Addressing Perinatal Mental Health and Opportunities for Public Health

In this issue of AJPH, Luca et al. (p. 888) used mathematical modeling to estimate the projected costs of untreated perinatal mood and anxiety disorders on mothers and their children up to five years old in 2017 inflation-adjusted dollars. The authors reviewed the literature on the association of perinatal mood and anxiety disorders with outcomes such as maternal employment productivity and childhood emergency department visits to inform the inputs to their cost model. They estimated that the societal cost was $14 billion over the six-year study time frame covering conception to five years postpartum. The average cost per affected dyad was estimated to be $31 800, with 65% and 35% of the cost incurred by the mother and child, respectively.

These findings must be considered in the context of the study’s limitations, mainly a reflection of the available literature on the topic. First, although the rationale for the study was to provide an estimate of the cost of perinatal mood and anxiety disorders overall, most of the studies used as inputs in the mathematical model were focused on depression. Additionally, the generated cost estimate is likely conservative, not only because it does not account for co-occurring depression and anxiety, which were only separately considered in this study, but also because it does not account for mental health conditions such as bipolar disorder, which was not included in the literature review. Second, many of the studies used to estimate the prevalence of mental health conditions and associations with outcomes do not distinguish between untreated and treated conditions, which also may underestimate the cost attributable to untreated conditions specifically. Although the authors attempted to mitigate double counting, the co-occurrence or correlation of some outcomes (e.g., childhood injury and emergency department visits) may have resulted in overestimation of the aggregate cost. Last, the aggregated cost estimate range is wide ($2.5–$63.4 billion), a reflection of the heterogeneity of sample populations and data sources from study inputs.

Limitations withstanding, this study is an important contribution to understanding the societal cost of perinatal mood and anxiety disorders, especially as the availability of linked mother and child longitudinal data is limited. The findings of Luca et al. highlight that the largest costs were attributable to reduced economic productivity, reflecting the well-established impacts of mental health conditions.¹ Addressing unmet treatment needs for mental health conditions across the lifespan remains a challenge and continues to be an opportunity for public health and clinical interventions such as the promotion and facilitation of continuous treatment and care. Ensuring continuity of care for mental health conditions is especially challenging during pregnancy. Despite recent attention to and progress toward improving maternal mental health, it is not fully integrated into obstetric settings and mental health providers are not completely comfortable with providing pharmacotherapy for women in the perinatal period.² Thus, gaps in care continue. There is inconsistency in screening and identification practices; a lack of evaluation for underdiagnosed and undertreated conditions such as bipolar depression, anxiety, and substance use disorders; and poor monitoring of symptoms and treatment adherence over time.²

Multiple professional organizations have released guidelines on perinatal depression, emphasizing the importance of screening pregnant and postpartum women (see the box on p. 766). For example, the US Preventive Services Task Force recommends that depression screening be provided in the general adult population, including among pregnant and postpartum women, and that clinicians provide or refer to counseling pregnant and postpartum women who are at increased risk of depression. The American College of Obstetricians and Gynecologists recommends depression screening at least once during the perinatal period and during comprehensive postpartum checkups.

BOX 1— Select Professional Organization Guidelines on Perinatal Depression.

Professional Organization	Guideline Recommendations	Source
US Preventive Services Task Force	“Screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”(p380)	Siu AL; the US Preventive Services Task Force; Bibbins-Domingo K, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380–387.
	“Clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.”(p581)	US Preventive Services Task Force; Curry SJ, Krist AH, et al. Interventions to prevent perinatal depression: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(6):580–587.
American College of Obstetricians and Gynecologists	“Screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.”(pe208)	American College of Obstetricians and Gynecologists. ACOG committee opinion no. 757: screening for perinatal depression. Obstet Gynecol. 2018;132(5):e208–e212.
	“Complete a full assessment of mood and emotional well-being during comprehensive postpartum visit for each patient.”(pe208)
	“Be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both.”(pe208)
	“Systems should be in place to ensure follow-up for diagnosis and treatment.”(pe208)
American Academy of Pediatrics	“Routine screening for PPD [postpartum depression] should be integrated into the well-child visits at 1, 2, 4, and 6 months of age.”(p6)	Earls MF, Yogman MW, Mattson G, Rafferty J; Committee on Psychosocial Aspects of Child and Family Health. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. AAP policy statement. Pediatrics. 2019;143(1):e20183259.
	“When screening reveals a concern, next steps include communication and demystification, support, identification of community and family resources, and referrals as indicated.”(p5)
American Psychiatric Association	“All perinatal patients should be evaluated for depressive, anxiety, and psychotic disorders throughout the pregnancy and postpartum period. We recommend screening for depression with a validated screening tool twice during pregnancy, once in early pregnancy for preexisting psychiatric disorders and once later in the pregnancy; we also recommend postpartum patients be screened for depression during pediatric visits throughout the first six months postpartum as recommended by the American Academy of Pediatrics. A systematic response to screening should be in place to ensure that psychiatric disorders are appropriately assessed, treated, and followed.”(pp1–2)	Byatt N, Carter D, Deligiannidis KM, et al. Position statement on screening and treatment of mood and anxiety disorders during pregnancy and postpartum. 2018. Available at: http://www.psychnews.org/pdfs/Position%20Statement%20Screening_and_Treatment_of_Mood_and_Anxiety_Disorders_During_Pregnancy_and_Postpartum_2019.pdf. Accessed February 27, 2020.
American College of Nurse–Midwives	“CNMs [certified nurse–midwives]/CMs [certified midwives], as advocates and providers of women’s primary health care, should integrate prevention, universal screening, treatment, and/or referral for depression into the care they provide for women.”(p1)	American College of Nurse–Midwives, Division of Women’s Health Policy and Leadership. Position statement: depression in women. 2013. Available at: https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000061/Depression%20in%20Women%20May%202013.pdf. Accessed March 18, 2020.
American Academy of Family Physicians	“The AAFP supports the U.S. Preventive Services Task Force (USPSTF) clinical preventive service recommendation on this topic.”	American Academy of Family Physicians. Clinical preventive service recommendation. Depression. Available at: https://www.aafp.org/patient-care/clinical-recommendations/all/depression.html. Accessed February 27, 2020.
American College of Preventive Medicine	“Primary care providers should screen all adults for depression and that all primary care providers should have systems in place, either within the primary care setting itself or through collaborations with mental health professionals, to ensure the accurate diagnosis and treatment of this condition.”(p535)	Nimalasuriya K, Compton MT, Guillory VJ; Prevention Practice Committee of the American College of Preventive Medicine. Screening adults for depression in primary care: a position statement of the American College of Preventive Medicine. J Fam Pract. 2009;58(10):535–538.

Because of the potential effect of maternal depression on parenting and child health outcomes, the American Academy of Pediatrics recommends that pediatricians screen mothers for depression at the one-, two-, four-, and six-month well-child visits. Multiple professional organizations also note the importance of having systems, such as health care referrals, or a systematic approach in place to ensure continuous care and follow-up for diagnosis and treatment (see the box on page 766). Yet, evidence on the best approaches (e.g., colocated care, collaborative care, telemedicine) and what necessary systems need to be in place to ensure continuity of appropriate care in different health care settings and geographic environments is sparse. An interdisciplinary workgroup has provided guidance on the important components of the implementation of screening, intervention, referral, and follow-up care of mental health conditions in maternity care practices across health care settings.³

Population-level interventions, such as state perinatal mental health access programs, are emerging as a promising solution to build the capacity of providers who care for pregnant and postpartum women in the context of a limited behavioral health workforce. However, to ensure sustainability of these programs, there is a need to understand not only their efficacy but also their cost effectiveness. To do so requires linking providers’ use of these programs with patients’ symptoms and treatment engagement over time. An ongoing randomized control trial aims to provide some of this evidence by comparing differences in depression symptomatology, treatment engagement, and the cost of implementation between two active interventions: (1) a state perinatal access program: the Massachusetts Child Psychiatry Access Program for Moms; and (2) a practice-level intervention with intensive implementation support in addition to access to the Massachusetts Child Psychiatry Access Program for Moms: the Program in Support of Moms.⁴ Although these programs may build the evidence base for implementation, as well as the capacity of practicing perinatal providers, ensuring perinatal mental health training curricula for future generations of clinicians is important.

Lastly, there is a need for research and implementation studies and subsequent clinical guidelines to move beyond depression and anxiety and address co-occurring substance use disorders and less common mental health conditions such as bipolar disorder. Women with depression or anxiety have a higher prevalence of substance use disorders, but less than a quarter of these women receive both mental health and substance use treatment.⁵ Often, women with bipolar disorder predominantly experience a depressive mood state, frequently leading to a misdiagnosis of their bipolar disorder as unipolar depression.³ Misdiagnosis may result in inappropriate treatment and care. Thus, the proper identification of these conditions is important to provide comprehensive treatment and follow-up.

Perinatal depression, anxiety, substance use disorders, and other serious mental illnesses such as bipolar disorder can have a devastating impact on mothers, families, and infants. The importance of addressing perinatal mental health conditions has been highlighted in a recent report of data from 14 maternal mortality review committees.⁶ Mental health conditions were identified as the sixth leading cause of pregnancy-related deaths and the leading cause of pregnancy-related deaths in non-Hispanic White women (including deaths from suicide, overdosing or poisoning, and unintentional injuries determined by the maternal mortality review committee to be related to a mental health condition).⁶

There is a continued need for attention to and public health efforts to address behavioral aspects in addition to physical aspects of health. Efforts may include (1) implementation research to understand how best to ensure care continuity for mental health conditions and associated comorbidities in a variety of health care settings, (2) improvements to provider training and capacity to identify and assess mental health conditions, and (3) increased access to care through improved referral networks and a reduction in individual- and community-level barriers.