What Keeps Women with Perinatal Depression from Getting the Help They Need?

 

The U.S. Preventive Services Task Force (USPSTF) recently released recommendations on Screening for Depression in Adults. The Task Force recommended that clinicians screen ALL ADULTS for depression and noted that screening in the primary care setting is beneficial. Echoing the recommendations made by the American College of Obstetricians and Gynecologists last year, the  USPSTF also emphasized the importance of screening in populations at particularly high risk for depression: pregnant and postpartum women.

It is discouraging to note that recommendations regarding screening have not necessarily resulted in increased rates of treatment in women with perinatal depression.  Dr. Nancy Byatt and colleagues published an analysis of 17 studies (published between 1999 and 2014) where women were screened for perinatal depression, and they assessed levels of subsequent treatment.  

If you look at the women who were screened for depression but received no additional intervention, rates of treatment were very low.  An average of 22% (13.8-33.0%) of women who screened positive for depression received at least one mental health visit.

A recent study from Venkatesh and colleagues, including Dr. Marlene Freeman from the Center for Women’s Mental Health, makes me feel a little bit more optimistic.  This was a prospective observational cohort study conducted from July 2010 to June 2014 at Brigham and Women’s Hospital and Massachusetts General Hospital.  Pregnant women were screened at 24-28 weeks gestation and again 6 weeks after delivery using the Edinburgh Postnatal Depression Scale ( with a cutoff score of ?12).

Among 8985 women receiving prenatal care at the two sites, 8840 women (98%) were screened for depression shortly before delivery and 7780 women (86%) were screened after delivery. A total of 576 women (6.5%) screened positive for probable depression.

All women who screened positive were referred for an evaluation by a mental health professional; 79% of the women were evaluated, which was more common shortly before delivery than after delivery (83% vs 71%). One hundred twenty-one women (21%) were not evaluated further after a positive screen; primary reasons included declining a mental health evaluation (30%) or transferring obstetric care (12%).  Women who screened positive shortly before delivery were significantly more likely to link to mental health services compared with women who screened positive after delivery (adjusted odds ratio, 2.09; 95% CI, 1.24-3.24; P = .001).

This is a good start.  The majority of the women who screened positive for depression were evaluated by a mental health professional.  (At these two hospitals, this is typically carried out by a perinatal social worker within the obstetrics department.) While we do not know how many of those women ultimately engaged in ongoing mental health services, we have an opportunity with this sort of screening to further evaluate and educate women with perinatal depression.

As we have said many times before, simply screening for depression is not enough.  But before we can improve the system, we need to better understand the barriers to treatment.  Unfortunately little research has focused on this important issue.  An exploratory study identified several important barriers to treatment; the factors which prevented women from seeking treatment included the stigma associated with receiving mental health treatment and limited access to care.  Women were more likely to engage in treatment if they were encouraged to seek help and if that help was readily accessible.  

Going back to the review from Byatt and colleagues, they found that use of mental health services increased two- to fourfold when screening was combined with additional interventions geared to decrease potential barriers to treatment.   For example, studies including interventions offering systematic follow-up, supportive therapy, or support groups were associated with an average mental health care use rate of 31%  Use of mental health services was even better when these interventions targeted both patient- and health care provider-derived barriers to treatment by using patient engagement strategies (44%, 29.0–90.0%), on-site assessments (49%, 25.2–90.0%), and perinatal care provider training (54%, 1.0–90.0%).

One of these interventions reviewed in this article, the Perinatal Depression Management Program developed by Dr. Laura Miller, deserves special attention and may serve as a model for the multidisciplinary care and treatment of women with perinatal depression.  This intervention includes on-site screening and same-day evaluation by a perinatal care provider, training and support of perinatal healthcare providers, and patient engagement strategies.

This program was implemented in an urban community health center in Chicago serving a predominantly Hispanic population. The Patient Health Questionnaire (PHQ-9) was administered during perinatal visits. Women who had positive screens were followed up at the same visit by a brief diagnostic assessment and engagement strategies.

Before the intervention, 10% of women with positive screens received on-site assessment. None of the patients with identified perinatal depression entered into treatment. After implementation of the program, significantly more women (93.5%) completed the PHQ-9 screening, and of patients with positive screens, 84.8% received an on-site assessment. Among patients diagnosed with major depression and offered treatment, 90% entered into treatment.

Because stigma continues to be significant with regard to mental health issues in mothers and mothers-to-be and because there are concerns regarding the use of medication in pregnant and nursing women, we must make sure that after screening, we help women to access appropriate resources and treaters who have expertise in the treatment of women during pregnancy and the postpartum period.

Ruta Nonacs, MD PhD

Bell L, Feeley N, Hayton B, Zelkowitz P, Tait M, Desindes S.  Barriers and Facilitators to the Use of Mental Health Services by Women With Elevated Symptoms of Depression and Their Partners.  Issues Ment Health Nurs. 2016 May 18:1-9.

Miller L, Shade M, Vasireddy V. Beyond screening: assessment of perinatal depression in a perinatal care setting. Arch Womens Ment Health 2009;12:329–34.

Miller LJ, McGlynn A, Suberlak K, Rubin LH, Miller M, Pirec V. Now what? Effects of on-site assessment on treatment entry after perinatal depression screening. J Womens Health (Larchmt) 2012;21:1046–52.

Venkatesh KK, Nadel H, Blewett D, Freeman MP, Kaimal AJ, Riley LE.  Implementation of universal screening for depression during pregnancy: Feasibility and impact on obstetric care.  Am J Obstet Gynecol. 2016 May 19.  [Epub ahead of print]