Dr. Lee S. Cohen, Director of the Ammon-Pinizotto Center for Women’s Mental Health at Massachusetts General Hospital, recently shared his insights on accessing perinatal mental health care with Ob.Gyn News on May 23, 2024.
The first of May has been designated as World Maternal Mental Health Day, a time for patient groups, medical societies, clinicians and other colleagues who care for women to highlight maternal mental health and advocate for increased awareness, enhanced access in care, reducing stigma and developing more effective treatments.
In that vein, and in the context of greater mental health awareness, I wanted to point out the ironic dichotomy we see in reproductive psychiatry today. In particular, although we have many useful treatments available in the field to treat maternal psychiatric illness, there are barriers to accessing mental health care that prevent women from getting treatment and getting well.
Looking back on the last few years from the other side of the pandemic, when concerns about COVID transformed the experience of motherhood in many ways, we cannot help but recognize that it is an important moment in the field of reproductive psychiatry. We have seen not only the development of new pharmacological (neurosteroids) and non-pharmacological treatments (transcranial magnetic stimulation, cognitive-behavioral therapy for perinatal depression), but also a focus on new digital applications for perinatal depression that may be scalable and that can to help bridge the gaps in access to effective treatment from the most rural to the most urban settings.
In a previous column, I wrote about the potential difficulties in identifying women at risk of postpartum psychiatric illness, particularly in the context of different methods of data collection and data management. Hospital systems that favor paper triage methods over digital platforms create particular problems. I also noted an even larger concern: that is, once screened, it can be very difficult to engage women with postpartum depression in treatment, and women may ultimately not seek care for a variety of reasons. These ingredients are just one part of the so-called “perinatal treatment cascade.” When looking at access to care, patients would ideally be taken away from depression screening as an example and, after validating significant symptoms, would receive a referral, which would result in the patient being seen, followed up and good. But this is not the case.
A recent preliminary study published as a short communication in the Archives of Women’s Mental Health highlighted this issue. The authors used the Edinburgh Postpartum Depression Scale (EPDS) to monitor depressive symptoms in 145 pregnant women at ob.gyn. services, and found that there were low levels of adherence to psychiatric screening and referrals in the perinatal period. Another study Piwhich was issued in Journal of Clinical Psychiatry found that 30.8% of women with postpartum depression were clinically identified, 15.8% received treatment, and 3.2% achieved remission. This is the gap, in 2024, that we have not been able to bridge.
The findings show the difficulty women face in accessing perinatal mental health resources. While we’ve known for a long time that the “perinatal care cascade” is real, what we don’t understand are the variables in the mix, particularly for patients in marginalized groups. We also don’t know where women are missing out on access to care. In my mind, if we are going to make a difference, we need to know the answer to that question.
Part of the issue is that research into understanding why women fall off the curve is lacking. You can’t just hand a sheet to a woman with an EPDS score of 12 who is depressed and has a newborn and expect her to navigate care. What we really need to do is invest in navigating care for women.
The situation is analogous to the diagnosis and treatment of cardiac abnormalities in a catheterization laboratory. If a patient has a blocked coronary artery and needs a stent, then they need to go to the catheter lab. We have yet to understand the process in reproductive psychiatry to optimize the likelihood that patients will be screened and then referred to receive the best treatment available.
Some of our ob.gyn. colleagues are working to improve access to perinatal mental health services, such as offering on-site servicesand offer training and serviceto patients and providers about screening, assessment and treatment. At the Women’s Mental Health Center, we are conducting the Screening and Treatment Enhancement for Postpartum Depression study, which is a universal screening and referral program for women at our center. While some progress is being made, there are still too many women who fall through the cracks and don’t get the care they need.
It is ironic and sad that the increasing number of treatments available in reproductive psychiatry are scalable, yet we have not figured out how to facilitate access to care. While we should be excited about new treatments, we also need to take the time to understand what the barriers are for women at risk to accessing mental health care during the postpartum period.
Dr. Cohen is the director of the Ammon-Pinizotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric drugs. STEPS for PPD is funded by the Marriott Foundation. Full disclosure information about Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at obnews@mdedge.com.
