The U.S. Preventive Services Task Force (USPSTF), published recommendations recently urging clinicians to refer pregnant and postpartum women to counseling if they are at risk of depression.
The recommendations respond to the prevalence of perinatal depression, which is considered to be the most common pregnancy complication. Perinatal depression, affects up to one in seven women and can develop at any time after a woman becomes pregnant, immediately following the brith of a child, or even up to a year after.
Among the many concerning potential consequences of maternal depression are premature births and low birth weights, as well as neglect and inattentiveness from mothers after the baby is born, which can subject infants to risk of additional problems, according to Karina Davidson, a USPSTF member who helped write the recent recommendations.
In developing its recommendations, the USPSTF looked to convincing findings of the effectiveness of counseling interventions in preventing perinatal depression.
According to the USPSTF report, chances of developing perinatal depression were 39 percent lower among women who received one of two forms of counseling—cognitive behavioral therapy and interpersonal therapy—than among women who did not.
The USPSTF discussed the “Mothers and Babies” program as an example of cognitive behavioral therapy, which works to achieve positive mood and behavior changes by addressing and finding ways to manage negative thoughts and attitudes and by increasing positive activities and events. The USPSTF identified “Reach Out, Stand Strong, Essentials for New Mothers” as an interpersonal therapy approach, which works to treat interpersonal issues that may contribute to psychological disorders.
The USPSTF report stated that a pragmatic approach would be to provide counseling interventions for women who were found to have one or more of certain clinical risk factors or other social factors that are associated with a higher likelihood of developing perinatal depression. The list included: a history of depression, recent intimate partner violence, certain socioeconomic risk factors like low income, and a history of significant negative life events.
Cost and accessibility barriers pose concerns, however. According to Dr. Darius Tandon, an associate professor at Northwestern University’s Feinberg School of Medicine, it can cost clinics $40-50 per session to provide transportation and child care for the mother. And clinics often must absorb costs of staff time needed to provide it, given that there’s no reimbursement code under Medicaid for preventive counseling.
However, under the Affordable Care Act (ACA), private health plans must cover recommended services, such as the ones outlined in the USPSTF report, and may not require co-payments.
The prevalence of pregnancy-related depression is also among concerns motivating a push for greater inclusion of pregnant women in clinical research of medications. In September, the Task Force on Research Specific to Pregnant Women and Lactating Women (PRGLAC), which advises the Secretary of Health and Human Services, submitted a 388 page report which, among other recommendations, advocated for increasing “the quantity, quality, and timeliness of research on safety and efficacy of therapeutic products used by pregnant women and lactating women.”
The PRGLAC report discussed that while the most common childbirth-related complication is Perinatal Mood and Anxiety Disorders (PMAD), far too often it is left unrecognized untreated. Supporters of increasing drug research among pregnant women and lactating women say that the need for evidence-based information is especially great as the number of child-bearing age women that are taking medications to treat anxiety and depression rises.
The USPSTF recommendations also closely follow Congressional efforts to address maternal health and mortality.
In September 2018, Democratic Senators Cory Booker, Kristen Gillibrand, Tammy Baldwin, Ben Cardin, Richard Blumenthal, and Kamala Harris introduced a bill called the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act, or the “MOMMIES Act.” Mental health is not a central focus of the proposed bill, but it is addressed.
And in December, Congress passed the Preventing Maternal Deaths Act of 2018, which aims to support states in their efforts to protect maternal health during pregnancy, childbirth, and postpartum and to eliminate maternal health outcome disparities in deaths associated with pregnancy. The recent trajectory of maternal mortality rates is incredibly troubling, having increased between 2000 and 2014 in almost all states. Significant racial and ethnic disparities in the number of women who die from complications arising from pregnancy or delivery make the situation all the more disturbing.
And while legislative attention on maternal deaths is exciting, there is concern regarding the fact that contributing mental health factors have had a diminished place in policy discussions, in contrast to a greater focus on the physical causes of maternal mortality.
A 2018 report from nine maternal mortality review committees discussed data on mental health’s significant role in maternal mortality, reporting that underlying mental health conditions were associated with 7 percent of pregnancy-related deaths.
And the interactions between race, poverty, and maternal mental health are particularly alarming. One report, for example, explained that, while over half of poor infants live with a mother who is experiencing depressive symptoms at some level, mothers are not affected equally across racial groups.
One in two black mothers who have ever suffered a major depressive episode were found to be living in poverty, in contrast to one in four white mothers. And because there are effective treatments for maternal depression, the need to address the fact that over one in three low-income mothers who suffer a major depressive disorder receive no treatment is all the more urgent.
The focus on maternal health from a diverse range of policymakers and advocates is promising. And given the evidence of widespread maternal mental health complications and the associated racial and economic disparities, in conjunction with promising evidence of the benefits of certain treatments, it is critical to bring mental health to the fore in conversations surrounding maternal health. The USPSTF recommendations take an important step in this direction.
Rebecca Friedman is a 2018-2019 Petrie-Flom Center Student Fellow.