the fundamental absence of adequate referral networks and systems for follow-up for those women who suffer from perinatal depression.
It is well established that postpartum depression is the most common complication in modern obstetrics. The data presented in this paper suggest that most women identified with perinatal depressive illness are not getting well. Assuming a prevalence of 10% for antenatal depression and 13% for postpartum depression, there are about 657,000 women with antenatal depression and about 550,000 women with postpartum depression in the United States. If this review is correct, more than 31,000 women with antenatal depression and almost 18,000 women with postpartum depression achieved remission. That leaves more than 600,000 women with undermanaged depression in pregnancy and more than 500,000 women with incompletely treated postpartum depression.
This is a wake-up call to consider a refocusing of effort. The importance of identification of women suffering from postpartum depression is clear and intuitive. We should certainly not abandon screening, but perhaps there has been an overemphasis on identification and incomplete attention to ensuring that referral networks and opportunities for clinical follow-up are in place following positive screening. There also has been inadequate focus on the obstacles to getting women in to see clinicians and getting those clinicians up to speed on the evidence base that supports treatment, both pharmacologic or nonpharmacologic.
Right now, we don’t even know for sure what obstacles exist to referral and treatment. Surveys of community clinicians suggest that collaborative care in managing reproductive-age women or pregnant and postpartum women has not evolved to the point where we have a clear, user-friendly system for getting patients referred and treated. In Massachusetts, where I practice, we have a state-funded effort () to train colleagues in obstetrics about how to identify and treat perinatal depression; perinatal psychiatrists also are available to consult with community-based clinicians. However, we do not have data to tell us if these efforts and the resources used to support them have yielded improvement in the overall symptom burden associated with perinatal mood disorders.
The bottom line is that even after identification of perinatal depression through screening programs, we still have women suffering in silence. It is so easy to get on the bandwagon regarding screening, but it seems even more challenging to design the systems that will accommodate the volume of women who are being identified. The fact that we do not have parallel efforts focusing on getting these women referred and treated, and a system to monitor improvement, conjures the image of setting off to sail without checking whether the boat is equipped with life preservers.
Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.