The American College of Obstetricians and Gynecologists (ACOG) now recommends screening for perinatal depression and anxiety, stating that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standard, validated tool.”   Approximately 40 states have instituted guidelines and recommendations regarding screening for perinatal depression; however, we are still gathering information on how successful these recommendations have been in terms  identifying and treating women with perinatal depression.  

The biggest problem, and perhaps the most difficult to navigate, is that we are attempting to care for this vulnerable patient population without adequate mental health resources in the United States.  We simply do not have enough treaters with expertise in perinatal mood and anxiety disorders.   

At the present time, we are dealing with the inadequacy of mental health services in our healthcare system by recruiting ancillary providers — for example, using obstetric providers to screen for and manage perinatal depression.  The American College of Obstetricians and Gynecologists (ACOG) has recommended that clinical staff in the practice “should be prepared to initiate medical therapy, refer patients to appropriate health resources when indicated, or both.” 

However, if 15% to 20% of the women screen positive, this will require additional, more thorough evaluation.  And how long will this evaluation take? If you are an obstetrician who sees 20 patients per day, how will you fold in the extra time it needs to evaluate six or seven additional patients? And what if one of those patients is reporting suicidal thoughts or intrusive thoughts about harming her child? How will that be managed in a busy outpatient obstetrics practice?

Previous studies have indicated that referrals to mental health providers outside of the obstetric practice are problematic.  Women who need care may face many obstacles in obtaining that care, including stigma, inadequate childcare, limited access to specialized care, and high cost of mental health services.  Could specialized women’s mental health programs ensure that more women with perinatal psychiatric illness receive care? 

 

The Women’s Health Concerns Clinic

A recent article looks at what happens to women referred to a specialized outpatient women’s mental health program.   The Women’s Health Concerns Clinic (WHCC) is a multidisciplinary mental health clinic affiliated with the Department of Psychiatry and Behavioural Neurosciences at McMaster University and St. Joseph’s Healthcare in Hamilton, Ontario, Canada.

Women are typically referred to the WHCC by community providers but are also self-referred.  During the perinatal period, women are followed for the management of active symptoms and for monitoring, even in the absence of symptoms if they are at high risk for recurrent illness.  At the WHCC, patients are assessed by a psychiatrist and a registered nurse, social worker, or a master’s level therapist. The first consult consists of a psychiatric assessment, and patients are typically followed throughout pregnancy and up to 9?months postpartum and then referred back to community providers.

Four non-pharmacological treatment options are provided in group format during the perinatal period: CBT for perinatal anxiety, CBT for perinatal depression, psychoeducation for perinatal bipolar disorder, and emotional regulation skills. If necessary, patients may also access individual therapy. Pharmacologic treatment and follow-up with a psychiatrist are also available.  Patients are also provided with information on community and online resources for further education. 

At the first consultation at the WHCC, patients are asked to complete the Mood Disorder Questionnaire (MDQ), the Perinatal Obsessive-Compulsive Scale (POCS), the EPDS and the GAD-7.  The EPDS and GAD-7 are repeated in each follow-up visit.

In the current study, researchers reviewed service utilization data from the electronic medical records of 226 women referred between 2015 and 2016.  The majority of patients seen were pregnant at baseline (54%) and the remainder were postpartum (44.2%). The majority of patients were partnered/married (83.2%).

Most patients accessing the WHCC had a diagnosis of major depressive disorder (54.9%). Other diagnoses included generalized anxiety disorder (43.8%), posttraumatic stress disorder (8%), social anxiety disorder (10.2%), other anxiety disorders (13.7%), bipolar disorder (I or II; 8%), obsessive-compulsive disorder (10.2%), substance use disorder (5.8%), and eating disorders (4%).

Most women seen in the WHCC  were prescribed a change in their medication or dose (61.9%), and accessed psychotherapy for perinatal anxiety (30.1%). Women referred to the WHCC experienced a decrease in the severity of  depressive symptoms, as well as in anxiety with large effect sizes. A secondary analysis showed that patients with more severe depression and anxiety symptoms demonstrated even greater improvements in depressive symptoms and anxiety.  A secondary analysis showed that patients with more severe depression and anxiety symptoms demonstrated even greater improvements in symptoms.

While this study did not include a comparison group of women with treatment as usual, the data provide support for specialized care in terms of reducing perinatal depressive symptoms and anxiety.  While specialized clinics could offer many advantages, it is unclear why we don’t have more of them in the United States.  One thing that might be an obstacle is the cost; however, in Minneapolis, a collaborative care management model for the treatment of postpartum depression offered timelier and higher quality care to women with PPD, without contributing to higher healthcare utilisation (Truitt et al, 2013).

 

Ruta Nonacs, MD PhD

 

Caropreso L, Saliba S, Hasegawa L, Lawrence J, Davey CJ, Frey BN. Quality assurance assessment of a specialized perinatal mental health clinic   BMC Pregnancy Childbirth. 2020 Aug 24;20(1):485. 

Truitt FE, Pina BJ, Person-Rennell NH, Angstman KB.  Outcomes for collaborative care versus routine care in the management of postpartum depression.  Qual Prim Care. 2013;21(3):171-7.