Perinatal mood disorders affect one in seven pregnant people, but many never receive screening and care. In California, AB 2193 aims to change that by mandating providers screen perinatal patients for mood disorders and instituting a case management system in order to get patients the treatment they need. The bill takes a somewhat unique approach to this issue, and is one that could become a model for other states.
Postpartum depression may be one of the most well-known perinatal mood disorders, but people can also develop anxiety, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, and, in rarer cases, panic disorder or psychosis both during and after pregnancy.
Dr. John Straus, the founding director of the Massachusetts Child Psychiatry Access Program (MCPAP), told Rewire.News that non-gestational parents can experience perinatal mood disorders too: “And it’s not just moms actually. It’s dads and adoptive parents as well.”
Issues like depression, anxiety, and PTSD can become disabling, interfering with a parent’s ability to bond with a child and perform tasks of daily living. While psychosis is rare, it can cause breaks with reality that endanger parents, children, and other family members. Long-term untreated mental health conditions may also make it difficult to go back to work and may make parents feel isolated and alienated. But many of these conditions are very responsive to medication and therapy—meaning that accurate diagnosis and treatment is all the more important.
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The American College of Obstetricians and Gynecologists (ACOG) says that while more information on screening is still necessary, evidence suggests it should be offered by obstetrical caregivers. This is mirrored by screening recommendations from the U.S. Preventive Services Task Force. States like New Jersey have enacted laws requiring care providers to screen, but advocates argue this is not enough: If health-care providers have nowhere to send their patients, screening them and identifying a perinatal mood disorder can be an exercise in futility.
That’s what makes AB 2193 distinctive: If passed, providers will be required to screen gestational parents once during pregnancy and at least once in a postpartum checkup. But it’s also accompanied with a mandate to insurance companies to set up a case management system for perinatal mood disorders akin for that used with other common medical issues that may require coordination across several medical specialties. Asthma and diabetes, for example, are both common targets for case management programs to ensure patients are identified, provided with treatment, and followed to make sure they improve.
Both of these measures were recommended in an April 2017 report from the California Task Force on the Status of Maternal Mental Health Care, along with another important facet of improving access to care: setting up a provider-to-provider network that would allow general practitioners, birth care providers, and others treating patients with perinatal mood disorders to connect with experts in perinatal psychiatry. Such a network is critical for allaying fears on the part of providers who don’t feel comfortable providing treatments like medication management, or who need help finding counseling services for their patients.
This model is in part based on MCPAP for Moms, which provides psychiatry consults across the state of Massachusetts to providers encountering patients who screen positive for perinatal mood disorders. “If [providers] start screening, [they] need to be able to treat if [they] find a positive screen. Providers are very reluctant to screen if [they] can’t get help,” Straus said. With MCPAP, primary care physicians, obstetricians, and other first-point-of-contact providers can pick up a phone to talk to a perinatal psychiatrist and work through the best options for a patient in trouble. A psychiatric expert can help “the doctor make the right diagnosis, decide what kind of treatment is appropriate, help with medicine. If the mom needs help getting therapy, referrals, we also have a care coordinator who works along with the doctor who can help the family get to a therapist.”
The program has helped 4,000 women since the summer of 2014, and it’s universally available to everyone regardless of insurance status. Straus notes that there’s another important component to MCPAP’s success: provider training. In addition to offering resources online for care providers to take advantage of, the program also travels to provide training, increasing provider confidence and competence in screening patients and referring them to care. Ultimately, he says, the goal is to reduce the load on perinatal psychiatrists, who are relatively rare, instead allowing primary care providers to handle the bulk of treatment and referring challenging cases to experts—akin to the way many practices manage basic mental health needs currently. For example, a patient with perinatal depression could be prescribed medications safe for use in pregnancy or breastfeeding by a trusted and familiar primary care provider, with an option for referral to individual or group counseling. Conversely, in a case of perinatal psychosis—often a psychiatric emergency that requires specialist care—a physician could refer a patient to mental health services.
“OBs are trained to address the physical body, not the mind,” says Kelly O’Connor Kay, the development director of Maternal Mental Health Now, one of the groups advocating on the bill. She argues that providing mandated screening without backup doesn’t support birth care providers, and doesn’t benefit people dealing with perinatal mood disorders. Maternal Mental Health Now offers trainings for providers to help them get more familiar and comfortable with these issues, with an end goal of getting as many parents as possible screened and into treatment if they need it.
But, Kay adds, even a screening and case management system won’t address all health-care disparities. Though the structure of the bill includes Medi-Cal, the state’s Medicaid program, along with insurance programs, some patients will fall through the gaps, including those who are uninsured or underinsured. Even access to treatment in theory has to contend with obstacles like limited access to transit, inability to take time off from work, few providers in a given area, and the need for child care. Kay says she hopes having a case manager assigned to a patient to connect people with resources may help to mitigate some of these problems, meeting patients where they are.
Not everyone is thrilled about the bill—some obstetricians in particular have voiced concerns. These include worries about being unable to perform screenings, failures in connecting patients to care, limited numbers of providers capable of offering treatment in perinatal psychiatry, and obstacles like affordability and accessibility. In these settings, they stress, screening could lead providers and patients alike on a path that ultimately goes nowhere. Others say that poor insurance reimbursement for screening makes it difficult to carve out time in their practices. The bill does not address these issues as written.
In discussing these bills, it is vital, too, to remember the role that history can play in parents’ interactions with the medical system. After the Andrea Yates case in 2001, in which a mother struggling with untreated postpartum depression and psychosis drowned her five children, awareness of the risks of failing to identify parents in need of support has increased dramatically. But it comes with a dark side. In February, a new parent asked for emotional help and a nurse called law enforcement on her. In other cases, children have been taken from parents who are dealing with perinatal mood disorders. These trends can have a chilling effect: Some patients who need help may avoid reaching out or resist screening out of fear they might be separated from their children.
In a statement provided to Rewire.News, Dr. Laura Sirott, ACOG’s California state legislative chair, said: “We must do better as a medical community to properly screen for perinatal and postpartum depression and initiate medical therapy, when indicated. OB-GYNs, nurses, pediatricians, emergency department staff, and others must be equipped to refer patients to appropriate behavioral health resources. ACOG is committed to working with state leaders to expand provider knowledge and training, improve care coordination, and build a robust network of community-based resources.”
According to Maternal Mental Health Now, AB 2193 will in April be scheduled for a hearing before the California Assembly’s Health Committee, after which it will need to be approved by both houses of the legislature before going to the governor for signature.
Even proponents of AB 2193 agree that it’s only one piece of a larger picture when it comes to addressing perinatal mood disorders, but it could be an important one if the state implements it carefully. The provision of training in how to screen patients and treat basic issues rolled out alongside the screening and case management requirement could result in more patients getting the treatment they need for very manageable mental health issues.