Postpartum depression (PPD) is one of the most common problems affecting new mothers worldwide. Though physiological changes in the postpartum period may be associated with shifts in mood, PPD differs from typical baby blues. While the “blues” are characterized by feelings of sadness or emotional reactivity in the immediate postpartum, these symptoms do not necessarily interfere with daily activities or lead to significant difficulty in normal functioning. In contrast, PPD is more severe and persistent. PPD can involve loss of interest in usual activities, mood swings, changes in appetite and sleep habits, and suicidal thoughts, among other symptoms in the period following childbirth.
PPD affects more than 1 in 7 women and, if left untreated, may be associated with maternal morbidity and mortality as well as numerous negative implications for infant attachment, child development, and overall public health and societal well-being. A combination of genetic factors, hormonal shifts in the postpartum, socioeconomic drivers, and underlying psychiatric illness increase the likelihood of PPD. Recognizing specific risk factors may help with PPD prevention and treatment with interventions including psychotherapy, medication, hormonal interventions, and social support.
Approaches to Screening for Postpartum Mood Disorders
A review published in 2019 found that upwards of 50% of women with PPD go undiagnosed. According to a systematic review Byatt and colleagues observed that only 22% of women screening positive for depression received mental health treatment. While routine screening does not necessarily lead to increased levels of treatment, implementation of interventions such as the Perinatal Depression Management Program developed by Dr. Laura Miller, which included on-site screening and same-day evaluation by a perinatal care provider, led to a two-to-four-fold increase in mental healthcare utilization. However, racial and socioeconomic disparities continue to plague maternal mental health treatment outcomes – perinatal mood disorders are twice as likely to go undiagnosed and untreated for those experiencing poverty, material hardship, and racism. Experiences of emotional upset due to racism have been found to be a potentially key predictor of worse PPD outcomes.
Routine screening for perinatal mental health disorders is recommended given that only about 20% of these disorders are diagnosed without standardized screening. The Edinburgh Postnatal Depression Scale is typically administered around 6 weeks postpartum as a clinical screening tool for depression. The Patient Health Questionnaire-9 is also a valid and reliable psychometric scale to screen for PPD. However, there is significant variation among recommendations for perinatal screening: the U.S. Preventive Services Task Force, as well as National Institute for Health in the United Kingdom, recommend screening only when there are resources for effective treatment in the follow up. Alternatively, the Canadian Task Force on Preventive Health Care recommends against screening individuals for depression during pregnancy and the postpartum period using standardized questionnaires based on evidence identified by the task force indicating uncertainty as to whether screening is more beneficial than usual clinical care. The American Academy of Pediatrics recommends screening at well-child visits, 1, 2, 4, and 6 months perinatal. The American College of Obstetrics and Gynecology (ACOG) recommends screening for depression and anxiety at least once during the perinatal period using a standardized and validated tool. ACOG specifically recommends that obstetric care providers screen at the comprehensive postpartum visit and initiate treatment if the patient screens positive.
State-Specific Policies for Postpartum Mood Disorders
The National Academy for State Health Policy recently evaluated recommendations or requirements across states pertaining to screening for depression in the mother during well-child visits covered by Medicaid:
- 12 states allow screening for maternal depression during well-child visits
- 25 states recommend screening for maternal depression during well-child visits
- 6 states require screening for maternal depression during well-child visits
- 8 states do not have an active maternal depression screening policy in place
In terms of follow-up for individuals with positive screens, 32 states have a specific protocol for tracking and referrals. For states that require PPD screening, some studies have found that these policies do not necessarily influence clinical outcomes. Some states also have programs to extend Medicaid coverage for follow-up treatment beyond the typical 60 days of coverage. Private or other types of insurance have various policies regarding PPD screening and treatment coverage.
In a recent systematic review of evidence, researchers found that screening programs that involved universal and targeted screening for PPD reduced perinatal depression and anxiety. Overall, these programs identified and treated undiagnosed cases and increased accessibility of mental health services. The authors noted that increasing acceptability and accessibility of screening for maternal mental health conditions should also bolster effective treatment options and follow-up care. It was found in this systematic review and meta-analysis that no studies were conducted in under-resourced settings. The authors concluded that implementation research would help to identify and address the best screening practices for specific clinical settings.
Barriers and Facilitators to Care
Despite existing screening and treatment recommendations, many women do not receive adequate care for PPD. Numerous barriers may prevent effective care, including but not limited to delayed or missed screening at primary care appointments, failure to follow up with specially trained depression care clinicians, and overwhelmed and understaffed mental health facilities.
There are many potential strategies which can be used to improve the screening to treatment pathways for PPD. One program aiming to improve perinatal depression screening to treatment pathways is PRISM (PRogram In Support of Moms) which provides clinic-specific training, on-demand psychiatric telephone consultations for patients, clinical resources for providers, and proactive tracking of women who screen positive for depression.?Another initiative – implemented by the California legislature in 2018 – requires health insurance companies to follow through with case management programs to support patients in finding mental health services (similar to case management programs for those with diabetes or other medical conditions).
Given that many patients begin experiencing depressive symptoms during or before pregnancy, screening and treating before delivery could improve postpartum outcomes. Digital screening platforms and standardized flow of patient referrals could be used to facilitate this process. Strengthening perinatal mental health programs and investing in research can also help busy clinicians in providing them with the best evidence-based clinical practices for the care of women with PPD. Efforts to destigmatize perinatal mental health problems through education and community resources would not only raise awareness about PPD but would also empower women on the path to becoming well.
STEPS for PPD: Screening and Treatment Enhancement for Postpartum Depression
The Center for Women’s Mental Health at MGH recently launched a research study, funded by the Marriott Foundation, which aims to assess screening to treatment pathways in individuals with postpartum depression across the Mass General Brigham (MGB) hospital system: Screening and Treatment Enhancement Program For Postpartum Depression in the MGB System or STEPS for PPD. In collaboration with multiple obstetric clinics across MGB, the STEPS project will assess clinical and treatment outcomes of postpartum screening and explore barriers and facilitators to screening and treating PPD. STEPS builds on previous research to investigate systems of PPD screening, referral, and treatment. Ultimately, we hope that findings from the project will ensure that patients are universally screened for postpartum depression and, if they do screen positive, are referred to receive adequate care and treatment of symptoms. The knowledge gained from this study will illuminate factors associated with utilization of treatment services for postpartum depression and can inform how best to increase access and uptake of services for future patients.
Margaret Gaw, BA
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