Preventing Perinatal Depression Now: A Call to Action

Abstract

In the United States, perinatal depression (PD) affects an estimated 11.5% of pregnant and postpartum individuals annually and is one of the most common complications of pregnancy and the postpartum period. Alarmingly, up to 51% of people with PD are undiagnosed. Despite the availability of tools to screen for PD, there is no consensus on which tool is most accurate, nor is there a universal policy on when and how to best screen patients with PD. Screening to identify PD is essential, but prevention of depression is even more critical, yet traditionally not well addressed until recently with the US Preventive Services Task Force (USPSTF) recommendation in 2019. When the USPSTF recommended implementing programs to prevent PD in at-risk individuals, the recommendation cited two evidence-based PD prevention programs by name. One of these, ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns), is a four-session class taught in prenatal settings. The second program mentioned is the Mothers and Babies program, which has been shown to be effective in using a cognitive behavioral therapy approach to prevent PD. Although scientists develop effective mental health interventions to prevent PD, community-based advocacy groups are engaged in grassroots efforts to provide support and encouragement to racially and ethnically diverse pregnant and postpartum women. To increase the number of pregnant and postpartum women who are screened and supported so that they do not develop PD, research supports three key strategies: (1) Establish a standard combination of multicultural PD screening tools with evidence-based timepoints for screening administration. (2) Introduce an evidence-based definition of PD that accurately captures the prevalence and incidence of this mental health condition. (3) Improve our understanding of PD by incorporating the psychosocial context in which mental health complications occur into routine clinical practice for pregnant and postpartum women.

Overview of Perinatal Depression

In the United States, perinatal depression (PD) affects an estimated 11.5% of pregnant and postpartum individuals annually and is one of the most common complications of pregnancy and the postpartum period.¹ Alarmingly, up to 51% of people with PD are undiagnosed.^2,3 PD is defined as depression in pregnancy, near childbirth or within the first-year postpartum. It is well established that PD can result in negative short- and long-term effects on both the mother and child.^4,5 PD can be one of the contributors to the increasing trends in US maternal self-harm deaths from suicide and opioid misuse if the mother has a history of major depression, substance use disorder, or intimate partner violence.⁶

Postpartum depression (PPD) has an incidence rate between 10% and 15%, and has been implicated in some cases of maternal mortality.⁷ Although the etiology of PPD is unclear, several risk factors have been noted, including adolescence, low socioeconomic status, immigrant status, and a history of psychiatric illness and substance abuse.^7–9 Those with low income have higher rates of PPD than other income groups, especially unrecognized and untreated PPD.^10–15 In addition, the consequences of PPD are often more severe for low-income women and their children. The negative effects of untreated PPD on mother–infant interactions, maternal caregiving, infant development, and child language development appear to be potentiated by the presence of socioeconomic adversity.^16–18 Among low-income women, the higher the prevalence of PPD, the more reduced is the likelihood of treatment. This adverse impact of untreated PPD on the development of children leads to health disparities in the children of those with PPD.^19–21 Currently, there are several barriers to advancing both prevention and identification of PPD. In this commentary, the authors will refer to PD, which includes PPD.

Barriers to Identify PD

Despite the availability of a myriad tools to screen for PD, there is no consensus on which tool is most accurate, nor is there a universal policy on when and how to best screen patients with PD.²² It will take the combined efforts of researchers and professional societies to build a consensus statement on the most effective PD screening tools, the best time and frequency to screen women, the most effective settings for screening, and the best approach to validate the screening tools to be culturally and linguistically relevant to a diverse group of women who are at risk for PD.

In a comprehensive literature review spanning 2001–2016 that was undertaken to determine the accuracy of PD screening tools based on specificity and sensitivity, Ukatu and colleagues reported that the most widely used and validated tools are as follows: Edinburgh Postnatal Depression Scale (EPDS), Postpartum Depression Screening Scale (PDSS), and the Pregnancy Risk Questionnaire (PRQ).²³ Other screening tools that have also been used to screen for PD include the Beck Depression Inventory-II (BDI-II), the General Health Questionnaire-12 (GHQ-12), the Center for Epidemiological Studies Depression Scale (CES-D), and the Patient Health Questionnaire (PHQ) versions 2, 8, and 9.²³

Screening tools that do not account for certain symptoms, more specifically, physical symptoms, such as fatigue, energy loss, and sleep changes, may not be as accurate as more comprehensive tools. Furthermore, it is important to note that the initial psychological symptoms for PD may not be sadness, but rather anxiety, irritability, insomnia, and confusion.²⁴ It also remains to be established whether the best timing for screening for PD is during the antenatal period, perinatal period, postpartum period, or at multiple times along this continuum. Moreover, using a combination of screening tools may affect the accuracy of the method of evaluation for PD.²⁵

In addition, differences in the patient populations screened may affect the accuracy of a given tool. For example, patients of low socioeconomic status with a significant burden of life stressors may display altered scores when screened, but are not depressed.²⁶ Also, the manifestation of PD symptoms may differ along a cultural spectrum. Depressive symptoms in non-Western cultures tend to manifest as somatization, whereas those of Western cultures tend to report feelings of sadness. Thus, current screening tools based on Western notions of depressive symptoms may not be accurate, transculturally.²⁶

Screening to identify PD is essential, but prevention of depression is even more critical, yet traditionally not well addressed until recently with the US Preventive Services Task Force (USPSTF) recommendation in 2019.

USPSTF Recommendation

To help remedy this mental health complication associated with pregnancy and the postpartum period, in 2019, the USPSTF published a B-level preventive services recommendation that clinicians provide or refer pregnant and postpartum individuals, who are at increased risk of PD, to counseling interventions (e.g., cognitive behavioral therapy and interpersonal therapy) based on convincing medical evidence from numerous clinical studies.²⁷ The evidence indicated that counseling interventions are effective in preventing PD in those at increased risk, and the interventions pose a low likelihood of harm to individuals who are pregnant or postpartum.²⁷

It should be noted that this USPSTF recommendation represents a landmark event as it is one of the first guidelines to recommend prevention of PD in at-risk individuals be included as clinical standard of care. Although, the American College of Obstetricians and Gynecologists (ACOG) recommends early postpartum follow-up care, including screening for depression and anxiety, for all postpartum women, no other guidelines, to date, have been found on the prevention of PD.^28,29

The USPSTF B grade certainly elevates the attention to and the importance of the prevention of PD given its large impact on the US population, including pregnant and postpartum persons. This rings true in the current US crisis in rising maternal mortality rates that are partially due to PD.³⁰ Of note, the Task Force has a separate recommendation (also Grade B) to screen all adolescents and adults for depression, including pregnant and postpartum persons.^31,32

It is important to emphasize that more work needs to be done to put the USPSTF recommendation on prevention of PD into clinical practice across the United States. To make the USPSTF recommendation fully actionable, it will require that researchers, payors, clinicians, and health care workers work collaboratively to ensure that prevention of PD is both achieved and sustainable. The USPSTF works to improve the health of all Americans by making evidence-based recommendations on a variety of clinical preventive services such as screenings, counseling services, and preventive medications. As with all USPSTF recommendations, under the current Patient Protection and Affordable Care Act (ACA), services that received the grade of an A or B must be covered by most private insurance plans with no copay for patients.

However, part of the barriers to implementation of the USPSTF recommendation is that most clinicians and agencies providing prenatal services do not routinely take any measures to prevent PD. As a field, perinatal researchers are making some headway on routine screening and referral after PPD develops.^33,34 This is important given that low-income women are more likely than others to develop PD and less likely to receive treatment. Thus, scaling current evidence-based programs to prevent PD is important.

Evidence-Based Interventions to Prevent PD

When the USPSTF recommended implementing programs to prevent PD in at-risk individuals, the recommendation cited two evidence-based PD prevention programs by name.^1,27 One of these, ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns), is a four-session class taught in prenatal settings. It can be taught by nonmental health specialists, including nurses and community health workers. Five randomized clinical trials have demonstrated that ROSE reduces risk of PD in low-income women (including racially and ethnically diverse women) by half.^35–39 Implementation of the ROSE intervention is being tested in a variety of settings, including obstetrics and gynecology clinics, federally qualified health centers, and Healthy Start and other home visiting programs to determine what outside supports and technical assistance are needed to implement and sustain ROSE over time.⁴⁰

The second program mentioned in the USPSTF recommendations is the Mothers and Babies program, which has been shown to be effective in using a cognitive behavioral therapy approach to prevent PD.^41–44 It involves 6–12 weekly 1- to 2-hour group sessions during pregnancy and two to five postpartum booster sessions. The program includes modules on the cognitive behavioral theory of mood and health, physiological effects of stress, the importance of pleasant and rewarding activities, how to reduce cognitive distortions and automatic thoughts, and the importance of social networks, positive mother–child attachment, and parenting strategies to promote child development and secure attachment in infants.

Both ROSE and Mother and Babies programs can be offered by nonmental health specialists, such as nurses and community health workers. However, nurses and community health workers are often not billable providers. Furthermore, existing billing codes are better suited for payment of treatment rather than preventive services. Payors, especially Medicaid payors, could adequately reimburse the existing nonphysician health education codes (98960–98962), which can be used for preventive education offered by nurses and community health workers. Additional billing codes are under development.

Community-Level Efforts to Prevent PD

Although scientists develop effective mental health interventions to prevent PD, community-based advocacy groups are engaged in grassroots efforts to provide support and encouragement to racially and ethnically diverse pregnant and postpartum women. It is community-based groups, such as the Black Mamas Matter Alliance, that are on the front lines of preventing PD by serving the community from a lens of cultural responsiveness, compassion, and, most importantly, trust.⁴⁵

Community-based programs fill an unmet need with respect to a community-level connection for women who are at risk for experiencing PD. Through impactful stakeholders, community-based efforts present a nontraditional approach to combating and reducing the inequities around maternal mental health among women. Research findings indicate that PD can be prevented with regular counseling sessions.⁴⁶ Women who live in under-resourced communities continue to face barriers that prevent them from seeking maternal mental health treatment. There is a need for research that incorporates community-based approaches into PD prevention interventions.

Community-based organizations (CBOs), such as community health centers, can also play an active role in leveraging local resources to identify and support women who are at risk for developing PD. When women participate in community-based programs, the support and camaraderie that women experience are helpful in reducing disparities in maternal mental health complications in black women and other women of color.⁴⁷ CBOs that partner with perinatal mental health researchers demonstrate the importance of supporting community-led and community-engaged efforts to prevent PD that are relevant and actionable in the community.

Future Directions

To increase the number of pregnant and postpartum women who are screened and supported so that they do not develop PD, research supports three key strategies. These include the following: (1) Establish a standard combination of multicultural PD screening tools with evidence-based timepoints for screening administration. Given our heterogeneous demography and the vast range of cultural constructs of depression in the United States, it is unlikely that one screening tool will successfully capture all PD cases. (2) Introduce an evidence-based definition of PD that accurately captures the prevalence and incidence of this mental health condition, so that appropriate metrics can be developed to track progress on efforts to prevent, diagnose, and treat PD. (3) Improve our understanding of PD by incorporating the psychosocial context in which mental health complications occur into routine clinical practice for pregnant and postpartum women. By doing so, we will create methods that offer a more effective identification of women at risk for PD.

The USPSTF played a critical role in highlighting the importance of trying to prevent PD in those at risk. Programs identified in the recommendation should be considered for dissemination. In addition to the recommendation of the USPSTF, it is critical that scientists, clinicians, and professional societies build a consensus statement of best practices in screening for and preventing PD. Similarly, public and private payors, as well as policy makers, play critical roles in ensuring that preventive intervention services, including education for PD, such as the ROSE and Mothers and Babies programs, are covered under insurance plans. Funding is equally important for community-level on-the-ground PD prevention efforts among low-income and racially and ethnically diverse populations. By working in partnership with community leaders, clinicians, advocates, scientists, policymakers and payors, we can prevent PD in this decade.

Disclaimer

Dr. Simon is a member of the US Preventive Services Task Force (USPSTF) and her views in this article do not necessarily represent those of the Task Force. Ms. Lewis Johnson is the Chief of the Women's Mental Program of the National Institute of Mental Health and her views do not necessarily represent the official views of the National Institute of Mental Health, the National Institutes of Health, or the US government.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Dr. Simon is supported by NIH NIMHD R01 MD0140168. Dr. Johnson's work on this article was supported by NIH R01 MH114883.