Expanding screening for postpartum depression: A summary of the research and data
In December 2016, the Bringing Postpartum Depression Out of the Shadows Act was signed into law as a part of the 21st Century Cures Act. The law authorizes $5 million for each of fiscal years 2018 through 2022 to support screening and treatment for postpartum depression, which a recent study deemed cost-effective. The next step is for Congress to decide whether to appropriate funds to support the new federal grants to states. President Trump’s 2018 budget request includes no funding for the program.
To inform Congress’ deliberations, we offer the following summary of research and data on postpartum depression, which afflicts as many as 19 percent of mothers of infants in the general population, and 38 percent of low-income women of color. Postpartum depression symptoms include depressed mood, anxiety, guilt, irrational fears, anger, and difficulty bonding with the infant. For 3 percent of all new mothers, their symptoms progress to postpartum psychosis, which includes confusion, hallucinations, and an increased risk of suicide and self-harm. Women who suffer from postpartum depression are less likely to play with, tell stories to, or read books to their children, and the children of depressed parents can exhibit symptoms of attention problems within their first year of life.
Nevertheless, it is not standard practice to screen all new mothers for postpartum depression in the United States, and only about 18 to 25 percent of postpartum depression or psychosis cases are detected without screening. Suicide is a more common cause of U.S. maternal mortality than hemorrhage, eclampsia, and embolisms, all of which have established screening and treatment pathways. The U.S. Preventive Services Task Force recently recommended that the federal government make resources available for states to implement or improve screening and treatment for postpartum depression.
Useful but incomplete: Medicaid and WIC
For the moment, many of the screening and treatment options for low-income women fall to Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Medicaid is the largest insurer for pregnant women in the United States and now encourages postpartum depression screening. However, coverage generally ends 60 days postpartum, even though depression symptoms may manifest up to a year after childbirth. If a woman is ineligible for Medicaid and screens positive for postpartum depression, she is only eligible for treatment from Medicaid that includes her child, such as family therapy, and only pending the physician’s recommendation.
Alongside Medicaid, WIC has begun to integrate postpartum depression screening into its intake process. However, numerous barriers to the successful implementation of postpartum depression services by WIC have been identified. WIC employees do not often feel that they possess adequate skills to handle the needs of women with mental health diagnoses. In the instances when screenings are provided by skillful medical staff in WIC clinics, women still face barriers to attending the clinics. For example, they may not be able to find consistent transportation and child care services, and some women may encounter additional cultural and linguistic barriers.
A national model for expanded screening
A nationwide standard of accessible postpartum depression screenings would help overcome these barriers. Home-visiting postpartum programs, which are funded by nearly every state, may be the best chance to achieve this for now. One specific example of current federal support for home visiting programs is the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grant, which is implemented in 30 percent of U.S. counties. MIECHV targets populations at an increased risk of depression, including low-income families, teen parents, and families with reported histories of child maltreatment. The initiative also provides screening, referrals, and resources for mothers.
Evaluations of MIECHV programs have found significant improvements in the lives of families, the emotional well-being of mothers and their children, as well as parenting skills. The MIECHV programs are evidence-based and focus on continued evaluation and quality improvement. States have worked toward building stronger systems for their MIECHV programs in order to narrow the gaps between research and practice. This strategy is an example of an approach that improves the lives of all members of a family by targeting those in need, addressing the mental health of mothers and children, and providing continued support.
Bolstering this approach and others would improve the standard of postpartum depression screening and treatment. In doing so, it would also improve our understanding of maternal mental health and how to treat some of the most widespread challenges that new mothers experience.