Publication
Article
Psychiatric Times
The Perinatal Mental Health Crisis
Key Takeaways
- PMADs are a leading complication of pregnancy, with untreated cases costing the US $14.2 billion annually and leading to severe outcomes like suicide and overdose.
- Barriers to treatment include stigma, lack of screening, and inadequate professional training, disproportionately affecting marginalized groups.
Perinatal mood and anxiety disorders affect 1 in 5 of perinatal individuals who are pregnant or up to 1 year postpartum. Over the past 2 decades, the US has seen an alarming rise in these disorders.
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Our nation is facing a mental health crisis. This crisis is magnified for perinatal individuals who are pregnant or up to 1 year postpartum. Perinatal mood and anxiety disorders (PMADs) affect 1 in 5 of this group.1 Over the past 2 decades, the US has seen an alarming rise in PMADs,2 a trend that has been exacerbated by the COVID-19 pandemic. Mental health conditions are now the most common complication of pregnancy and childbirth.3 Untreated PMADs pose significant consequences for perinatal individuals and their families. Suicide and overdose combined are the leading cause of maternal mortality.3
Moreover, these disorders are associated with adverse parent, infant, and child outcomes including preterm birth, extended hospital stay, and behavioral problems and developmental difficulties in childhood.4 Untreated mood and anxiety disorders cost the US $14.2 billion each year.5
Perinatal mental health conditions can be prevented and treated effectively. Despite the availability of evidence-based treatments and the urgent need for such treatment among many perinatal individuals, perinatal mental health treatment often remains elusive. Nearly 75% of those affected are not able to access treatment.6 Perinatal individuals experiencing mood and anxiety disorders experience a myriad of barriers, including stigma, lack of screening and identification, inadequate health professional training, and shortages of mental health professionals with expertise in this population.7 These barriers have a disproportionate impact on individuals marginalized by racism, including pregnant and postpartum persons who are Black/African American, Hispanic/Latinx, American Indian or Alaska Native, or Native Hawaiian or other Pacific Islander.8 Efforts are underway to address this crisis, including programs and policies addressing perinatal mental health at the national, state, and local levels (Figure 1).
Figure 1. Multilevel Population-Based Approaches to Addressing the Perinatal Mental Health Crisis
Addressing Perinatal Mental Health at the Population Level
The Centers for Disease Control and Prevention funds, oversees, coordinates, and evaluates perinatal mental health through maternal mortality review committees (MMRCs), which are multidisciplinary committees that review all deaths that occur during pregnancy or up to 1 year postpartum, and Perinatal Quality Collaboratives, which are networks of teams working to improve the quality of care for perinatal individuals and their newborns and infants. These groups work together at the state level to understand factors contributing to maternal mortality and inequities to inform interventions and programs to address these issues.3
Many of these initiatives focus on obstetric settings where perinatal individuals already receive their care. The US Preventive Services Task Force and the American College of Obstetricians and Gynecologists (ACOG) recommend using validated tools to screen for PMADs in pregnancy and postpartum.9 However, it is essential that the appropriate resources are available to facilitate follow-up to a positive screen, as screening alone does not improve PMADs. The Alliance for Innovation on Maternal Health’s Perinatal Mental Health Conditions Patient Safety Bundle10 was developed to summarize guidelines and provide resources for perinatal care professionals to identify and respond to perinatal mental health concerns. This bundle guides perinatal care professionals in critical concerns such as which screens are recommended; when to screen; and how to develop a protocol response based on available resources, including the identification of community-based resources. Other tools include the following: 1) Addressing Perinatal Mental Health Conditions in Obstetric Settings e-Module, 2) Perinatal Mental Health Tool Kit, and 3) Guide for Integrating Mental Health Care Into Obstetric Practice. ACOG is currently disseminating these tools, with the potential to reach the estimated 70,000 obstetric professionals across the country.
Perinatal Psychiatry Access Programs
State-level interventions include the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms.11 The Massachusetts Department of Mental Health funds MCPAP for Moms to increase perinatal care professional capacity to address mental health and substance use concerns. The program conducts trainings, offers real-time consultation with professionals, provides face-to-face consultation with patients, and offers resources and referral support. The consultation line is available to perinatal care professionals, including obstetricians, pediatricians, psychiatrists, primary care physicians, as well as physicians, nurse practitioners, and other prescribers in substance use programs. This model has since been adopted in 28 states, with the potential to cover 65% of US births, or more than 2.3 million.12
These programs hold significant potential for helping to address the perinatal mental health crisis. A study conducted in Massachusetts examined mental health and treatment participation of perinatal individuals (N = 312) with elevated symptoms of depression receiving care at obstetric practices enrolled in MCPAP for Moms.11 Participants were recruited from obstetric practices and were followed for 11 to 13 months postpartum. Participants in practices enrolled in MCPAP for Moms reported a decrease in depression symptoms by 11 to 13 months postpartum. In addition, 43% of participants receiving MCPAP for Moms initiated treatment, compared with previous studies finding rates lower than 25%.6 The study also compared MCPAP for Moms with a more intensive practice-level intervention, the PRogram In Support of Moms (PRISM), which included obstetric practice-level implementation support. Of practices in the study, half received MCPAP for Moms and half received MCPAP for Moms plus PRISM.11 The study found that both interventions were equally effective in reducing symptoms of depression and both were associated with higher rates of treatment initiation and sustainment. These findings are important, as they suggest that a state-level intervention can have a significant impact with few resources, as MCPAP for Moms costs just $14 per birth annually.13
While this represents progress, an analysis of inequities in the MCPAP for Moms and PRISM interventions found that while minoritized perinatal individuals (those who are Black, Asian, Hispanic/Latinx, Pacific Islander, Native American, multiracial, or White Hispanic/Latinx) initiated mental health treatment at the same rate as non-Hispanic White individuals, this group was significantly less likely to be referred.14 More work is needed to address discrimination in health care and community settings that contributes to lower screening and treatment rates among marginalized populations.
The Benefits of the Collaborative Care Model
The collaborative care model (CoCM) is a robust, evidence-based, integrated behavioral health model that has shown to improve symptoms of depression and anxiety across diverse settings, mental health diagnoses, patient populations, and medical specialties. The CoCM focuses on providing integrated behavioral health services for a defined patient population. Core principles include a patient-centered care team, population-based care, measurement-based treatment, evidence-based care, and accountable care.15-18
More recently applied to obstetric patients during pregnancy and in the postpartum period, the CoCM model includes behavioral health specialists and care managers within the obstetric setting.15 The CoCM model aims to increase PMAD screening rates, triage the severity of symptoms, and accurately diagnose and treat PMADs by utilizing social workers and licensed therapists, with obstetricians, psychiatrists, and other medical providers empowered to practice at the top of their license. CoCM has shown to decrease depression symptoms by more than 50% by 12 months in a randomized controlled trial compared with usual obstetric care.15 CoCM has also been shown to increase screening rates for perinatal depression, and patients are more likely to receive treatment when they have a positive screen.17 This model has also shown to reduce depression severity, increase depression remission, reduce severity of posttraumatic stress disorder, increase treatment participation in marginalized perinatal populations,18 and reduce racial inequities by increasing screening and treatment.16
The CoCM model provides financial incentives for obstetric providers to care for their patients’ physical and mental health.19 CoCM medical codes are uniquely designed to allow medical providers (not behavioral or psychiatric providers) to bill for care coordination by a behavioral care manager who is integrated in the medical provider’s clinical workflow.
Exploring FamilyWell’s Tech-Enabled CoCM
Recent innovations have built on the CoCM to support obstetric practices to adopt this approach. FamilyWell Health uses a tech-enabled, coach-driven, perinatal CoCM to improve equitable access to mental health services. The tech-enabled care delivery model aims to address barriers that large health systems face when attempting to implement CoCM at scale. The program includes hybrid in-person and virtual mental health services delivered by psychiatric consultants, licensed therapists, and certified coaches who engage frequently with patients at several touch points in the perinatal journey (Figure 2). FamilyWell’s program lowers the cost of care by training and deploying certified coaches who deliver evidence-based techniques to bolster the mental health workforce. These services are covered by nearly all commercial insurance plans and Medicaid plans in 32 states across the US, making it affordable for patients. Additionally, obstetrics providers are able to generate additional revenue for their practice by billing for the collaborative care Current Procedural Terminology codes.
Figure 2. FamilyWell Collaborative Care Model Clinical Team Structure
Individual and Health Care Professional Level Initiatives
Recent initiatives offer direct services and resources for perinatal individuals. For instance, the American Psychiatric Association released the Perinatal Mental Health Toolkit in 2023. The toolkit includes a white paper, webinars, fact sheets, and other resources developed for individuals considering becoming pregnant, who are currently pregnant, or postpartum.
Initiatives also focus on increasing the mental health workforce with the expertise to address perinatal mental health. Currently, psychiatrists are not required to be trained in perinatal mental health. To address this gap and build provider capacity, the National Curriculum in Reproductive Psychiatry (NCRP) provides training across the US to increase the capacity of psychiatrists to care for perinatal individuals. NCRP trainings include learning modules and classroom materials for psychiatry residency programs.20
Other efforts have sought to expand the perinatal mental health workforce by leveraging peer support. Peers are nonspecialists who do not hold specialized degrees in mental health but can provide psychological interventions, psychoeducation, support, and navigation of the mental health care system.21 Brief psychoeducational interventions for depression and psychological distress can reduce symptoms of depression and psychological distress and can be an initial intervention in medical settings or community models. Peer mentors can help perinatal individuals engage in mental health treatment and support in accessing resources for adverse social determinants of health such as food insecurity. Peer support is accessible to anyone across the US through the Postpartum Support International National Helpline (800-944-4PPD). In addition, the Health Services Resources and Services Administration also offers the National Maternal Mental Health Hotline. Launched on Mother’s Day 2022, this program enables access to mental health providers, maternal health providers, and certified peer specialists. This resource offers a free, confidential national maternal mental health hotline available 24 hours a day, 7 days a week to pregnant and new mothers and individuals who have given birth. Its services are available in English, Spanish, and more than 60 other languages by phone or text at 1-833-TLC-MAMA (1-833-852-6262).21
Challenges and Progress
Professional organizations, policy makers, and patients with lived experience of PMADs recommend addressing perinatal mental health in health care and community settings.4 Advocates and policy makers changed the trajectory of perinatal mental health care, with data and accounts of lived experience that have brought attention to this urgent need. These efforts paved the way for MMRC funding, perinatal psychiatry access programs, and the National Maternal Mental Health Hotline. These multilevel initiatives target barriers at the patient, provider, community, and system levels and are critical to addressing the perinatal mental health care crisis.
To continue to improve care, perinatal care settings—especially those with limited resources—can leverage the available resources to facilitate screening, treatment, and linkages with community-based services (eg, psychotherapy, peer support, psychoeducation, or navigation). Perinatal care professionals can collaborate with mental health professionals who can assist them in addressing perinatal mental health. Leveraging mental health professionals’ knowledge, skills, and resources to build perinatal care professionals’ capacity to serve large populations can improve the quality of mental health care and depression outcomes among patients in perinatal care settings.11 Community organizations can employ evidence-based approaches such as peer support to provide psychoeducation, navigation, and support. Public health systems can partner with community organizations to strengthen connections between perinatal individuals and community resources.
Given that gaps and inequities persist across the perinatal mental health care pathway, future interventions must use an antiracist approach to address inequities at the patient, community, provider, practice, and systems levels. By creating and nurturing partnerships within and across disciplines and care settings, we can address the multitude of barriers to perinatal mental health care.
Dr Zimmermann is an assistant professor of psychiatry at UMass Chan Medical School in Shrewsbury. She is also faculty for the Lifeline for Moms Program at the Lifeline for Families Center. Ms Zahlaway Belsito is the founder of the Maternal Mental Health Leadership Alliance. Dr Gaulton is the CEO and founder of FamilyWell. Dr Byatt is the executive director of the Lifeline for Families Center and Lifeline for Moms Program, as well as a professor with tenure of psychiatry, obstetrics and gynecology, and population and quantitative health sciences at UMass Chan Medical School and UMass Memorial Health in Worcester.
References
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