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Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans

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Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans IdentIfyIng and treatIng Maternal depressIon: strategIes & ConsIderatIons for HealtH plans nIHCM foundatIon Issue BrIef June 2010 INTRODUCTION of perinatal depression.3 The Healthy People 2010 framework initially included a sub-objective to reduce Approximately 10 to 20 percent of women experience hospitalizations due to postpartum complications, depression either during pregnancy or in the first 12 including postpartum depression, but it was eliminated months postpartum.1 Maternal depression can lead to during midcourse review due to a lack of supporting serious health risks for both the mother and infant, data.4 However, reflecting the continued widespread increasing the risk for costly complications during birth prevalence of maternal depression, the American and causing long-lasting or even permanent effects on Congress of Obstetricians and Gynecologists (ACOG) child development and well-being. Despite the fact that recently suggested an objective for Healthy People the health risks and costly complications associated with 2020 targeted at increasing the proportion of pregnant maternal depression are well-documented, pregnant and postpartum women who receive screening for women and new mothers experiencing depression maternal depression and referral for evidence-based often do not get the treatment they need due to fear of therapy.5 discussing mental health concerns with their providers or a lack of education about depression. According to Health plans play an important role in ensuring early the 2002 Listening to Mothers Survey, nearly six out identification of maternal depression and coordinating of ten women scoring 13 or higher on the Edinburgh management of care following a diagnosis. Health Postnatal Depression Scale (indicating that they were plans have an opportunity to pinpoint those at highest likely to be suffering some degree of depression) had risk by encouraging obstetricians, pediatricians, not seen a professional for concerns about their mental primary care physicians and other health care health since giving birth.2 Furthermore, since screening professionals to screen for maternal depression, raising is not standard practice for most providers, maternal awareness of maternal depression through patient depression often goes undiagnosed and therefore education in maternity programs and offering access untreated. to nurse case management during the pregnancy and postpartum period. Such simple interventions could Over the past decade, maternal depression has received have a substantial impact on the number of maternal increased attention on several fronts. The release of depression diagnoses and would aid in the prevention the Surgeon General’s Report on Mental Health in of further complications and unnecessary costs. 2000 was followed by a rise in media attention on postpartum depression and postpartum psychosis. In this issue brief we review the various forms of Federal support for screening and treating maternal maternal depression, symptoms and prevalence in depression also rose during this time with Congress the United States, the costs (including monetary, life earmarking funding for the Health Resources and course and developmental impacts), current screening Services Administration’s Maternal and Child Health tools and recommendations for early identification and Bureau (MCHB) to address perinatal depression in treatment of maternal depressive disorders, and barriers 2004. MCHB continues to fund activities across the to diagnosis and access to treatment and care. Lastly, we country in support of early identification and treatment share opportunities for health plans to play an active role 1 Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans in supporting a comprehensive approach to care that she would normally. Labor and delivery, in addition to will facilitate early identification of maternal depression caring for a newborn, bring another level of stress, and proper referral to evidence-based treatment. especially for a first time mother. It is physically and mentally draining on a woman, which is why so many women experience what is referred to as the “baby DEFINITIONS blues” or “postpartum blues.” Because it affects the majority of mothers, the baby blues is not considered Maternal depression is an all-encompassing term a form of maternal depression. Mothers experience a for a spectrum of depressive conditions that can range of emotions that are a common reaction the first affect mothers (up to twelve months postpartum) few days after delivery. However, if these symptoms and mothers-to-be. These depressive conditions persist for more than two weeks, the mother may be include prenatal depression, postpartum depression experiencing postpartum depression, which requires and postpartum psychosis. Maternal depression is medical attention. In contrast, symptoms of the baby increasingly recognized as a worldwide public health blues will disappear fairly quickly with the patience and issue and can have a negative impact on an individual’s support of family and social networks.8 life that is far reaching, affecting work, family and the health and development of the baby. Table 1 provides a detailed overview of conditions related to maternal Postpartum Depression depression, their usual time of onset, and their prevalence and symptoms. Postpartum depression is an affective mood disorder with symptoms similar to those of the baby blues; however the primary distinguishing factor is that these Prenatal Depression symptoms will persist beyond the first two weeks after the baby is born. Symptoms can occur immediately after Prenatal depression encompasses major and minor birth and up to one year after delivery. Undiagnosed depressive episodes beginning during pregnancy and depression during pregnancy is the number one lasting up to six months to a year after pregnancy.6 risk factor for postpartum depression. A mother Evidence suggests that women experiencing prenatal experiencing postpartum depression will generally depression may have an underlying vulnerability to experience at least five of the symptoms identified in changing hormone levels which trigger the onset of Table 1.9 Many of the symptoms are difficult to assess symptoms.7 In addition to hormonal changes, genetics, in the postpartum period as they must be differentiated psychosocial factors and life stressors all play a role from “normal” conditions of being a new mother. in triggering a prenatal depressive episode. However, This is especially true for first time mothers. These because pregnancy involves a variety of changes in difficult-to-distinguish symptoms include insomnia mind and body due to fluctuating hormone levels, or hyperinsomnia, significant decrease or increase in distinguishing between symptoms of depression and appetite, moderate to severe anxiety and some somatic normal responses to stressful experiences of pregnancy symptoms, such as headaches or chest pains. can be difficult. In general, the symptoms of prenatal depression parallel those of major depression and those experienced in postpartum depression. It is a serious, Postpartum Psychosis but treatable disorder. Postpartum psychosis is a rare but serious disorder requiring immediate psychiatric evaluation and medical Baby Blues attention. This condition usually presents within the first few days to a month after delivery, though it can occur Pregnancy is a particularly stressful time for a woman; up to a year after the baby is born. Unlike other forms she experiences a number of hormonal and physical of maternal depression, symptoms may develop rapidly. changes that can make her act and feel differently than Mothers with postpartum psychosis will experience 2 NIHCM Issue Brief n June 2010 TABLE 1. TYPES, PREVALENCE, AND SYMPTOMS OF MATERNAL DEPRESSSION & RELATED CONDITIONS Type Onset Prevalence Symptomsi Prenatal During pregnancy 10 to 20 percent • Crying, weepiness depression of pregnant • Sleep problems mothers • Fatigue • Appetite disturbance • Anhedonia • Anxiety • Poor fetal attachment • Irritability Baby blues Begins during the As high as 80 • Crying, weepiness first few weeks percent of new • Sadness after delivery mothers • Irritability (usually in first week, peaking at 3 • Exaggerated sense of empathy to 5 days) • Anxiety Symptoms usually • Mood lability (“ups” and “downs”) resolve by two • Feeling overwhelmed weeks after delivery • Insomnia; trouble falling or staying asleep; Fatigue/exhaustion • Frustration Postpartum Usually within the 10 to 20 percent • Persistent sadness depression first two to three of new mothers • Frequent crying, even about little things months post- • Poor concentration or indecisiveness partum, though onset can be imme- • Difficulty remembering things diate after delivery • Feelings of worthlessness, inadequacy or guilt (distinguishable • Irritability, crankiness from “baby blues” as it lasts beyond • Loss of interest in caring for oneself two weeks post- • Not feeling up to doing everyday tasks partum) • Psychomotor agitation or retardation • Fatigue, loss of energy • Insomnia or hyperinsomnia • Significant decrease or increase in appetite • Anxiety manifested as bizarre thoughts and fears, such as obsessive thoughts of harm to the baby • Feeling overwhelmed • Somatic symptoms (headaches, chest pains, heart palpitations, numbness and hyperventilation) • Poor bonding with the baby (no attachment), lack of interest in the baby, family or activities • Loss of pleasure or interest in doing things
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