For a long time, postpartum depression has been written off as the “baby blues” but new national guidelines and efforts by insurance companies to highlight the costs of untreated post-partum and incentivize OBs to screen moms-to-be are helping to change this mindset.
The U.S. Preventive Services Task Force issued new recommendations this year for pregnant and postpartum women to undergo more rigorous screenings for depression and other mental health issues. The task force found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women. Screening are done using either a Patient Health Questionnaire or PHQ, or the Hospital Anxiety and Depression Scale for adult women.
Shannon O’Donnell, an RN for Manchester Memorial Hospital of the Eastern CT Health Network, says there is a difference between baby blues and postpartum depression. “It’s normal to be hormonal and emotional in the first days of this life changing event,” O’Donnell says. But postpartum depression is a much more concerning state. It can sometimes progress to postpartum psychosis. “It should never be brushed off as ‘baby blues’ when a patient has significant symptoms.”
O’Donnell says health insurance companies should be focusing more on preventative measures and early intervention for postpartum depression, encouraging and covering support group sessions for new mothers, and making therapy more attainable coverage wise.
Some insurers are likely to embrace this. Barry Lachman, the medical director for Parkland Health Plan in Dallas, says he’d like to incentivize OBGYN groups to do more depression screening during the pre-term phase. Lachman, a board-certified pediatrician by training, says there’s evidence that depression in this time increases the likelihood of pre-term labor. ‘We should be doing more to avoid this and the complications from it,’ Dr. Lachman says.
Other insurers are finding more unique ways to pay OBGYNs to address post-partum. Humana entered into contracts with women’s health groups in Indiana, Kansas, Ohio and Texas this year giving the doctors a share of savings if they reduce pre-term births. Cigna offers bonuses to more than 1,700 OBs for reducing postpartum and Horizon Blue Cross Blue Shield became the first first commercial health plan in the country to set up a bundled payment for OBs from 300 some New Jersey groups – the payment is designed to cover services in the months before and after delivery.
New Mom Support
Group sessions are in the works for new mothers at many hospitals around the country, but not all.
O’Donnell works as an RN in a family birthing center where she provides care to both high and low risk antepartum, intrapartum, and postpartum women, as well as newborns. The center uses a labor, delivery, recovery, and postpartum model, which means all of these services are in the same room. “So that means RNs here need to know how to provide care for every step of the labor and postpartum course,” she says.
A women’s mental and physical well-being after giving birth is important to how women can care for their babies. Fewer than two-thirds of women reported being asked about symptoms of depression at their postpartum office visits and only 44% reported that their care providers had enough information about postpartum depression during their office visits, according to a national survey by Childbirth Connection (results of survey). New mothers can experience extreme sadness that makes it difficult for them to complete daily activities to care for their children, and this depression does not occur because of something a mother does or does not do. Some women are just more likely to experience postpartum depression, including women who have symptoms of depression during or after a previous pregnancy or medical complications during childbirth, as well as those dealing with alcohol or drug abuse, or a lack of strong emotional support from a partner, family or friends.
Talk Therapy is an effective treatment that comes in two forms for women with postpartum depression including cognitive behavioral therapy and interpersonal therapy. The US Task Force found adequate evidence that treatment with cognitive behavioral therapy improves clinical outcomes in pregnant and postpartum women with depression.
But there remains confusion about when postpartum depression begins. In a straw poll of 192 mothers, 92% thought it began ‘the day I got home’ or ‘in the maternity ward’, but just 8% thought it may occur sooner. It usually begins during pregnancy, confirmed Dr. Lachman. One part of the new task force recommendations is to more broadly educate clinicians to make sure that no woman goes undiagnosed. The American Academy of Pediatrics recommends that pediatricians, not just OBs and midwives, also screen new mothers at their baby’s one-month, two-month, and four month checkups.
“In my opinion the biggest trend in postpartum care right now are the attempts to educate patients while they are in the hospital, especially those with increased depression risk factors, signs and symptoms needing intervention. It’s preventative care,” said O’Donnell.
As many as 40% of women skip their post-partum visit, rates that are higher among low-income women of color according to the American College of Obstetricians and Gynecologists, which released its own recommendations for postpartum care earlier this year. The guidelines indirectly mention the importance of depression, suggesting that the final post-partum visit be held within 12 weeks of delivery and allow the practitioner to discuss mom’s social and psychological well-being.
“I see women’s healthcare evolving to a more comprehensive and holistic model,” hopes O’Donnell. “There are more midwives now that provide the same obstetrical care to low risk women, and in my opinion provide more “personal” care to these patients. They build relationships with all of their patients, and in a sense provide more emotional support alongside the medical support to each and every patient. This is very important when it comes to postpartum depression, because with the stigma surrounding this diagnosis, a patient needs to feel trust in the care provider she is reaching out to for help. This comes from my own personal experience after the birth of my daughter, when I was diagnosed with postpartum depression.”
Report by Erin O’Donnell