Friday March 23, 2018

Is Mom Depressed?

We know some women are at increased risk for depression during and following pregnancy. We also know that when moms are depressed, kids pay a price. So maternal mental health screening is a no brainer, right? Not really…

happy pregnant woman with her child

California is set to vote on a bill that would mandate screening for maternal depression during pregnancy and after birth. It has unleashed quite some controversy. What’s the big deal?

1.

The science is strong. A mom’s depressive symptoms during pregnancy are actually associated with altered brain structure and function in her child, with potential long-term consequences for child development. However, thanks to a body of work led by Dr Myrna Weissman and international collaborators, we also know that if we treat depressed moms to the point of remission of their symptoms, we can significantly reduce risk of depression among her children. Science is rarely this clear. So shouldn’t we be screening all moms? What is all the controversy about in California?

 
2.

California is not the first to mandate screening. Although there are no US federal policies that require screening for maternal depression, at least twelve states have either adopted legislation, developed awareness campaigns, or convened task forces. But California’s bill goes beyond other states’ actions by requiring health insurance companies to set up case management programs to help moms find a therapist and connect obstetricians or pediatricians to a psychiatric specialist. And therein lies the rub.

3.

Cost. The health care cost and incentive system is not set up to reward doctors for screening. The reimbursement the doctor might receive is not likely to cover the cost of administering the depression screening. And beyond the time of administration, many doctors do not feel prepared for the times when they may actually identify someone who is depressed. What do they do if they unleash a torrent of tears? And what if that means an even longer office visit? And then there are those who argue against universal screening say that the standard screening strategies produce too many false positives, with many women being sent for further treatment when they are not actually depressed – resulting in costly misuse of resources.

4.

Effectiveness? The US organizations with the greatest authority on this topic – the US Preventative Services Task Force and the American College of Obstetricians and Gynecologists – released only a lukewarm recommendation for routine screening for perinatal depression in 2015, stating that “direct and indirect evidence support moderate certainty that screening for depression in pregnant and postpartum women is of moderate net benefit.” In fact, four other states – Illinois, Massachusetts, New Jersey, and West Virginia – have tried mandated screening, and it did not result in more women getting treatment. Overall, among perinatal women who screen positive for the depression, 78% don’t actually get any mental health treatment.

 
5.

Mandated screening vs community support. California is trying to go beyond screening to mandate services that connect those who screen positive to mental health care. Given the limited success of this strategy in other states, and given the complexities of the US insurance systems to actually implement such a program, a different tack might be in order. An alternative strategy that has demonstrated efficacy is when nurses or mental health providers visit new moms at home. Home visits after childbirth by healthcare professionals are provided across northern and western European countries with great success. Maybe the US could take a page from their playbook.

Last week, I wrote about what must be our evolutionary heritage – the universality of older generations to worry about the younger generation’s ability to preserve the future of humanity. Addressing maternal mental health is one place where we can really make a difference if we heed the data.