The current model for perinatal depression treatment is flawed because the vast majority of medical practices are not equipped to address the mental health needs of their patients. There is a general lack of access to reproductive and perinatal mental healthcare due to three key factors: 1) shame associated with mood and anxiety disorders, 2) an alarmingly low rate of help-seeking behaviors among depressed perinatal women, and 3) a high attrition rate for external referrals.
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Supporting Research
Perinatal Mood and Anxiety Disorders (PMADs) during a woman’s reproductive years have an alarmingly high prevalence, indicating the necessity of a widespread, reliable mental health care system during this critical time period. Depression is the most underdiagnosed and undertreated obstetrics complication in the United States, with over 400,000 infants born to depressed mothers every year [1]. In the days following delivery, up to 80% of women are affected by ‘maternity blues’, a state characterized by bursts of tears, anxiety, mild depressive moods, and the lability of moods. Provided mothers receive the necessary reassurance and emotional support, symptoms should only persist for up to 2 weeks [1]. Estimates of the prevalence of the more acute, chronic condition, postpartum depression (PPD), range from 13-60%, with low-income women struggling at disproportionate rates [1]. 65% of individuals who have suffered previous bouts of depression or other psychiatric conditions develop PPD [2-3]. Postpartum psychosis affects between one and three out of every 1,000 mothers following delivery, resulting in delusions, hallucination, and suicidal thoughts or actions [3]. Some studies have indicated that suicide is the number one cause of death among mothers in the first year postpartum [4]. At NAPS, we are dedicated to combating the epidemic level of suffering that afflict women throughout their reproductive years. By providing women with the necessary support and follow up, we insure that these women do not fall through the cracks of our perinatal health care system.
The current model for prenatal and postpartum depression treatment is flawed because the vast majority of practices are simply not equipped to address the mental health needs of their patients. Research has found that PPD occurs more commonly than most physicians realize [5]. In one study only 31% of pediatricians said they feel confident in their ability to identify the condition and only 7% were familiar with screening tools [6]. There is also a general lack of access to perinatal mental health care and women are often too filled with shame for needing help so they do not reach out. Studies have found alarmingly low rates of help-seeking behaviors among depressed postpartum women [7]. Research highlights that those struggling with the most acute symptoms of perinatal mood and anxiety disorders, including suicidal ideation, might not be willing to offer this information unless they are asked directly [3]. The patients who do take it upon themselves to find support are more likely to seek help from primary care doctors rather than from mental health professionals [5]. Combined, this information suggests the critical importance of an in-house mental health care system to support this patient population. When practices refer patients externally for mental health, there is an alarmingly high rate of low to follow-up. Previous studies have shown that as few as 11.8% mothers who screen positive for perinatal mood and anxiety disorders receive follow up mental health services [8]. The problem is heightened among low-income women, where prevalence of symptoms is higher, the treatment gap is larger and initiation is later [9]. Without the necessary support, symptoms persist. Over half of women who develop PPD are still suffering from symptoms a year later [5]. NAPS not only initiates prevention of PMADs, but also reduces the barrier to entry to postpartum depression treatment, most notably for patients at the most critical point in their perinatal mental health. The comprehensive nature of this program allows for patients’ needs to be met in a manner that far exceeds the current standard of care available from existing practices. By working with patients within an environment they already trust, the NAPS programming combines prevention, assessment, and routine follow-up in order to help reduce the stigma surrounding patients’ mental health needs and to ensure that women who are struggling receive the necessary support. By providing these services internally, we normalize getting support which allows patients to bypass the shame of getting help or feeling dismissed by being passively given a referral.
The downstream implications of perinatal mood and anxiety disorders are vast for the woman as well as her offspring, emphasizing the critical importance of early screening, support, and treatment during this vulnerable time frame [10]. Women who suffer with PPD are at an increased risk for subsequent depressive, anxiety and bipolar disorders [10]. Maternal depression presents a risk of poverty, substance abuse, domestic violence, among other consequences, resulting in an increased cumulative risk [1]. Depression can impair an individual’s parenting skills, leading to fewer positive parent-infant interactions and can negatively affect judgment and attention regarding the child, impacting the health and safety of the child [1]. Several caregiving activities appear to be compromised by postpartum depression including feeding practices, most especially breastfeeding, sleep routines, well-child visits, vaccinations and basic safety practices [11-12]. Research has shown that depression experienced around the time of childbirth increases the risk for costly complications during delivery and inappropriate medical treatment of the infant, which can contribute to long-lasting negative and even permanent effect on a child’s development [13,26]. Exposure to maternal stress sensitizes a child’s pituitary-adrenal response to subsequent stress exposure [14]. Research has shown when untreated, the effects of PPD and poor mother-infant bonding can result in delays in infant growth and brain development, and an increased risk for psychiatric problems later in the child’s life [3,15,16]. These negative effects extend beyond the early years, including greater rates of sick and emergency room visits and lower rates of well-child-visits across all child and adolescent age groups [17-18]. The important and long-lasting impacts of maternal depression on a child’s mental health are found to be more severe with earlier exposure [19]. Due to the persistent and severe negative effects of maternal depression on child outcomes, treatment of this group should be a priority [18]. Continued efforts to treat maternal depression until remission is achieved has been associated with a decrease in psychiatric symptoms and improved functioning in the offspring [16]. Perinatal depression is a treatable condition and negative effects on the mother, infant, and family can be buffered by preventative practices [20].
The literature suggests that preventive interventions beginning in early pregnancy onward serves to benefit not only maternal, offspring, and familial health but also the American medical system in general. Perinatal depression is a prevalent, high-risk illness that requires increased psychiatric care as well as non-psychiatric services. Research has shown that perinatal depression leads to increased cost of medical care, with depressed women incurring 90% higher health expenditures than non-depressed women [12,21]. Recent research and expert opinion have suggested approaches to combating maternal depression that establish a place for routine care, which would yield a decrease in need for costly acute care services [22]. NAPS programming provides the urgently necessary, consistent mental health support that can effectively mitigate the costs perinatal mood and anxiety disorders place on our mothers, children, and healthcare system. NAPS has the distinct ability to lighten the load of our overburden healthcare system and to support the individual practitioner. Doctors are often overextended or do not have the time or proper training to help their struggling patients. Estimates of the prevalence of burnout in medicine vary widely but are consistently greater than 40% and often as high as 75% [23]. Obstetricians and gynecologists rank among the top medical specialties for the rate of professional burnout reported. When burnout is present, there is reduced job satisfaction, lower productivity, increased medical errors (and morbidity), degraded interpersonal interactions, and higher physician dropout rates [23]. Professional burnout affects not only the individual, but, by extension, the patients they serve. NAPS programming reduces the burden on providers who have not received the proper training to provide mental health support and may not be trained in identifying symptoms in struggling patients.
Systemic, universal screening for perinatal depression has been widely recommended, but, if there is any hope of improving patient outcomes, screening must be combined with a strong collaborative relationship with between mental health and primary care providers who can ensure accurate diagnosis, effective treatment, appropriate follow-up, and longitudinal case management [24-27]. With significant impacts of maternal depression on the woman and her infant combined with the low-help seeking behaviors of depressed postpartum women, there must be reliable support systems in place to facilitate appropriate follow up and intervention [7]. Compared with usual postpartum care, psychosocial and psychological intervention has been proven to be effective in reducing maternal depressive symptoms [28]. Interpersonal and cognitive behavioral therapy in both individual or group settings have proven to be effective in treating mild to moderate PPD [28]. NAPS partners with other professionals in the perinatal community in order to connect women with reliable, effective support when it is most critical.
Perinatal mood and anxiety disorders are treatable conditions. Given their alarmingly high prevalence and vast implications for mothers, families, and the medical system as a whole, treatment of this group should be a priority. The NAPS program comes equipped with all program materials and includes multiple mental health screeners, follow-up support, support for the physician, patient management, calls, group facilitation, and one-on-one therapy for patients. NAPS works to bridge the gaps in perinatal health care by partnering with practices to assist in managing the program and its program employees, as well as maintaining financials and development. NAPS is an organization committed to changing the incidence of untreated perinatal mood and anxiety disorders by rebuilding a culture of mothering the mother.
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