Multiple studies have shown that routine medical care is not adequate when it comes to identifying and treating women with perinatal mood disorders.  Universal screening can help to increase the identification of mothers with mood and anxiety disorders during pregnancy and the postpartum period; however, there are still significant obstacles in terms of accessing mental health services.

Teen mothers are at high risk for perinatal mood and anxiety disorders.  In this population, there is a confluence of multiple psychosocial risk factors, including poverty, inadequate social supports, and exposure to physical and emotional abuse.  These factors increase teen mothers’ vulnerability to postpartum depression and may interfere with accessing appropriate care. Treatment is a challenge in this population as pregnant adolescents are poorly adherent with mental health services, so we are in need of programs that support and address the mental health needs of adolescent mothers.  (Read more about the impact of teen pregnancy on mental health HERE.)

The Colorado Adolescent Maternity Program (CAMP) is a comprehensive, multidisciplinary program for pregnant and parenting adolescent mothers and their children which serves an ethnically diverse and low socioeconomic status population in the Denver metropolitan area.  One element of that program is the Healthy Expectations Adolescent Response Team or HEART, an embedded mental health care program focused on improving the identification of mental health issues in this population and increasing rates of mental health treatment in adolescent mothers.  The key components of the program include:

  1.  At intake, all patients enrolled in CAMP participate in a one hour psychosocial interview conducted by a social worker or case coordinator.
  2. At intake, patients are screened for depressive symptoms using the CES-D. Additional screens, the My Mood Monitor (M3) and Mood Disorder Questionnaire (MDQ), are included to screen for anxiety, trauma, and bipolar symptoms.  These questionnaires are administered again in the third trimester.
  3. After delivery, pediatric providers care for mothers and their children simultaneously at clinic visits. Adolescent mothers are screened using the Edinburgh Postnatal Depression Scale (EPDS) and M3 at 2 week, 2, 4, 6, 9 and 12 month well-child visits.
  4. Patients who have positive EPDS or M3 scores or are experiencing mental health symptoms are referred to the HEART program. Initial diagnostic evaluations are conducted by a psychologist and patients are then triaged into four possible treatment options:
  • Referral back to the community if mental health treatment services are already in place.
  • Referral back to CAMP social workers if symptoms do not meet criteria for mental disorder and symptoms are secondary to social stressors.
  • Individual psychotherapy with the psychologist.
  • Individual psychotherapy and referral to HEART medical providers for psychopharmacology management.

Over a three year period, 894 pregnant adolescents were enrolled in CAMP and 885 patients were screened for mental health issues. Prior to the inception of the HEART program, 20 % of the patients were identified as having postpartum depressive symptoms. Successful referrals to community mental health facilities occurred in only 5 % of identified patients. After the inception of HEART, 41 % of the patients were identified as needing mental health services. Nearly half of the identified patients (47 %) engaged in mental health treatment with the psychologist affiliated with the program.  While various demographic factors, including age, parity, ethnicity, and parent and partner involvement,  did not appear to have a significant impact on treatment engagement, having a trauma history was associated with lower treatment engagement.

These findings indicate that a mental health program embedded into an adolescent obstetric and pediatric medical home can be successful in improving the identification and engagement in mental health treatment.  The key components of this program include universal screening, intensive social work and case management involvement, and ready access to onsite mental health care providers.  While this program is specifically designed for adolescents, one might wonder if a similar program could be integrated into obstetrical and pediatric practices in order to improve the identification of all women with perinatal mood and anxiety disorders.

Ruta Nonacs, MD PhD

Ashby B, Ranadive N, Alaniz V, St John-Larkin C, Scott S.  Implications of  Comprehensive Mental Health Services Embedded in an Adolescent Obstetric Medical Home.  Matern Child Health J. 2016 Mar 9. [Epub ahead of print]