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Duckworth M, Garfield CF, Santiago JE, Gollan J, O'Sullivan K, Williams D, Lee Y, Muhammad LN, Miller ES. The design and implementation of a multi-center, pragmatic, individual-level randomized controlled trial to evaluate Baby2Home, an mHealth intervention to support new parents. Contemp Clin Trials 2024; 142:107571. [PMID: 38740296 DOI: 10.1016/j.cct.2024.107571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/12/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Becoming a parent is a transformative experience requiring multiple transitions, including the need to navigate several components of health care, manage any mental health issues, and develop and sustain an approach to infant feeding. Baby2Home (B2H) is a digital intervention built on the collaborative care model (CCM) designed to support families during these transitions to parenthood. OBJECTIVES We aim to investigate the effects of B2H on preventive healthcare utilization for the family unit and patient-reported outcomes (PROs) trajectories with a focus on mental health. We also aim to evaluate heterogeneity in treatment effects across social determinants of health including self-reported race and ethnicity and household income. We hypothesize that B2H will lead to optimized healthcare utilization, improved PROs trajectories, and reduced racial, ethnic, and income-based disparities in these outcomes as compared to usual care. METHODS B2H is a multi-center, pragmatic, individual-level randomized controlled trial. We will enroll 640 families who will be randomized to: [1] B2H + usual care, or [2] usual care alone. Preventive healthcare utilization is self-reported and confirmed from medical records and includes attendance at the postpartum visit, contraception use, depression screening, vaccine uptake, well-baby visit attendance, and breastfeeding at 6 months. PROs trajectories will be analyzed after collection at 1 month, 2 months, 4 months, 6 months and 12 months. PROs include assessments of stress, depression, anxiety, self-efficacy and relationship health. IMPLICATIONS If B2H proves effective, it would provide a scalable digital intervention to improve care for families throughout the transition to new parenthood.
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Affiliation(s)
- Megan Duckworth
- Warren Alpert Medical School, Brown University, Providence, RI, USA.
| | - Craig F Garfield
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Lurie Children's Hospital, Chicago, IL, USA
| | - Joshua E Santiago
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jacqueline Gollan
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Young Lee
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lutfiyya N Muhammad
- Department of Preventive Medicine and Biostatistics, Northwestern University, Evanston, IL, USA
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
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Executive summary: Workshop on maternal mental health, February 11-12, 2024, co-sponsored by the American College of Obstetricians and Gynecologists. Am J Obstet Gynecol 2024:S0002-9378(24)00517-9. [PMID: 38604469 DOI: 10.1016/j.ajog.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
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Matovina CN, Sakowicz A, Allen EC, Alvarado-Goldberg MI, Millan D, Miller ES. The association between postpartum depressive symptoms and contraception. Am J Obstet Gynecol 2024:S0002-9378(24)00472-1. [PMID: 38552816 DOI: 10.1016/j.ajog.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/18/2024] [Accepted: 03/24/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Postpartum depression affects 10% to 20% of birthing people and is associated with changes in healthcare use. Little is known about the association between postpartum depressive symptoms and choice to use contraception; however, both untreated or undertreated depression and short interpregnancy intervals pose substantial perinatal health risks. OBJECTIVE This study aimed to evaluate whether postpartum depressive symptoms are associated with changes in decisions to use any method of contraception. STUDY DESIGN This retrospective cohort study included birthing people who delivered between 2017 and 2022 and were referred to a collaborative care program for mental healthcare. Through this program, birthing people with mental health conditions have access to specialized perinatal mental healthcare and prospective symptom monitoring via a patient registry. Postpartum depressive symptoms are assessed via the Patient Health Questionnaire-9, and scores were stratified by severity according to clinical cutoffs. Contraceptive method choice was determined by documentation in the electronic health record and dichotomized as "none" if the participant declined all forms of contraception both at delivery and at the postpartum visit. Bivariable and multivariable analyses were performed. RESULTS Of the 1871 participants that met the inclusion criteria, 160 (8.5%) had postpartum Patient Health Questionnaire-9 scores of >14, representing moderately severe or worse depressive symptoms, and 43 (2.3%) had severe (Patient Health Questionnaire-9 of >19) depressive symptoms. Birthing people with higher Patient Health Questionnaire-9 scores were more likely to have medical comorbidities; to have a higher body mass index; to self-identify as Black, Native Hawaiian or Pacific Islander, or Hispanic or Latina; and to have a preterm delivery and less likely to be married or nulliparous than those with Patient Health Questionnaire-9 scores of ≤14. There was no difference in any other sociodemographic or clinical characteristics. The choice to use any contraceptive method decreased with increasing depressive symptoms in bivariable and multivariable analyses, reaching statistical significance in birthing people with severe depressive symptoms (adjusted odds ratio, 2.92; 95% confidence interval, 1.46-5.84). CONCLUSION Severe perinatal depressive symptoms are associated with a declination of any form of postpartum contraception. This finding becomes increasingly relevant as abortion access continues to be threatened across the United States, compounding the potential effect of opting not to use contraception.
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Affiliation(s)
- Chloe N Matovina
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Allie Sakowicz
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Obstetrics and Gynecology, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Emma C Allen
- Northwestern University Feinberg School of Medicine, Chicago, IL; Penn State College of Medicine, Hershey, PA
| | | | - Danielle Millan
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
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Nagle-Yang S, Miller ES, Lebin LG, Blissett G, Dossett EC. Perinatal Psychopharmacology: Innovative Approaches to Care Delivery. Clin Obstet Gynecol 2024; 67:186-199. [PMID: 38281175 DOI: 10.1097/grf.0000000000000839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Perinatal mental health conditions are the most common complications of childbirth and have well-established enduring negative effects. Obstetric (Ob) clinicians care for patients with perinatal mental health conditions across a spectrum of acuity, severity, and complexity. Ob and psychiatric clinicians can collaborate to create a cohesive continuum of psychopharmacologic care for perinatal patients. This chapter provides an overall framework for Ob-psychiatric clinician collaboration with examples of innovation in care delivery.
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Affiliation(s)
- Sarah Nagle-Yang
- Department of Psychiatry, University of Colorado, Aurora, Colorado
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Lindsay G Lebin
- Department of Psychiatry, University of Colorado, Aurora, Colorado
| | | | - Emily C Dossett
- Department of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology at the Keck School of Medicine, University of Southern California, Los Angeles, California
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Gimbel LA, Zimmermann M, Byatt N, Moore Simas TA, Hoffman MC. Screening, Assessment, and Treatment of Perinatal Mental Health in Obstetrical Settings. Clin Obstet Gynecol 2024; 67:134-153. [PMID: 38281173 DOI: 10.1097/grf.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Perinatal mood and anxiety disorders (PMADs) are common, yet obstetricians receive little training prior to independent practice on screening, assessing, diagnosing, and treating patients with depression and anxiety. Untreated PMADs lead to adverse pregnancy and fetal outcomes. Obstetricians are in a unique position to address PMADs. The following serves as a resource for addressing PMADs in obstetric practice.
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Affiliation(s)
- Lauren A Gimbel
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Martha Zimmermann
- Department of Psychiatry, UMass Chan Medical School, Shrewsbury, Massachusetts
| | - Nancy Byatt
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Tiffany A Moore Simas
- Department of Obstetrics & Gynecology, UMass Chan Medical School/UMass Memorial Health, Worcester, Mssachusetts
| | - M Camille Hoffman
- Departments of Obstetrics & Gynecology and Psychiatry, University of Colorado School of Medicine, Aurora, Colorado
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Monk C. Editorial: In Utero Exposure to Maternal Affective Symptoms: Prenatal Programming of Child Psychopathology Is Independent of Shared Genes of Risk. J Am Acad Child Adolesc Psychiatry 2023:S0890-8567(23)02269-4. [PMID: 38159904 DOI: 10.1016/j.jaac.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
The womb is an influential first home. This felicitous phrase is attributed to David Barker, often called the father of the late 20th century developmental origins of health and disease hypothesis, which asserts that maternal experiences during pregnancy are biologically transmitted to, and embedded in, the fetus, shaping child development.1 Specifically, Barker focused on maternal inadequate nutrition as a key in utero exposure to which the fetus biologically adapts, leading to biologically programmed changes, meaning long-lasting, that potentially put the offspring at risk for future metabolic diseases.1 In more recent developmental origins of health and disease publications, the impact of affective symptoms in pregnant women-defined broadly to include perceived stress, depression, and anxiety-on fetal and infant brain and behavior development has been identified. There is a third pathway for the familial inheritance of risk for psychiatric illness beyond shared genes and compromised parental postnatal mental health and caregiving: prenatal programming of risk for psychopathology originating in mental health symptoms of mothers.1 However, despite decades of experimental preclinical studies demonstrating maternal prenatal stress predicting altered offspring outcomes,2 the alternative interpretation-that shared genes of risk account for the outcomes-has remained challenging to disprove for human studies, perhaps particularly when the mother reports on her own and her child's mental health (a common study design further addressed below). In this context, the article by Chen et al.3 using polygenic risk scores to provide a single measure of genomic risk for complex phenotypes reports rigorous and original results demonstrating effects of maternal affective symptoms on child psychiatric outcomes while controlling for genomic risk.
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Affiliation(s)
- Catherine Monk
- Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York.
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Hawkins SS. Screening and the New Treatment for Postpartum Depression. J Obstet Gynecol Neonatal Nurs 2023; 52:429-441. [PMID: 37806320 DOI: 10.1016/j.jogn.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
In August 2023, the U.S. Food and Drug Administration approved Zurzuvae (zuranolone) as the first oral medication to treat postpartum depression. Despite recommendations to screen and treat depression during pregnancy and after birth, perinatal depression is still considered under-detected and under-treated. In this column, I review screening recommendations and the new pharmacological treatment for postpartum depression, research findings on gaps in the cascade of mental health care, integrative care models, and recommendations from professional organizations on screening and treating postpartum depression within broader systems of mental health care.
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Glassgow AE, Wagner-Schuman M, Knepper A, Holicky A, Angulo M, Handler A, Harris B, Hickey E, Manrique Y, Mauro A, Rodriguez A, Schulte J, Scott S, Wainwright S, Caskey R. Addressing Maternal Health Disparities: Building a Novel Two-Generation Approach to Comprehensive Postpartum Care. Popul Health Manag 2023; 26:275-282. [PMID: 37677001 DOI: 10.1089/pop.2023.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
The United States is facing a maternal health crisis with increasing rates of severe maternal morbidity and mortality. To improve maternal health and promote health equity, the authors developed a novel 2-generation model of postpartum and pediatric care. This article describes the Two-Generation Clinic (Two-Gen) and model of care. The model combines a dyadic strategy for simultaneous maternal and pediatric care with the collaborative care model in which seamless primary and behavioral health care are delivered to address the physical health, behavioral health, and social service needs of families. The transdisciplinary team includes primary care physicians, nurse practitioners, psychiatrists, obstetrician-gynecologists, social workers, care navigators, and lactation specialists. Dyad clinic visits are coscheduled (at the same time) and colocated (in the same examination room) with the same primary care provider. In the Two-Gen, the majority (89%) of the mothers self-identify as racial and ethnic minorities. More than 40% have a mental health diagnosis. Almost all mothers (97.8%) completed mental health screenings, >50.0% have received counseling from a social worker, 17.2% had a visit with a psychiatrist, and 50.0% received lactation counseling. Over 80% of the children were up to date with their well-child visits and immunizations. The Two-Gen is a promising model of care that has the potential to inform the design of postpartum care models and promote health equity in communities with the highest maternal health disparities.
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Affiliation(s)
- Anne Elizabeth Glassgow
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
- Department of Pediatrics, and College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Melissa Wagner-Schuman
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
- Department of Psychiatry, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amanda Knepper
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Abigail Holicky
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Maria Angulo
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Arden Handler
- Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Bianca Harris
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Erin Hickey
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Yolanda Manrique
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ana Mauro
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Aida Rodriguez
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jennifer Schulte
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Shirley Scott
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Samuel Wainwright
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Rachel Caskey
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
- Department of Pediatrics, and College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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Moses-Kolko EL, Li R, Gopalan P, Poerschke R, Schlesinger AB. Impact of colocated behavioral health on OB-GYN clinicians' rate of perinatal behavioral health diagnosis and psychotropic prescription. Gen Hosp Psychiatry 2023; 84:18-24. [PMID: 37295135 DOI: 10.1016/j.genhosppsych.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To examine the association of colocated behavioral health(BH) care with rates of OB-GYN clinician coding of BH diagnoses and BH medications. METHOD Using 2 years of EMR data from perinatal individuals treated across 24 OB-GYN clinics, we tested the hypothesis that colocated BH care would increase rates of OB-GYN BH diagnoses and psychotropic prescription. RESULTS Psychiatrist integration(0.1 FTE) was associated with 45.7% higher odds of OB-GYN coding for BH diagnoses and BH clinician integration was associated with 25% lower odds of OB-GYN BH diagnosis and 37.7% lower odds of BH medication prescription. Non-white patients had 28-74% and 43-76% lower odds of having a BH diagnosis and a BH medication ordered, respectively. The most common diagnoses were anxiety and depressive disorders(60%) and the most prescribed BH medications were SSRIs(86%). CONCLUSIONS OB-GYN clinicians made fewer BH diagnoses and prescribed fewer psychotropics after 2.0 FTE BH clinician integration, a possible indication of external referrals for BH treatment. Non-white patients received BH diagnoses and medications less often than white patients. Future research in real world implementation of BH integration in OB-GYN clinics should examine fiscal strategies that support BH care manager-OB-GYN collaboration as well as methods to ensure equitable delivery of BH care.
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Affiliation(s)
- Eydie L Moses-Kolko
- University of Pittsburgh Medical Center, Western Psychiatric Hospital, Pittsburgh, PA, USA.
| | - Runjia Li
- University of Pittsburgh, Department of Biostatistics, Pittsburgh, PA, USA
| | - Priya Gopalan
- University of Pittsburgh Medical Center, Western Psychiatric Hospital, Pittsburgh, PA, USA
| | - Rachel Poerschke
- University of Pittsburgh Medical Center, Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Abigail Boden Schlesinger
- University of Pittsburgh Medical Center, Western Psychiatric Hospital, Childrens Hospital of Pittsburgh, Pittsburgh, PA, USA
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Allen EC, Goslawski MM, Taple BJ, Sakowicz A, Alvarado-Goldberg M, Miller ES. The association between adverse childhood experiences and perinatal depression symptom trajectories. Am J Obstet Gynecol MFM 2023; 5:101039. [PMID: 37247667 DOI: 10.1016/j.ajogmf.2023.101039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/13/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Having a history of adverse childhood experiences is associated with an increased risk for treatment-resistant depression in the general population. Whether this relationship is true in the perinatal context is unknown. OBJECTIVE This study aimed to examine the association between adverse childhood experiences and the trajectories of antenatal and postpartum depression among people enrolled in a perinatal collaborative care program for mental healthcare. STUDY DESIGN This retrospective cohort study included all pregnant and postpartum people who were referred to and enrolled in a perinatal collaborative care program for mental healthcare and who delivered at a single, quaternary care institution between March 2016 and March 2021. Individuals referred to the collaborative care program were linked with a care manager and had access to evidence-based mental health treatment such as a psychiatric consult, pharmacotherapy, and psychotherapy. All individuals enrolled in the collaborative care program underwent adverse childhood experience screens at intake. A score of >3 on the validated Adverse Childhood Experiences Questionnaire was defined as a high adverse childhood experience score. Depression symptom monitoring occurred via electronic Patient Health Questionaire-9 screening every 2 to 4 weeks, and escalation of care was recommended for those without evidence of improvement. Antenatal depression trajectories were determined by comparing the earliest available prenatal Patient Health Questionaire-9 score closest to the time of referral to collaborative care with the latest Patient Health Questionaire-9 score before delivery. Postpartum trajectories were determined by comparing the earliest postpartum Patient Health Questionaire-9 score after delivery with the latest score before 12 weeks' postpartum. Depression trajectories were categorized as improved, stable, or worsened based on whether the Patient Health Questionaire-9 scores changed by at least 2 standard deviations (ie, 5 points on the Patient Health Questionaire-9 scale). Bivariable and multivariable analyses were performed. RESULTS Of the 1270 people who met the inclusion criteria, 294 (23.1%) reported a high adverse childhood experience score. Those with a high adverse childhood experience score were more likely to experience a worsened antenatal depression trajectory than those with a low adverse childhood experience score (10.3% vs 4.3%; P=.008). This association persisted after adjusting for potential confounders (adjusted odds ratio, 2.39; 95% confidence interval, 1.05-5.46). There was no significant difference in the postpartum depression trajectories between those with a high and those with a low adverse childhood experience score. CONCLUSION Having a high adverse childhood experience score is associated with a worsened antenatal depression trajectory for those enrolled in a collaborative care program. Given its high prevalence, future research should evaluate effective modalities of perinatal depression prevention and treatment specific for pregnant people with a history of adverse childhood experiences.
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Affiliation(s)
- Emma C Allen
- Northwestern University Feinberg School of Medicine, Chicago, IL (Ms Allen and Ms Alvarado-Goldberg).
| | - Melissa M Goslawski
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Dr Goslawski)
| | - Bayley J Taple
- Center for Behavioral Intervention Technologies, Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (Dr Taple)
| | - Allie Sakowicz
- Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC (Dr Sakowicz)
| | - Mayán Alvarado-Goldberg
- Northwestern University Feinberg School of Medicine, Chicago, IL (Ms Allen and Ms Alvarado-Goldberg)
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Dr Miller)
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Mazel S, Alexander K, Cioffi C, Terplan M. Interventions to Support Engagement in Addiction Care Postpartum: Principles and Pitfalls. Subst Abuse Rehabil 2023; 14:49-59. [PMID: 37424702 PMCID: PMC10327918 DOI: 10.2147/sar.s375652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023] Open
Abstract
There is a fundamental disconnect between the optimal management of addiction in general and care delivery in pregnancy and postpartum. Addiction is a chronic condition requiring some degree of management across the life course. Yet, in the US, reproductive care is episodic and centers more on pregnancy than at other stages of the reproductive life course. Pregnancy is prioritized in access to insurance as almost all pregnant people are Medicaid eligible but access ends at varying points postpartum. This results in a structural mismatch: the episodic management of the chronic condition of addiction only within gestational periods. Though people with substance use disorder (SUD) may access care in pregnancy, treatment attrition is common postpartum. Postpartum is a time of increased vulnerabilities where insurance churn and newborn caretaking responsibilities collide in a context of care withdrawal from the health system and health providers. In part in consequence, return to use, SUD recurrence, overdose, and overdose death are more common postpartum than in pregnancy, and drug deaths have become a leading cause of maternal deaths in the US. This review addresses interventions to support engagement in addiction care postpartum. We begin with a scoping review of model programs and evidence-informed interventions that have been shown to increase continuation of care postpartum. We then explore the realities of contemporary care through a review of clinical and ethical principles, with particular attention to harm reduction. We conclude with suggestions of strategies (clinical, research, and policy) to improve care postpartum and highlight potential pitfalls in the uptake of evidence-based and person-centered services.
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Affiliation(s)
- Shayna Mazel
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | | | - Camille Cioffi
- Center on Parenting and Opioids, Prevention Science Institute, University of Oregon, Eugene, OR, USA
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12
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Braunschneider LE, Seiderer J, Loeper S, Löwe B, Kohlmann S. Nurses' experiences of a screening and associated psychosomatic consultation service for mental comorbidities in somatic care inpatients - a qualitative study. Front Psychiatry 2023; 14:1148142. [PMID: 37333932 PMCID: PMC10272840 DOI: 10.3389/fpsyt.2023.1148142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Background Screening for mental comorbidities and related liaison service can reduce hospital length of stay in somatic hospital care. To develop, test and sustain such health care services, stakeholder feedback is required. One of the most important stakeholders in general hospital care and health care processes are nurses. Aim The aim of this study is to explore nurses' experiencess on standardized nurse-led screening for mental comorbidities and associated psychosomatic consultation service in routine somatic inpatient care. Method Semi-structured qualitative interviews were conducted with 18 nurses that were involved in a nurse-led screening service for mental comorbidities on internal medicine or dermatological wards. Data were analyzed using thematic analysis. Results Eight thematic groups were developed. On the one hand, participants reported benefits of screening: mental health education, general mental health awareness, holistic treatment approach, opportunity to build rapport with patients and reduction in workload. On the other hand, possible psychological effects of the intervention, reasons why patients may not want to be referred and application requirements to facilitate delivery were identified. None of the nurses opposed screening and associated psychosomatic consultation service. Conclusion All nurses endorsed the screening intervention and considered it meaningful. Nurses particularly emphasized the potential for holistic patient care and nurses' improved skills and competencies, but partly critizised current application requirements. Relevance to clinical practice This study adds on existent evidence on nurse-led screening for mental comorbidities and associated psychosomatic consultation service by emphasizing its potential to improve both patient care as well as nurses' perceived self-efficacy and job satisfaction. To take full advantage of this potential, however, usability improvements, regular supervision, and ongoing training for nurses need to be considered.
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Vanderkruik R, Freeman MP, Nonacs R, Jellinek M, Gaw ML, Clifford CA, Bartels S, Cohen LS. To screen or not to screen: Are we asking the right question? In response to considering de-implementation of universal perinatal depression screening. Gen Hosp Psychiatry 2023; 83:81-85. [PMID: 37141774 DOI: 10.1016/j.genhosppsych.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/10/2023] [Accepted: 04/21/2023] [Indexed: 05/06/2023]
Abstract
This Editorial is a response to the Canadian Task Force on Preventive Health Care's recent recommendation "against instrument-based depression screening using a questionnaire with cut-off score to distinguish 'screen positive' and 'screen negative' administered to all individuals during pregnancy and the postpartum period (up to 1 year after childbirth)." While we acknowledge the gaps and limitations in research on perinatal mental health screening, we have concerns regarding the potential impact of a recommendation against screening and for "de-implementation" of existing perinatal depression screening practices, particularly if there is not careful attention to the specificity as well as limitations of the recommendation, or if there are not clear alternative systems put in place to support the detection of perinatal depression. In this manuscript, we highlight some of our key concerns and suggest considerations for perinatal mental health practitioners and researchers.
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Affiliation(s)
- Rachel Vanderkruik
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, USA.
| | - Marlene P Freeman
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, USA
| | - Ruta Nonacs
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, USA
| | | | - Margaret L Gaw
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America
| | - Charlotte A Clifford
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America
| | - Stephen Bartels
- Harvard Medical School, Boston, MA, USA; The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Lee S Cohen
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, USA
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Sakowicz A, Allen E, Alvarado-Goldberg M, Grobman WA, Miller ES. Association Between Antenatal Depression Symptom Trajectories and Preterm Birth. Obstet Gynecol 2023; 141:810-817. [PMID: 36897146 DOI: 10.1097/aog.0000000000005125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/05/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate whether, among pregnant people referred for mental health care, improvement in antenatal depression symptoms before delivery was associated with a reduction in preterm birth. METHODS This retrospective cohort study included all pregnant people referred to a perinatal collaborative care program for mental health care who delivered between March 2016 and March 2021. Those referred to the collaborative care program had access to subspecialty mental health treatment, including psychiatric consultation, psychopharmacotherapy, and psychotherapy. Depression symptoms were monitored with the self-reported PHQ-9 (Patient Health Questionnarie-9) screens in a patient registry. Antenatal depression trajectories were determined by comparing the earliest prenatal PHQ-9 score after collaborative care referral with the score closest to delivery. Trajectories were categorized as improved, stable, or worsened according to whether PHQ-9 scores changed by at least 5 points. Bivariable analyses were performed. A propensity score was generated to control for confounders that were significantly different on bivariable analyses according to trajectories. This propensity score was then included in multivariable models. RESULTS Of the 732 pregnant people included, 523 (71.4%) had mild or more severe depressive symptoms (PHQ-9 score 5 or higher) on their initial screen. Antenatal depression symptoms improved in 256 (35.0%), remained stable in 437 (59.7%), and worsened in 39 (5.3%); the corresponding incidence of preterm birth was 12.5%, 14.0%, and 30.8%, respectively ( P =.009). Compared with those with a worsened trajectory, pregnant people who had an improved antenatal depression symptom trajectory had a significantly decreased odds of preterm birth (adjusted odds ratio 0.37, 95% CI 0.15-0.89). CONCLUSION Compared with worsened symptoms, an improved antenatal depression symptom trajectory is associated with decreased odds of preterm birth for pregnant people referred for mental health care. These data further underscore the public health importance of incorporating mental health care into routine obstetric care.
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Affiliation(s)
- Allie Sakowicz
- Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; the Northwestern University Feinberg School of Medicine and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
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Ayala NK, Lewkowitz AK, Whelan AR, Miller ES. Perinatal Mental Health Disorders: A Review of Lessons Learned from Obstetric Care Settings. Neuropsychiatr Dis Treat 2023; 19:427-432. [PMID: 36865680 PMCID: PMC9971615 DOI: 10.2147/ndt.s292734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
Perinatal mental health has garnered significant attention within obstetrics over the last couple of decades as the long- and short-term morbidities of untreated perinatal mental health disorders on both the mother and fetus/neonate have become increasingly apparent. There have been major strides in increasing screening for perinatal mental health disorders, clinician comfort with prescribing common psychiatric medications, and integrating mental health professionals into prenatal care via health services approaches such as the collaborative care model. Despite these advances, however, gaps still remain in the tools used for screening and diagnosis, obstetric clinician training in diagnosis and management of perinatal mood and anxiety disorders, as well as patient access to mental health care during pregnancy and especially postpartum. Herein we review the state of perinatal mental health from the perspective of the obstetric provider and identify areas of ongoing innovation.
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Affiliation(s)
- Nina K Ayala
- Division of Maternal Fetal Medicine, Women and Infants Hospital of Rhode Island, Providence, RI, USA.,Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam K Lewkowitz
- Division of Maternal Fetal Medicine, Women and Infants Hospital of Rhode Island, Providence, RI, USA.,Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Anna R Whelan
- Division of Maternal Fetal Medicine, Women and Infants Hospital of Rhode Island, Providence, RI, USA.,Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Emily S Miller
- Division of Maternal Fetal Medicine, Women and Infants Hospital of Rhode Island, Providence, RI, USA.,Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
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Pregnancy-Associated Homicide and Suicide: An Analysis of the National Violent Death Reporting System, 2008-2019. Obstet Gynecol 2022; 140:565-573. [PMID: 36075083 DOI: 10.1097/aog.0000000000004932] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/07/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To analyze differences in the demographic and social factors associated with pregnancy-associated violent deaths due to homicide compared with suicide by pregnancy timing. METHODS This was a retrospective cohort study using the Centers for Disease Control and Prevention's National Violent Death Reporting System from 2008 to 2019. We included females aged 15-44 years who died by suicide , defined as intentional self-harm, or homicide. Pregnancy-associated deaths were defined as those that occurred during or within 1 year of pregnancy. RESULTS Of 38,417 female victims aged 15-44 years identified in the data set, 10,411 had known pregnancy status; 1,300 of those deaths were pregnancy associated. Of all deaths with known pregnancy status, 3,203 were by homicide (30.8%) and 7,208 (69.2%) were by suicide. Pregnancy-associated homicide deaths made up 20.6% of all homicide deaths, and pregnancy-associated suicide deaths made up 8.8% of all suicide deaths. Individuals who died by homicide were younger (29.4±8.2 years vs 31.5±8.6 years), more likely to be single or never married (61.0% vs 50.0%), and had a higher proportion of associate's degree-level education or less as compared with individuals who died by suicide (28.1% vs 43.9%). Of individuals who died by homicide, 37.7% were Black or African American, 13.4% were Hispanic, and 56.0%% were White. In comparison, 6.9% of individuals who died by suicide were Black or African American, 8.0% were Hispanic, and 85.0% were White. Having a mental health problem and any substance use were significantly more often associated with suicide deaths compared with homicide deaths (77.4% vs 7.2%, P <.001 for mental health, 33.3% vs 12.8%, P <.001 for substance use, respectively). Intimate partner violence was prevalent in both groups, although significantly higher in homicide deaths (57.3% vs 37.1%, P <.001). This pattern persisted when stratified by pregnancy status. CONCLUSION Mental health problems, substance use disorder, and intimate partner violence are preceding circumstances to pregnancy-associated suicide and homicide.
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Abstract
AIM To identify implementation strategies for collaborative care (CC) that are successful in the context of perinatal care. BACKGROUND Perinatal depression is one of the most common complications of pregnancy and is associated with adverse maternal, obstetric, and neonatal outcomes. Although treating depressive symptoms reduces risks to mom and baby, barriers to accessing psychiatric treatment remain. CC has demonstrated benefit in primary care, expanding access, yet few studies have examined the implementation of CC in perinatal care which presents unique characteristics and challenges. METHODS We conducted qualitative interviews with 20 patients and 10 stakeholders from Collaborative Care Model for Perinatal Depression Support Services (COMPASS), a perinatal collaborative care (pCC) program implemented since 2017. We analyzed interview data by employing the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to organize empirically selected implementation strategies from Expert Recommendations for Implementing Change (ERIC) to create a guide for the development of pCC programs. FINDINGS We identified 14 implementation strategies used in the implementation of COMPASS. Strategies were varied, cutting across ERIC domains (eg, plan, educate, finance) and across EPIS contexts (eg, inner context - characteristics of the pCC program). The majority of strategies were identified by patients and staff as facilitators of pCC implementation. In addition, findings show opportunities for improving the implementation strategies used, such as optimal dissemination of educational materials for obstetric clinicians. The implementation of COMPASS can serve as a model for the process of building a pCC program. The identified strategies can support the implementation of this evidence-based practice for addressing postpartum depression.
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Associations Between Implementation of the Collaborative Care Model and Disparities in Perinatal Depression Care. Obstet Gynecol 2022; 140:204-211. [PMID: 35852270 PMCID: PMC9307131 DOI: 10.1097/aog.0000000000004859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/28/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate whether perinatal collaborative care model implementation was associated with a reduction in racial disparities in depression care. METHODS This retrospective cohort study included pregnant and postpartum people who self-identified as either Black or White, and received prenatal care at academic faculty offices affiliated with an urban quaternary medical center. Individuals were divided into two cohorts to reflect the epochs of implementation. The primary outcome was the frequency of depression screening. The secondary outcome was the frequency of provision of a treatment recommendation for those with a positive depression screen. Antenatal and postpartum care were analyzed separately. A propensity score was used in multivariable models to control for confounders chosen a priori across implementation epoch. Interaction terms were created between race and implementation epoch to identify whether effect modification was present. Subgroup analyses were performed for outcomes with significant race-by-epoch interaction terms. RESULTS Of the 4,710 individuals included in these analyses, 4,135 (87.8%) self-identified as White and 575 (12.2%) self-identified as Black. Before implementation, Black individuals were more likely to receive screening (adjusted odds ratio [aOR] 2.44) but less likely to have a treatment recommended when a positive screen was identified (aOR 0.05). In multivariable models, race-by-epoch interaction terms were significant for both antenatal screening (P<.001) and antenatal treatment recommendation (P=.045), demonstrating that implementation of the perinatal collaborative care model was associated with reductions in extant racial disparities. After implementation, there were no significant differences by race (referent=White) in screening for antenatal depression (aOR 1.22, 95% CI 0.89-1.68) or treatment recommendations for those who screened positive (aOR 0.64, 95% CI 0.27-1.53). Race-by-epoch interaction terms were not significant in multivariable models for either postpartum screening or treatment recommendation. CONCLUSION Implementation of the perinatal collaborative care model is associated with a mitigation of racial disparities in antenatal depression care and may be an equity-promoting intervention for maternal health.
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Monk C, Dimidjian S, Galinsky E, Gregory KD, Hoffman MC, Howell EA, Miller ES, Osborne C, Rogers CE, Saxbe DE, D'Alton ME. The Transition to Parenthood in Obstetrics: Enhancing Prenatal Care for Two Generation Impact. Am J Obstet Gynecol MFM 2022; 4:100678. [PMID: 35728782 DOI: 10.1016/j.ajogmf.2022.100678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Abstract
Obstetrics, the specialty overseeing infant and parent health before birth, could be expanded to address the inter-related areas of parents' prenatal impact on children's brain development and their own psychosocial needs during a time of immense change and neuroplasticity. Obstetrics is primed for the shift that is happening in pediatrics, which is moving from its traditional focus on physical health to a coordinated, whole child, two or multi-generation approach. Pediatric care now includes developmental screening, parenting education, parent coaching, access to developmental specialists, brain-building caregiving skills, linkages to community resources, and tiered interventions with psychologists. Drawing on decades of Developmental Origins of Health and Disease research highlighting the prenatal beginnings of future health and new studies on the transition to parenthood describing adult development from pregnancy to early postpartum, we propose that, similar to pediatrics, the integration of education and intervention strategies into the prenatal care ecosystem should be tested for its potential to improve child cognitive and social-emotional development and parental mental health. Pediatric care programs can serve as models of change for the systematic development, testing and, incorporation of new content into prenatal care as universal, first-tier treatment as well as evidenced-based, triaged interventions according to level of need. To promote optimal beginnings for the whole family, we propose an augmented prenatal care ecosystem that aligns with, and could build on, current major efforts to enhance perinatal care individualization through consideration of medical, social, and structural determinants of health.
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Affiliation(s)
- Catherine Monk
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY; Department of Psychiatry, Columbia University Irving Medical Center, New York, NY.
| | - Sona Dimidjian
- Department of Psychology and Neuroscience, University Colorado, Boulder
| | | | | | - M Camille Hoffman
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora; Department of Psychiatry, University of Colorado School of Medicine, Aurora
| | - Elizabeth A Howell
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL; Department of Psychiatry and Behavioral Health Sciences, Northwestern University, Chicago, IL
| | - Cynthia Osborne
- Department of Leadership, Policy, and Organizations, Peabody College, Vanderbilt University, Nashville, TN
| | - Cynthia E Rogers
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Darby E Saxbe
- Department of Psychology, University of Southern California, Los Angeles
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
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Allen EC, Sakowicz A, Parzyszek CL, McDonald A, Miller ES. The association between engagement in a perinatal collaborative care program and breastfeeding among people with identified mental health conditions. Am J Obstet Gynecol MFM 2022; 4:100591. [DOI: 10.1016/j.ajogmf.2022.100591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
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Postpartum Depression-Identifying Risk and Access to Intervention. Curr Psychiatry Rep 2022; 24:889-896. [PMID: 36422834 PMCID: PMC9702784 DOI: 10.1007/s11920-022-01392-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW As maternal mortality climbs in the USA with mental health conditions driving these preventable deaths, the field of reproductive psychiatry must shift towards identification of women and other birthing individuals at risk and facilitating access. This review brings together recent studies regarding risk of perinatal depression and highlights important comorbidities that place individuals at higher vulnerability to poor perinatal outcomes. RECENT FINDINGS Recent research suggests that identifying risk for perinatal depression including historical diagnoses of depression, anxiety, trauma, and comorbid substance use and intimate partner violence may move the field to focus on preventive care in peripartum populations. Emerging data shows stark health inequities in racial and ethnic minority populations historically marginalized by the health system and in other vulnerable groups such as LGBTQ+ individuals and those with severe mental illness. Innovative models of care using systems-level approaches can provide opportunities for identification and risk analyses of vulnerable peripartum patients and facilitate access to therapeutic or preventive interventions. Utilizing intergenerational approaches and leveraging multidisciplinary teams that thoughtfully target high-risk women and other birthing individuals could promote significant changes to population-level care in maternal health.
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22
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Sakowicz A, Allen EC, Nugooru A, Grobman WA, Miller ES. Timing of perinatal mental health needs: data to inform policy. Am J Obstet Gynecol MFM 2021; 4:100482. [PMID: 34517144 DOI: 10.1016/j.ajogmf.2021.100482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/29/2021] [Accepted: 09/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The policies pertaining to perinatal healthcare should be informed by medical needs. The windows of standard obstetrical care and mandated Medicaid coverage eligibility typically end approximately 8 weeks postpartum, even though women may have perinatal health concerns, including suicidal ideation, which are identified beyond this period. OBJECTIVE To evaluate the timing of mental health needs across the perinatal period with a focus on how frequently the initial referral and suicidal ideation occur outside of standard obstetrical care windows. STUDY DESIGN This retrospective cohort study included all women during pregnancy or up to one year postpartum referred to a perinatal mental health collaborative care program (COMPASS) between September 2017 and September 2019. The timing of initial referral to COMPASS was identified, with women referred postpartum categorized by whether the referral was made after 8 weeks postpartum. The characteristics of the women were compared according to the timing of the initial mental health referral with receiver operating characteristic curves to identify whether patient characteristics could accurately classify women whose initial mental health needs were not recognized until after 8 weeks postpartum. Similarly, the assessment of suicidal ideation, either at or after referral, was ascertained, with the evaluation of the timing at which suicidal ideation was first expressed. RESULTS Of 1421 women referred for mental healthcare during the study period, 774 (54%) were initially referred antenatally and 647 (46%) were initially referred postpartum. The women who were referred antenatally exhibited no clustering in the timing of referral. Of the women referred postpartum, 203 (31%) were referred after 8 weeks postpartum. Sociodemographic and medical characteristics were unable to accurately classify which women were referred for mental health care after 8 weeks postpartum (area under the curve, 0.64; 95% confidence interval, 0.58-0.68). A total of 215 (16%) women reported suicidal ideation at or after the time of initial referral: 129 (17%) antenatally and 86 (14%) postpartum. The incidence of suicidal ideation was not significantly different before vs 8 weeks postpartum. CONCLUSION Perinatal mental health needs, including suicidal ideation, are often first recognized beyond 8 weeks postpartum. These data should be taken into consideration in policymaking discussions pertaining to the approach to medical care continuity and postpartum healthcare coverage.
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Affiliation(s)
- Allie Sakowicz
- Northwestern University Feinberg School of Medicine, Chicago, IL (Mses Sakowicz, Allen, and Nugooru).
| | - Emma C Allen
- Northwestern University Feinberg School of Medicine, Chicago, IL (Mses Sakowicz, Allen, and Nugooru)
| | - Aishwarya Nugooru
- Northwestern University Feinberg School of Medicine, Chicago, IL (Mses Sakowicz, Allen, and Nugooru)
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Grobman and Miller)
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Grobman and Miller)
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