New Jersey's efforts to improve postpartum depression care did not change treatment patterns for women on medicaid

Perinatal Depression Associated With Increased Pediatric Emergency Department Use And Charges In The First Year Of Life

In New Jersey, universal screening for perinatal depression at the time of delivery has resulted in a 95 percent screening rate. The widespread availability of screening data allowed me to investigate the association between perinatal depression severity and infant emergency department (ED) use and charges in the first year of life. I used birth records linked to hospital discharge records for the period 2016-19. Compared with infants who had mothers with no symptoms, infants with mothers with mild or moderate/severe depressive symptoms had significantly higher overall and nonemergent ED use, but not significantly higher emergent ED use. The positive associations between depressive symptoms and ED charges were particularly striking for infants with Medicaid, which pays for a disproportionate share of pediatric ED care in the United States. This study contributes to the evidence base linking perinatal depression screening and pediatric ED use. Opportunities may exist within Medicaid to optimize screening and referrals for perinatal depression, with potential cost-saving benefits for reducing nonemergent pediatric ED visits.

Meta-review of the barriers and facilitators to women accessing perinatal mental healthcare

Perinatal mental health (PMH) problems are common and can have an adverse impact on women and their families. However, research suggests that a substantial proportion of women with PMH problems do not access care.

OBJECTIVES

To synthesise the results from previous systematic reviews of barriers and facilitators to women to seeking help, accessing help, and engaging in PMH care, and to suggest recommendations for clinical practice and policy.

DESIGN

A meta-review of systematic reviews.

REVIEW METHODS

Seven databases were searched and reviewed using a Preferred Reporting Items for Systematic Reviews and Meta Analyses search strategy. Studies that focused on the views of women seeking help and accessing PMH care were included. Data were analysed using thematic synthesis. Assessing the Methodological Quality of Systematic Reviews-2 was used to assess review methodology. To improve validity of results, a qualitative sensitivity analysis was conducted to assess whether themes remained consistent across all reviews, regardless of their quality rating.

RESULTS

A total of 32 reviews were included. A wide range of barriers and facilitators to women accessing PMH care were identified. These mapped across a multilevel model of influential factors (individual, healthcare professional, interpersonal, organisational, political and societal) and across the care pathway (from decision to consult to receiving care). Evidence-based recommendations to support the design and delivery of PMH care were produced based on identified barriers and facilitators.

CONCLUSION

The identified barriers and facilitators point to a complex interplay of many factors, highlighting the need for an international effort to increase awareness of PMH problems, reduce mental health stigma, and provide woman-centred, flexible care, delivered by well trained and culturally sensitive primary care, maternity, and psychiatric health professionals.

PROSPERO REGISTRATION NUMBER

CRD42019142854.

The Art of Holding Perinatal Women in Distress

Therapies like cognitive behavioral therapy and interpersonal psychotherapy are regarded as highly effective treatments for perinatal mood and anxiety disorders. Therapists appreciate robust research supporting the efficacy of these evidenced-based treatments and the structure of the tools these therapies provide for effective intervention. Less has been written on supportive psychotherapeutic techniques and few of those writings provide instruction or tools for therapists who wish to strengthen their skills in this therapeutic approach. This article describes The Art of Holding Perinatal Women in Distress™, a model of perinatal treatment developed by Karen Kleiman, MSW, LCSW. Kleiman instructs therapists to incorporate six "Holding Points" into their approach to therapeutic assessment and intervention for the purpose of establishing a holding environment conducive to the release of authentic suffering. This article reviews the Holding Points and provides a case study that elucidates how the holding points function within the context of a therapy session.

Improving perinatal depression screening and management: results from a federally qualified health center

INTRODUCTION

Perinatal depression affects 8.5-20% of women. In a systematic review 22% of women with a positive depression screen use mental health services. The objective of this study was to examine the effectiveness of on-site management in the perinatal setting and barriers to care.

METHODS

This is a retrospective chart review of 1042 women who received perinatal care between 1 January to 31 December 2019. Primary outcome was percentage of patients who were assessed after a positive depression screen. The secondary outcome was to determine factors affecting patients' receptiveness to assessment/treatment.

RESULTS

9.52% of women screened positive. Sixty-two (63.9%) met with an on-site social worker for assessment, 6 (6.2%) misunderstood the screening questions, and 33 (34.0%) met criteria for depression. Of those, 9 (27.3%) attended at least one follow-up, 8 (24.2%) were referred to or already in care, 7 (21.2%) no-showed, and 9 (27.3%) declined further care. English speaking patients were more likely to meet with a social worker for diagnostic assessment (69.9% versus 45.8%, P = 0.033).

CONCLUSION

On-site management of a positive depression screen yielded a follow-up rate of 64% versus 49% in other studies. Non-English language may be a barrier to accessing mental health car.

Trends in postpartum mental health care before and during COVID-19

OBJECTIVE

To assess the impact of COVID-19 on trends in postpartum mental health diagnoses and utilization of psychotherapy and prescription drug treatment.

DATA SOURCES

Data were obtained from a large, national health insurance claims database that tracks individuals longitudinally.

STUDY DESIGN

We used interrupted time series models to examine changes in trends of postpartum mental health diagnoses before and during the COVID-19 pandemic and t-tests to examine differences in treatment.

DATA EXTRACTION METHODS

We used billing codes to identify individuals who received mental health-related diagnoses and treatment in the first 90 days after a birth hospitalization. We excluded individuals diagnosed with schizophrenia or bipolar disorder and those with an unknown payer at delivery.

PRINCIPAL FINDINGS

Compared to the pre-pandemic period, the trend in new postpartum mental health diagnoses increased significantly in the post-COVID-19 period (0.06 percentage points [95%CI 0.01, 0.11]). Over 12 months, the percentage of new diagnoses was 5.0% greater relative to what would be expected in absence of COVID-19. The percentage of diagnosed individuals who did not receive treatment increased from 50.4% to 52.7% (p = 0.003).

CONCLUSIONS

Findings point to an urgent need to improve screening and treatment pathways for perinatal individuals in the wake of COVID-19.

Mental Health and Postpartum Care in California: Implications from California's Provisional Postpartum Care Extension

BACKGROUND

California's Provisional Postpartum Care Extension (PPCE) extended Medicaid eligibility through 1 year postpartum for women enrolled in Medi-Cal with annual household incomes of 138%-322% of the federal poverty level and maternal mental health diagnoses.

METHODS

For this cross-sectional descriptive study, we used the 2017 Listening to Mothers in California survey of postpartum women to identify those potentially eligible for PPCE. We then sought to describe their demographic characteristics, self-reported mental health, and utilization of postpartum care and mental health services compared with those with Medi-Cal during pregnancy who did not meet PPCE eligibility criteria.

RESULTS

Overall, potentially PPCE-eligible women comprised 6.8% of respondents. Among those who did not qualify for PPCE, the primary reason was the absence of self-reported maternal mental health symptoms. Potentially PPCE-eligible women were approximately two-thirds Hispanic/Latina and more than one-third were ages 25 to 29. The most common self-reported mental health symptom was anxiety during pregnancy (78.9%). Among potentially PPCE-eligible women, 8.4% were taking medicine for anxiety/depression postpartum and 16.0% were receiving postpartum counseling/treatment for emotional or mental well-being.

CONCLUSIONS

Our analyses suggest that PPCE could have extended postpartum coverage eligibility for approximately 30,360 women statewide. However, our findings demonstrate how narrowly defined PPCE eligibility criteria likely excluded many postpartum women in Medi-Cal who would have been left with limited benefits or more cost-sharing under alternative coverage options. This research could inform state and federal policymakers considering other proposals to extend postpartum Medicaid eligibility.

Antidepressants Are the Most Commonly Discontinued Psychotherapeutic Medications in Pregnancy

BACKGROUND

Psychiatric illnesses are common during the perinatal period. The use of antipsychotic medication during pregnancy has increased over the past two decades. In many instances, clinicians agree that untreated psychiatric illness during the perinatal period is more dangerous than the risks imposed by continuing psychotherapeutic medication. We describe patterns of psychotherapeutic medication continuation and discontinuation during pregnancy in a large U.S. cohort.

METHODS

We assessed the relationship between the demographic and clinical characteristics of women who continued or discontinued psychotherapeutic medications-antidepressants, anxiolytics/sedatives, anticonvulsants, antipsychotics, mood stabilizers, and stimulants-during pregnancy. This study used data from 2008 to 2015 from the Medical Expenditure Panel Survey. We used t tests and Medical Expenditure Panel Survey Household Component longitudinal sampling weights in the analysis of this data.

RESULTS

There were few significant differences noted in clinical and demographic characteristics between women who continued and discontinued medications during pregnancy. Those who continued were less likely to be employed (46.95% of continuers were employed vs. 80.55% of discontinuers; p = .0053). Women taking antipsychotics were more likely to continue medications during pregnancy (64.60% continually used antipsychotics vs. 35.40% discontinued antipsychotics; p = .008), whereas women taking antidepressants were more likely to discontinue their use (19.62% continually used antidepressants vs. 80.38% discontinued antidepressants; p = .032). For each medication category, women resumed medication after pregnancy.

CONCLUSIONS

Antidepressants are the most commonly discontinued psychotherapeutic medication during pregnancy. We recommend further research examining factors that may influence this observed difference.

Perinatal Mental Health Care In The United States: An Overview Of Policies And Programs

In the United States, mental health conditions are the most common complications of pregnancy and childbirth, and suicide and overdose combined are the leading cause of death for new mothers. Although awareness of and action on perinatal mental health is increasing, significant gaps remain. Screening and treatment are widely recommended but unevenly implemented, and policies and funding do not adequately support the mental health of childbearing people. As a result, treatable perinatal mental health conditions can have long-term, multigenerational negative consequences. This article provides an overview of the perinatal mental health landscape in the United States by identifying serious gaps in screening, education, and treatment; describing recent federal and state policy efforts; highlighting successful models of care; and offering recommendations for robust and integrated perinatal mental health care.

Engagement in perinatal depression treatment: a qualitative study of barriers across and within racial/ethnic groups

Background

To better understand previously observed racial/ethnic disparities in perinatal depression treatment rates we examined care engagement factors across and within race/ethnicity.

Methods

Obstetric patients and women’s health clinician experts from a large healthcare system participated in this qualitative study. We conducted focus groups with 30 pregnant or postpartum women of Asian, Black, Latina, and White race/ethnicity with positive depression screens. Nine clinician experts in perinatal depression (obstetric, mental health, and primary care providers) were interviewed. A semi-structured format elicited treatment barriers, cultural factors, and helpful strategies. Discussion transcripts were coded using a general inductive approach with themes mapped to the Capability-Opportunity-Motivation-Behavior (COM-B) theoretical framework.

Results

Treatment barriers included social stigma, difficulties recognizing one’s own depression, low understanding of treatment options, and lack of time for treatment. Distinct factors emerged for non-White women including culturally specific messages discouraging treatment, low social support, trauma history, and difficulty taking time off from work for treatment. Clinician factors included knowledge and skill handling perinatal depression, cultural competencies, and language barriers. Participants recommended better integration of mental health treatment with obstetric care, greater treatment convenience (e.g., telemedicine), and programmatic attention to cultural factors and social determinants of health.

Conclusions

Women from diverse backgrounds with perinatal depression encounter individual-level, social, and clinician-related barriers to treatment engagement, necessitating care strategies that reduce stigma, offer convenience, and attend to cultural and economic factors. Our findings suggest the importance of intervention and policy approaches effecting change at multiple levels to increase perinatal depression treatment engagement.

Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review

The improvement of perinatal mental health formed part of WHO's Millennium Development Goals. Research suggests that the implementation of perinatal mental health care is variable. To ensure successful implementation, barriers and facilitators to implementing perinatal mental health services need to be identified. Therefore, we aimed to identify the barriers and facilitators to implementing assessment, care, referral, and treatment for perinatal mental health into health and social care services. In this systematic review, we searched CINAHL, Embase, MEDLINE, and PsycINFO with no language restrictions for primary research articles published between database inception and Dec 11, 2019. Forward and backward searches of included studies were completed by March 31, 2020. Studies were eligible if they made statements about factors that either facilitated or impeded the implementation of perinatal mental health assessment, care, referral, or treatment. Partial (10%) dual screening was done. Data were extracted with EPPI-Reviewer 4 and analysed by use of a thematic synthesis. The protocol is registered on PROSPERO, CRD42019142854. Database searching identified 21 535 citations, of which 46 studies were included. Implementation occurred in a wide range of settings and was affected by individual (eg, an inability to attend treatment), health-care professional (eg, training), interpersonal (eg, trusting relationships), organisational (eg, clear referral pathways), political (eg, funding), and societal factors (eg, stigma and culture). A complex range of barriers and facilitators affect the implementation of perinatal mental health policy and practice. Perinatal mental health services should be flexible and women-centred, and delivered by well trained health-care professionals working within a structure that facilitates continuity of carer. Strategies that can be used to improve implementation include, but are not limited to, co-production of services, implementation team meetings, funding, and coalition building. Future research should focus on implementation barriers and facilitators dependent on illness severity, the health-care setting, and inpatient care.

Perinatal Depression: Challenges and Opportunities

Perinatal depression (PND) is a major depressive episode during pregnancy or within 4 weeks after childbirth up to a year. Risk factors for PND include stressful life events, history of depression, poor social support, unplanned and unwanted pregnancies, poor relationship quality, current or previous abuse, and low socioeconomic status. This mental disorder has been shown to have negative effects on mothers' quality of life and their intimate relationships, birth outcomes, and breastfeeding likelihood, as well as long-term effects on children's cognitive and emotional development. To date, no nationally representative study has examined whether there are socioeconomic and/or racial/ethnic differences in PND. This study discusses the prevalence and risk factors for PND, as well as its health consequences for mothers and children, the reasons for its underreporting and undertreatment, the evidence for different screening instruments and different treatment options, and the existing supportive policies to address this disorder in the United States. We conclude with outlining next steps in addressing the gaps in the literature on PND.

Postpartum Depressive Symptoms during the Beginning of the COVID-19 Pandemic: An Examination of Population Birth Data from Central New Jersey

Objectives

To examine the mental health of women in the perinatal period prior to and during the COVID-19 pandemic.

Methods

We use provisional vital statistics data for births occurring in the central region of New Jersey. The Edinburgh Postnatal Depression Scale is employed to assess depressive symptoms. Our focal analysis uses linear regression models to test whether giving birth during the pandemic is associated with elevated depressive symptoms. All analyses are performed using time-matched (September 2019-April 2020; n = 18,531) and month-matched (January 2019-April 2019 and January 2020- April 2020; n = 18,346) samples.

Results

Women who gave birth in March and not in April reported higher levels of depressive symptoms than those who gave birth prior to the pandemic in our time-matched (b = 0.09) and month-matched (b = 0.09) samples. The magnitude of this association is approximately one-third the magnitude of the association between preterm birth and depressive symptoms.

Conclusion

These findings suggest that researchers and practitioners should pay special attention to signs of postpartum depression and women’s adaptive coping responses in the early stages of pandemics.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-020-03116-w.

Perinatal Anxiety and Depression in Minority Women

Depression and anxiety are common during pregnancy and are experienced at higher rates among women who are racial and ethnic minorities. Because depression and anxiety influence maternal and infant outcomes, intervening to improve perinatal mental health should be a priority for all healthcare providers. However, in the United States, a number of barriers including lack of mental health providers, lack of perinatal behavioral health systems, and stigma, limit access to care. Universal screening has been recommended and here we examine how universal screening can help nurses improve the mental health of childbearing women. Interventions that are currently in use to improve perinatal anxiety and depression are reviewed and include: psychopharmacology, cognitive behavioral therapy, interpersonal psychotherapy, and mindfulness. Recommendations for future research and healthcare system changes are made.

Association of Insurance Status With Provision of Recommended Services During Comprehensive Postpartum Visits

IMPORTANCE

Improving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits.

OBJECTIVE

To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics. Data analysis was conducted from November 1, 2019, to September 1, 2020.

EXPOSURES

Visit paid by Medicaid vs other payment types.

MAIN OUTCOMES AND MEASURES

Visit length and binary indicators of blood pressure measurement, depression screening, contraceptive counseling or provision, pelvic examinations, Papanicolaou tests, breast examinations, medication ordered or provided, referral to other physician, and counseling for weight reduction, exercise, stress management, diet and/or nutrition, and tobacco use.

RESULTS

A total of 20 071 093 weighted comprehensive postpartum visits to office-based family medicine or obstetrical-gynecological physicians were included (mean patient age, 29.7 [95% CI, 29.1-30.3] years). Of these visits, 34.3% (95% CI, 27.6%-41.1%) were covered by Medicaid. Mean visit length was 17.4 (95% CI, 16.4-18.5) minutes. The most common procedures were blood pressure measurement (91.1% [95% CI, 88.0%-94.2%]), pelvic examinations (47.3% [95% CI, 40.8%-53.7%]), and contraception counseling or provision (43.8% [95% CI, 38.2%-49.3%]). Screening for depression (8.7% [95% CI, 4.1%-12.2%]) was less common. When controlling for visit, patient, and physician characteristics, the only significant difference in visit length or provision of recommended services based on insurance type was a difference in provision of breast examinations (14.7% [95% CI, 8.0%-21.5%] for Medicaid vs 25.6% [95% CI, 19.4%-31.8%] for non-Medicaid; P = .02).

CONCLUSIONS AND RELEVANCE

These findings suggest that receipt of recommended services during comprehensive postpartum visits is less than 50% for most services and is similar across insurance types. These findings underscore the importance of efforts to reconceptualize postpartum care to ensure women have access to a range of supports to manage their health during this sensitive period.

Exposure to Racism and Other Adverse Childhood Experiences Among Perinatal Women with Moderate to Severe Mental Illness

We sought to determine the prevalence and correlates of conventional and expanded adverse childhood experiences (ACEs), including exposure to violence and racism, in perinatal women with mental illness. 133 perinatal women with mental illness completed the original ACEs (conventional ACEs) survey and the 6-question adverse environmental experiences (expanded ACEs) survey from the Philadelphia ACEs study. Associations between racial groups and ACE scores, mental health and psychosocial variables were evaluated. Subjects were predominantly white (68%) and married/partnered (66%), and 57% had at least 4 conventional ACEs. Compared to White women, Black women were significantly more likely to report conventional and expanded ACEs including experiencing racism and witnessing violence. Early life adversity was exceedingly common among pregnant and postpartum women with moderate to severe mental illness. Childhood exposure to racism and environmental trauma are important risk categories for perinatal mental illness.

The PRogram In Support of Moms (PRISM): study protocol for a cluster randomized controlled trial of two active interventions addressing perinatal depression in obstetric settings

BACKGROUND

Perinatal depression, the most common pregnancy complication, is associated with negative maternal-offspring outcomes. Despite existence of effective treatments, it is under-recognized and under-treated. Professional organizations recommend universal screening, yet multi-level barriers exist to ensuring effective diagnosis, treatment, and follow-up. Integrating mental health and obstetric care holds significant promise for addressing perinatal depression. The overall study goal is to compare the effectiveness of two active interventions: (1) the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, a state-wide, population-based program, and (2) the PRogram In Support of Moms (PRISM) which includes MCPAP for Moms plus a proactive, multifaceted, practice-level intervention with intensive implementation support.

METHODS

This study is conducted in two phases: (1) a run-in phase which has been completed and involved practice and patient participant recruitment to demonstrate feasibility for the second phase, and (2) a cluster randomized controlled trial (RCT), which is ongoing, and will compare two active interventions 1:1 with ten Ob/Gyn practices as the unit of randomization. In phase 1, rates of depressive symptoms and other demographic and clinical features among patients were examined to inform practice randomization. Patient participants to be recruited in phase 2 will be followed longitudinally until 13 months postpartum; they will have 3-5 total study visits depending on whether their initial recruitment and interview was at 4-24 or 32-40 weeks gestation, or 1-3 months postpartum. Sampling throughout pregnancy and postpartum will ensure participants with different depressive symptom onset times. Differences in depression symptomatology and treatment participation will be compared between patient participants by intervention arm.

DISCUSSION

This manuscript describes the full two-phase study protocol. The study design is innovative because it combines effectiveness with implementation research designs and integrates critical components of participatory action research. Our approach assesses the feasibility, acceptance, efficacy, and sustainability of integrating a stepped-care approach to perinatal depression care into ambulatory obstetric settings; an approach that is flexible and can be tailored and adapted to fit unique workflows of real-world practices.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02760004, registered prospectively on May 3, 2016.

Screening for and Treating Postpartum Depression and Psychosis: A Cost-Effectiveness Analysis

Objectives Postpartum depression impacts 6.5-12.9% of U.S. women. Postpartum depression is associated with impaired bonding and development, marital discord, suicide, and infanticide. However, the current standard of care is to not screen women for postpartum depression. This study modeled the cost-effectiveness of physicians screening for and treating postpartum depression and psychosis in partnership with a psychiatrist. Methods This study follows a hypothetical cohort of 1000 pregnant women experiencing one live birth over a 2-year time horizon. We used a decision tree model to obtain the outcomes of screening for and treating postpartum depression and psychosis using the Edinburgh Postnatal Depression Scale. We use a Medicaid payer perspective because they cover approximately 50% of births in the U.S. The cost-effectiveness of the intervention is measured in cost per remission achieved and cost per quality-adjusted life-year (QALY) gained. We conducted both deterministic and probabilistic sensitivity analyses. Results Screening for and treating postpartum depression and psychosis produced 29 more healthy women at a cost of $943 per woman. The incremental cost-effectiveness ratios of the intervention branch compared to usual care were $13,857 per QALY gained (below the commonly accepted willingness to pay threshold of $50,000/QALY gained) and $10,182 per remission achieved. These results were robust in both the deterministic and probabilistic sensitivity analyses of input parameters. Conclusions for Practice Screening for and treating postpartum depression is a cost-effective intervention and should be considered as part of usual postnatal care, which aligns with the recently proposed recommendations from the U.S. Preventive Services Task Force.

Post-traumatic stress disorder in the perinatal period: A concept analysis

AIMS AND OBJECTIVES

To report an analysis of the concept of perinatal post-traumatic stress disorder.

BACKGROUND

Prevalence of perinatal post-traumatic stress disorder is rising in the USA, with 9% of the U.S. perinatal population diagnosed with the disorder and an additional 18% being at risk for the condition. Left untreated, adverse maternal-child outcomes result in increased morbidity, mortality and healthcare costs.

DESIGN

Concept analysis via Walker and Avant's approach.

METHODS

The databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Academic Search Premier and PsychINFO were searched for articles, written in English, published between 2006-2015, containing the terms perinatal and post-traumatic stress disorder.

RESULTS

Perinatal post-traumatic stress disorder owns unique attributes, antecedents and outcomes when compared to post-traumatic stress disorder in other contexts, and may be defined as a disorder arising after a traumatic experience, diagnosed any time from conception to 6 months postpartum, lasting longer than 1 month, leading to specific negative maternal symptoms and poor maternal-infant outcomes. Attributes include a diagnostic time frame (conception to 6 months postpartum), harmful prior or current trauma and specific diagnostic symptomatology defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Antecedents were identified as trauma (perinatal complications and abuse), postpartum depression and previous psychiatric history. Consequences comprised adverse maternal-infant outcomes.

CONCLUSIONS

Further research on perinatal post-traumatic stress disorder antecedents, attributes and outcomes in ethnically diverse populations may provide clinicians a more comprehensive framework for identifying and treating perinatal post-traumatic stress disorder.

RELEVANCE TO CLINICAL PRACTICE

Nurses are encouraged to increase their awareness of perinatal post-traumatic stress disorder for early assessment and intervention, and prevention of adverse maternal-infant outcomes.

Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012

OBJECTIVE

To ascertain demographic and clinical characteristics of maternal deaths from self-harm (accidental overdose or suicide) to identify opportunities for prevention.

METHODS

We report a case series of pregnancy-associated deaths resulting from self-harm in the state of Colorado between 2004 and 2012. Self-harm deaths were identified from several sources, including death certificates. Birth and death certificates along with coroner, prenatal care, and delivery hospitalization records were abstracted. Descriptive analyses were performed. For context, we describe demographic characteristics of women with a maternal death from self-harm and all women with live births in Colorado.

RESULTS

Among the 211 total maternal deaths in Colorado over the study interval, 30% (n=63) resulted from self-harm. The pregnancy-associated death ratio from overdose was 5.0 (95% confidence interval [CI] 3.4-7.2) per 100,000 live births and from suicide 4.6 (95% CI 3.0-6.6) per 100,000 live births. Detailed records were obtained for 94% (n=59) of women with deaths from self-harm. Deaths were equally distributed throughout the first postpartum year (mean 6.21±3.3 months postpartum) with only six maternal deaths during pregnancy. Seventeen percent (n=10) had a known substance use disorder. Prior psychiatric diagnoses were documented in 54% (n=32) and prior suicide attempts in 10% (n=6). Although half (n=27) of the women with deaths from self-harm were noted to be taking psychopharmacotherapy at conception, 48% of them discontinued the medications during pregnancy. Fifty women had toxicology testing available; pharmaceutical opioids were the most common drug identified (n=21).

CONCLUSION

Self-harm was the most common cause of pregnancy-associated mortality, with most deaths occurring in the postpartum period. A four-pronged educational and program building effort to include women, health care providers, health care systems, and both governments and organizations at the community and national levels may allow for a reduction in maternal deaths.

Beyond Screening: A Stepped Care Pathway for Managing Postpartum Depression in Pediatric Settings

The negative consequences of untreated postpartum depression (PD) for both the woman and her infant are well established. The impact of maternal depression has led to recommendations on systematic perinatal depression screening. Unfortunately, large-scale initiatives on PD screening have found no benefit unless systems are in place to facilitate appropriate interventions for women who screen positive. Pediatric primary care has been a focus of efforts to support screening and management of PD because pediatric providers, unlike adult healthcare providers, have the most frequent contact with postpartum women through well-child visits. Well-child visits thus present an unparalleled opportunity to detect and intervene with PD. Literature reviews suggest that specific strategies are feasible within pediatric settings and could benefit both the woman and her child. In this article, we present a stepped care approach for screening and managing PD, integrating common elements found in existing pediatric-based models. A stepped care approach is ideal because PD is a heterogeneous condition, with a range of presentations and hence responsiveness to various interventions. This care pathway begins with systematic screening for depression symptoms, followed by a systematic risk assessment for women who screen positive and care management based on risk profiles and responsiveness. This approach allows pediatric providers to be optimally flexible and responsive in addressing the majority of women with PD within the context of the family-centered medical home to improve child well-being. Challenges to managing PD within pediatrics are discussed, including strategies for addressing them. Implications for research, policy, and practice are discussed.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees

OBJECTIVE

The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees.

METHODS

We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization.

RESULTS

MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)].

CONCLUSIONS

MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

Positive postpartum depression screening practices and subsequent mental health treatment for low-income women in Western countries: a systematic literature review

Problem statement and significance

Left undiagnosed and/or untreated, the short-and long-term sequelae of postpartum depression may negatively impact both mother and child. In Western countries, access to mental health care is influenced by socioeconomic factors. The objective of this systematic literature review is to compile factors that hinder and improve access to postpartum depression treatment in low-income women after a positive screen for postpartum depression. The key question of focus is: what are the characteristics associated with access to mental health treatment for low-income women with a positive postpartum depression screen in Western countries?

Methods

A PRISMA-based systematic literature review was conducted of studies published in English before February 2016 that looked at treatment for postpartum depression in low-income women who had been identified with the condition. PubMed and EBSCO databases were searched using MESH and key terms and found 100 articles that met the selection criteria. After review by two independent researchers, 18 studies with 17 unique populations were included in the literature review.

Results

Two independent abstractors searched the included articles for themes surrounding impediments and advantages for low-income women identified with postpartum depression in obtaining mental health treatment. Characteristics of successful mental health treatment included studies that employed the use of a home visitor and those that separated outcomes for women with previous mental health treatment. Themes that emerged as treatment obstacles included cultural barriers, physical barriers, systemic health care barriers, and social barriers.

Implications for practice

This review will help to better inform screening and treatment priorities for those in the medical field who may encounter women experiencing postpartum depression and are not aware of the various barriers to care specific to low-income women. This review will also help policymakers identify specific obstacles that are not addressed in postpartum screening mandate policies which can affect the implementation of these policies.

The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among "carve-out" enrollees

Interrupted time series with and without controls was used to evaluate whether the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and its Interim Final Rule increased the probability of specialty behavioral health treatment and levels of utilization and expenditures among patients receiving treatment. Linked insurance claims, eligibility, plan and employer data from 2008 to 2013 were used to estimate segmented regression analyses, allowing for level and slope changes during the transition (2010) and post-MHPAEA (2011-2013) periods. The sample included 1,812,541 individuals ages 27-64 (49,968,367 person-months) in 10,010 Optum "carve-out" plans. Two-part regression models with Generalized Estimating Equations were used to estimate expenditures by payer and outpatient, intermediate and inpatient service use. We found little evidence that MHPAEA increased utilization significantly, but somewhat more robust evidence that costs shifted from patients to plans. Thus the primary impact of MHPAEA among carve-out enrollees may have been a reduction in patient financial burden.

Closing the Gap between Policy and Practice in Screening for Perinatal Depression: A Policy Analysis and Call for Action

Although perinatal depression (PND) is one of the most common maternal morbidities, it is frequently undetected. Screening for early detection and intervention has the potential to prevent depressive symptoms from worsening. In the United States, five states have enacted legislation in relation to screening for PND, but a gap remains between policy and practice in providing continuum of care for mothers who may be suffering from depressive symptoms. From the perspective of policy formation, the reasons for this gap include a discrepancy between policy and practice goals, lack of regulations on capability building among perinatal care providers, and few pathways for establishing collaborations between medical providers and mental health professionals. The authors recommend involving social workers in the process to promote a better continuum of care after screening through comprehensive policy that explicitly states goals to effectively screen women in the perinatal period.

Implementation of universal screening for depression during pregnancy: feasibility and impact on obstetric care

BACKGROUND

Given the growing policy and public health interest in the identification and treatment of depression in pregnancy, an understanding of the feasibility, challenges, and implications for resource utilization of the implementation of a universal screening program is crucial.

OBJECTIVE

The purpose of this study was to assess the feasibility of large-scale implementation of universal screening for depression in pregnancy and during the postpartum period with the use of the Edinburgh Postnatal Depression Scale.

STUDY DESIGN

A prospective observational cohort study was conducted from July 2010 to June 2014 at a large academic medical center. Pregnant women were screened at 24-28 weeks gestation and again 6 weeks postpartum. An Edinburgh Postnatal Depression Scale score of ≥12 was the cutoff for referral to mental health services for diagnostic evaluation and treatment.

RESULTS

Among 8985 women who were enrolled in prenatal care at the participating sites, 8840 women (98%) were screened for depression antepartum, and 7780 women (86%) were screened postpartum. A total of 576 women (6.5%) screened positive for probable depression; of these, 69% screened positive antepartum, and 31% screened positive postpartum (P < .01). All women who screened positive were referred for an evaluation by a mental health professional; 79% of the women were evaluated, which was more common antepartum than postpartum (83% vs 71%; P < .01). One hundred twenty-one women (21%) were not evaluated further after a positive screen; primary reasons included declining a mental health evaluation (30%) or transferring obstetric care (12%). Among women who underwent a mental health evaluation, 67% were diagnosed with major depression; 37% were diagnosed with an anxiety disorder; 28% were diagnosed concurrently with major depression and an anxiety disorder; 76% were diagnosed with either depression or anxiety, and 35% were treated with an antidepressant medication, which was more frequent during the postpartum period than during the antepartum period (54% vs 28%; P < .001). After adjustment for maternal age, parity, race, and household income, women who screened positive antepartum were significantly more likely to link to mental health services compared with women who screened positive postpartum (adjusted odds ratio, 2.09; 95% CI, 1.24-3.24; P = .001).

CONCLUSION

This study demonstrates the feasibility of universal depression screening during both the antepartum and postpartum periods with the use of the Edinburgh Postnatal Depression Scale as an initial screen followed by mental health referral for further diagnostic evaluation and treatment. The population of women who screened positive and who accepted additional services differed at the 2 time points, which reinforces the utility of screening during both the antepartum and postpartum periods. Although universal screening for depression is feasible, further study of the barriers to mental health evaluation and treatment and the impact of treatment on obstetric outcomes are needed.

Recent Advances and Controversies in Peripartum Depression

PURPOSE OF REVIEW

The purpose of this review is to update readers on recent controversies and findings on the underlying biology and clinical management of peripartum depression.

RECENT FINDINGS

Topics discussed include the discovery and replication of two epigenetic biomarkers of peripartum depression, two well controlled studies that do NOT find associations between in utero antidepressant exposure and cardiac defects and persistent pulmonary hypertension of the newborn and ongoing controversy on whether antidepressant use during pregnancy prevents peripartum depression and whether or not hormonal treatments have a place in the management of postpartum depression.

SUMMARY

Peripartum depression, or depression during and/or immediately following pregnancy is a unique psychiatric illness that not only may have unique biological underpinnings but demands unique and thoughtful approaches to management due to the developing neonate. A number of controversies exist in this area ranging from the recent terminology change in psychiatry's Diagnostic and Statistical Manual from "postpartum" to "peripartum" depression, to the safety of antidepressant use during pregnancy, to whether or not antidepressants prevent or decrease peripartum depression. Research in this area is growing and a number of exciting developments have occurred including the identification of two epigenetic biomarkers of peripartum depression that may eventually lead to early identification and intervention, the potential for hormonal treatments and the recommendation for and early institution of universal screening for peripartum depression. These topics are explored and put into context from a clinical management perspective.

A systematic review on the acceptability of perinatal depression screening

BACKGROUND

Perinatal depression (PND) affects approximately 10-15% of women, worldwide. PND screening, using screening tools, has been undertaken by a broad range of healthcare professionals in different settings. Our objective was to explore the acceptability of PND screening and how acceptability was being assessed.

METHODS

A systematic literature review of studies that explored the acceptability of PND screening was carried out throughout MEDLINE, PsycINFO, PubMed, CINAHL, Embase, Maternity and Infant Care and Joanna Briggs Institute databases.

RESULTS

Twenty-eight out of twenty-nine publications reported PND screening to be acceptable to most participants. A wide range of terms, questions and statements was used to infer, assess or report on acceptability. There was no uniform, psychometrically tested tool used to measure acceptability across the studies.

LIMITATIONS

Broad inclusion criteria and methodological differences limited comparisons, but are overcome by the comprehensiveness of the data and the lack of uniformity across studies.

CONCLUSIONS

Even though PND screening appears acceptable, it is difficult to draw conclusions about PND screening acceptability as studies used different methods to infer, assess or report on acceptability. The lack of a uniform, psychometrically tested tool to measure acceptability is not unique to PND. Nonetheless, the majority of perinatal women and healthcare professionals reported positive attitudes towards PND screening using different tools in different settings, indicating that it may be the responsibility of all healthcare professionals who come into contact with perinatal women.

Can Postpartum Depression Be Managed in Pediatric Primary Care?

BACKGROUND

Postpartum depression is prevalent among women who have had a baby within the last 12 months. Depression can compromise parenting practices, child development, and family stability. Effective treatments are available, but access to mental healthcare is challenging. Routine infant healthcare visits represent the most regular contact mothers have with the healthcare system, making pediatric primary care (PPC) an ideal venue for managing postpartum depression.

METHODS

We conducted a review of the published literature on postpartum depression programs. This was augmented with a Google search of major organizations' websites to identify relevant programs. Programs were included if they focused on clinical care practices, for at-risk or depressed women during the first year postpartum, which were delivered within the primary care setting.

RESULTS

We found that 18 programs focused on depression care for mothers of infants; 12 were developed for PPC. All programs used a screening tool. Psychosocial risk assessments were commonly used to guide care strategies, which included brief counseling, motivating help seeking, engaging social supports, and facilitating referrals. Available outcome data suggest the importance of addressing postpartum depression within primary care and providing staff training and support. The evidence is strongest in family practices and community-based health settings. More outcome data are needed in pediatric practices.

CONCLUSION

Postpartum depression can be managed within PPC. Psychosocial strategies can be integrated as part of anticipatory guidance. Critical supports for primary care clinicians, especially in pediatric practices, are needed to improve access to timely nonstigmatizing care.

Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review

OBJECTIVE

To examine a wide range of study designs and outcomes to estimate the extent to which interventions in outpatient perinatal care settings are associated with an increase in the uptake of depression care.

DATA SOURCES

PubMed, CINAHL, PsycINFO, ClinicalTrials.gov, and Scopus (EMBASE) were searched for studies published between 1999 and 2014 that evaluated mental health care use after screening for depression in perinatal care settings.

METHODS OF STUDY SELECTION

Inclusion criteria were: 1) English language; 2) pregnant and postpartum women who screened positive for depression; 3) exposure (validated depression screening in outpatient perinatal care setting); and, 4) outcome (mental health care use). Searches yielded 392 articles, 42 met criteria for full-text review, and 17 met inclusion criteria. Study quality was assessed using a modified Downs and Black scale.

TABULATION, INTEGRATION, AND RESULTS

Articles were independently reviewed by two abstractors and consensus reached. Study design, intervention components, and mental health care use were defined and categorized. Seventeen articles representing a range of study designs, including one randomized controlled trial and one cluster randomized controlled trial, were included. The average quality rating was 61% (31.0-90.0%). When no intervention was in place, an average of 22% (13.8-33.0%) of women who screened positive for depression had at least one mental health visit. The average rate of mental health care use was associated with a doubling of this rate with patient engagement strategies (44%, 29.0-90.0%), on-site assessments (49%, 25.2-90.0%), and perinatal care provider training (54%, 1.0-90.0%). High rates of mental health care use (81%, 72.0-90.0%) were associated with implementation of additional interventions, including resource provision to women, perinatal care provider training, on-site assessment, and access to mental health consultation for perinatal care providers.

CONCLUSION

Screening alone was associated with 22% mental health care use among women who screened positive for depression; however, implementation of additional interventions was associated with a two to fourfold increased use of mental health care. Although definitive studies are still needed, screening done in conjunction with interventions that target patient, health care provider, and practice-level barriers is associated with increased improved rates of depression detection, assessment, referral, and treatment in perinatal care settings.

Perinatal depression screening in a Women, Infants, and Children (WIC) program: perception of feasibility and acceptability among a multidisciplinary staff

OBJECTIVE

Best practices for addressing women's mental health and screening for depression in public health clinics are not available. Clinic staff are often responsible for screening for depression; however, few studies examine staff perceptions on feasibility and acceptability of using perinatal screening for mood disorders in ethnically diverse public health clinics.

METHODS

During December 2012, we conducted four focus groups using a semistructured interview guide with public health clinic staff of varying disciplines (n=25) in a Special Supplemental Nutrition Program for Women, Infants, and Children. All interviews were audio recorded and analyzed using thematic analysis.

RESULTS

We found five descriptive themes related to acceptability and feasibility of screening for perinatal depression in a public health clinic. The main themes include (1) literacy barriers, (2) need for referrals and follow-up with outside services, (3) training and capacity needs, (4) stigma of depression, and (5) location and privacy of screening. Although multiple barriers to universal depression screening in a public health clinic were identified, participants found value in practice of screening low-income women for depression.

CONCLUSION

Factors for facilitating implementation of systematic depression screening in a public health clinic have been identified. Implications discuss how policy makers and public health clinic administrators can improve the universal depression screening process.

Repeated depression screening during the first postpartum year

PURPOSE

Postpartum depression (PPD) screening at 4 to 12 weeks' postpartum can improve outcomes for women when linked to in-practice management programs. The benefit of repeated PPD screening during the first year postpartum remains unclear.

METHODS

We report a substudy of a large pragmatic trial of early PPD screening and practice management, the Translating Research into Practice for Postpartum Depression (TRIPPD) study. Outcome analyses were based on demographic information and Patient Health Questionnaire (PHQ-9) screening scores from questionnaires mailed to all enrolled women at baseline (4 to 12 weeks' postpartum) and again at 6 and at 12 months' postpartum. The main outcomes of this substudy were the 6- and 12-month rates of PHQ-9 scores that were 10 or greater for women whose baseline PHQ-9 scores were less than 10. Women whose scores were 10 or greater would be considered at high risk of PPD and appropriate for further evaluation.

RESULTS

At 6 months, 134 (10.9%) of the 1,235 women who did not have PHQ-9 scores greater than 10 at baseline had elevated scores appropriate for further evaluation. At 12 months, 59 (6.1%) of the 969 women who did not have PHQ-9 scores greater than 10 at baseline or at 6 months had elevated scores. Together the 6- and 12-month repeated screenings identified 193 women at high risk of depression. This finding represents 13.5% of the 1,432 women whose screening results were negative for PPD at baseline.

CONCLUSIONS

Repeated PPD screening at 6 and 12 months' postpartum increases the percentage of women identified as being at high risk of PPD. Further work will be required to understand the impact of this repeated screening on patient outcomes.

The impact of routine assessment of past or current mental health on help-seeking in the perinatal period

BACKGROUND

Clinical practice guidelines now recommend that women be asked about their past or current mental health as a routine component of maternity care. However, the value of this line of enquiry in increasing engagement with support services, as required, remains controversial.

AIM

The current study aimed to examine whether assessment of past or current mental health, received with or without referral for additional support, is associated with help-seeking during pregnancy and the postpartum.

METHODS

A subsample of women drawn from the Australian Longitudinal Study on Women's Health (young cohort) who reported experiencing significant emotional distress during pregnancy (N=398) or in the 12 months following birth (N=380) participated in the study.

RESULTS

Multivariate analysis showed that women who were not asked about their emotional health were less likely to seek any formal help during both pregnancy (adjOR=0.09, 95%CI: 0.04-0.24) and the postpartum (adjOR=0.07, 95%CI: 0.02-0.13), as were women who were asked about these issues but who were not referred for additional support (antenatal: adjOR=0.26, 95%CI: 0.15-0.45; postnatal: adjOR=0.14, 95%CI: 0.07-0.27). However, considerable levels of consultation with general practitioners, midwives and child health nurses, even in the absence of referral, were evident.

CONCLUSION

This study demonstrates that enquiry by a health professional about women's past or current mental health is associated with help-seeking throughout the perinatal period. The clinical and resource implications of these findings for the primary health care sector should be considered prior to the implementation of future routine perinatal depression screening or psychosocial assessment programmes.

Depression screening and patient outcomes in pregnancy or postpartum: a systematic review

OBJECTIVE

Clinical practice guidelines disagree on whether health care professionals should screen women for depression during pregnancy or postpartum. The objective of this systematic review was to determine whether depression screening improves depression outcomes among women during pregnancy or the postpartum period.

METHODS

Searches included the CINAHL, EMBASE, ISI, MEDLINE, and PsycINFO databases through April 1, 2013; manual journal searches; reference list reviews; citation tracking of included articles; and trial registry reviews. RCTs in any language that compared depression outcomes between women during pregnancy or postpartum randomized to undergo depression screening versus women not screened were eligible.

RESULTS

There were 9,242 unique titles/abstracts and 15 full-text articles reviewed. Only 1 RCT of screening postpartum was included, but none during pregnancy. The eligible postpartum study evaluated screening in mothers in Hong Kong with 2-month-old babies (N=462) and reported a standardized mean difference for symptoms of depression at 6 months postpartum of 0.34 (95% confidence interval=0.15 to 0.52, P<0.001). Standardized mean difference per 44 additional women treated in the intervention trial arm compared to the non-screening arm was approximately 1.8. Risk of bias was high, however, because the status of outcome measures was changed post-hoc and because the reported effect size per woman treated was 6-7 times the effect sizes reported in comparable depression care interventions.

CONCLUSION

There is currently no evidence from any well-designed and conducted RCT that screening for depression would benefit women in pregnancy or postpartum. Existing guidelines that recommend depression screening during pregnancy or postpartum should be re-considered.

Practitioner review: maternal mood in pregnancy and child development--implications for child psychology and psychiatry

BACKGROUND

The empirical base suggesting a link between prenatal maternal anxiety, stress or depression and cognitive, behavioral, and biological outcomes in the infant and child has increased dramatically in the past 10 years.

METHODS

In this review, we consider the relevance of prenatal maternal mood for child mental health practitioners; the empirical base for a likely causal impact of the link between prenatal anxiety, depression, or stress and child outcomes; the degree to which the available evidence is sufficient for informing or altering clinical practice; and the possible role of prenatal interventions for promoting child health and development. A selective review of PubMed, Cochrane Library and other sources was undertaken.

FINDINGS

Clinically significant links between maternal prenatal distress and child behavioral and cognitive outcomes have been reported; predictions to stress physiology, immunology, and neurodevelopment have been reported but the effect sizes and clinical significance is less clear. Several candidate mechanisms have been proposed, with some supporting evidence. Many behavioral treatments for prenatal maternal distress exist, but their application to promoting child health is largely unknown.

CONCLUSIONS

Research on maternal prenatal distress is a good example of translational research and offers a strong paradigm for promoting interdisciplinary clinical research on child health and development.

There are no randomized controlled trials that support the United States Preventive Services Task Force Guideline on screening for depression in primary care: a systematic review

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening.

METHODS

We re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries.

RESULTS

Of the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review.

CONCLUSIONS

The USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation. Please see related article: http://www.biomedcentral.com/1741-7015/12/14 REGISTRATION: PROSPERO (#CRD42013004276).

Perinatal depression: a review of US legislation and law

Accumulating research documenting the prevalence and negative effects of perinatal depression, together with highly publicized tragic critical incidents of suicide and filicide by mothers with postpartum psychosis, have fueled a continuum of legislation. Specialists in perinatal mental health should recognize how their work influences legislative initiatives and penal codes, and take this into consideration when developing perinatal services and research. Yet, without legal expertise, the status of legislative initiatives can be confusing. To address this shortfall, we assembled an interdisciplinary team of academics specializing in law, as well as perinatal mental health, to summarize these issues. This review presents the relevant federal and state legislation and summarizes the criminal codes that governed the court decisions on cases in which a mother committed filicide because of postpartum psychosis. Moreover, the review aims to help researchers and providers who specialize in perinatal depression understand their role in this legal landscape.

A critical review of methods to evaluate the impact of FDA regulatory actions

PURPOSE

To conduct a synthesis of the literature on methods to evaluate the impacts of FDA regulatory actions and identify best practices for future evaluations.

METHODS

We searched MEDLINE for manuscripts published between January 1948 and August 2011 that included terms related to FDA, regulatory actions, and empirical evaluation; the review additionally included FDA-identified literature. We used a modified Delphi method to identify preferred methodologies. We included studies with explicit methods to address threats to validity and identified designs and analytic methods with strong internal validity that have been applied to other policy evaluations.

RESULTS

We included 18 studies out of 243 abstracts and papers screened. Overall, analytic rigor in prior evaluations of FDA regulatory actions varied considerably; less than a quarter of studies (22%) included control groups. Only 56% assessed changes in the use of substitute products/services, and 11% examined patient health outcomes. Among studies meeting minimal criteria of rigor, 50% found no impact or weak/modest impacts of FDA actions and 33% detected unintended consequences. Among those studies finding significant intended effects of FDA actions, all cited the importance of intensive communication efforts. There are preferred methods with strong internal validity that have yet to be applied to evaluations of FDA regulatory actions.

CONCLUSIONS

Rigorous evaluations of the impact of FDA regulatory actions have been limited and infrequent. Several methods with strong internal validity are available to improve trustworthiness of future evaluations of FDA policies.

Strategies for improving perinatal depression treatment in North American outpatient obstetric settings

OBJECTIVE

To identify core barriers and facilitators to addressing perinatal depression and review clinical, programmatic, and system level interventions that may optimize perinatal depression treatment.

METHOD

Eighty-four MEDLINE/PubMed searches were conducted using the terms perinatal depression, postpartum depression, antenatal depression, and prenatal depression in association with 21 other terms. Of 7768 papers yielded in the search, we identified 49 papers on barriers and facilitators, and 17 papers on interventions in obstetric settings aimed to engage women and/or providers in treatment.

RESULTS

Barriers include stigma, lack of obstetric provider training, lack of resources and limited access to mental health treatment. Facilitators include validating and empowering women during interactions with health care providers, obstetric provider and staff training, standardized screening and referral processes, and improved mental health resources.

CONCLUSION

Specific clinical, program, and system level changes are recommended to help change the culture of obstetric care settings to optimize depression treatment.

Postpartum Depression: Screening, Diagnosis, and Management Programs 2000 through 2010

The value and appropriateness of universal postpartum depression (PPD) screening remains controversial in the United States. To date, several PPD screening programs have been introduced and a few have been evaluated. Among those programs that have been evaluated, most report screening rates, diagnosis rates, or treatment initiation rates. Only four studies included patient outcomes such as the level of depressive symptoms at 6 to 12 months postpartum, and only two reported success in improving outcomes. Program characteristics that appear to result in low rates of diagnosis and followup after PPD screening include requirements for a formal psychiatric evaluation, the need to refer women to another site for therapy, and failure to integrate the PPD screening into the care provided at the woman's or her child's medical home. The two programs that reported improved outcomes were both self-contained within primary care and included specific followup, management, and therapy procedures. Both resulted in the need for outside referrals in less than 10% of women diagnosed with postpartum depression. Future studies should be based on the successful programs and their identified facilitators while avoiding identified barriers. To affect policies, the future program must report maternal outcomes going beyond the often reported process outcomes of screening, referral, and therapy initiation rates.

TRIPPD: a practice-based network effectiveness study of postpartum depression screening and management

PURPOSE

Postpartum depression is common but inadequately recognized and undertreated. Continuing depressive symptoms are associated with adverse outcomes for the woman, her infant, and family. We wanted to determine the effect of a practice-based training program for screening, diagnosis, and management of depression in postpartum mothers.

METHODS

In this practice-based effectiveness study, 28 practices were randomized to usual care (n = 14) or intervention (n = 14), and 2,343 women were enrolled between 5 and 12 weeks' postpartum. The intervention sites received education and tools for postpartum depression screening, diagnosis, initiation of therapy, and follow-up within their practices. Usual-care practices received a 30-minute presentation about postpartum depression. Screening information for the usual care was obtained from baseline surveys sent directly to the central site but was not available for patient care. Outcomes were based on patient-reported outcomes (level of depressive symptoms) from surveys at 6 and 12 months, plus medical record review (diagnosis and therapy initiation).

RESULTS

Among the 2,343 women enrolled, 1,897 (80.1%) provided outcome information, and were included in the analysis. Overall, 654 (34.5% of 1,897) women had elevated screening scores indicative of depression, with comparable rates in the intervention and usual-care groups. Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis (P = .0006) and therapy for postpartum depression (P = .002). They also had lower depressive symptom levels at 6 (P = .07) and 12 months' (P=.001) postpartum.

CONCLUSIONS

Primary care-based screening, diagnosis, and management improved mother's depression outcomes at 12 months. This practical approach could be implemented widely with modest resources.

Perinatal depression screening and intervention: enhancing health provider involvement

OBJECTIVE

The authors of this study collaborated in the analysis of public health survey data in order to inform future statewide interventions that could systematically enhance depression screening and mental health service use for women of reproductive age. The primary objective of the study was to empirically inform and test the program theory components of a motivational interviewing intervention that we anticipate will guide statewide practice and policy priorities.

METHODS

Data were examined from a survey of healthcare practitioners statewide (n=1498) regarding their practices with and perceptions of perinatal depression care for women. Confirmatory factor analysis (CFA) was used to measure two latent constructs: health provider confidence in the ability to diagnose and treat and the importance placed on screening and treatment. Structural equation modeling (SEM) was used to test a program theory supporting motivational interviewing using a model implied relationship between confidence and importance on screening and treatment/referral practices.

RESULTS

The data fit the model; the model provisionally supports motivational interviewing as an intervention influencing provider attitudes and practices surrounding perinatal depression screening and treatment/referral.

CONCLUSIONS

Ultimately, study findings support statewide public health efforts to expand the role of health providers in recognizing and responding to perinatal depression and suggest that motivational interviewing techniques that augment importance and confidence may lead to enhanced screening and referral/treatment outcomes for pregnant and postpartum women.