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870 Market Street, Suite 928, San Francisco, CA 94102 Phone: (415) 421-2926 � Fax: (415) 421-2928 � www.mentalhealthsf.org

MATERNAL MENTAL HEALTH POLICY BRIEF

by Erin Huie, MSW

Special Projects Manager, The Center for Dignity, Recovery and Empowerment

February 2015

Copyright reserved, Center for Dignity, Recovery and Empowerment 2015. All rights, reproduction, and usage is limited and prohibited without expressed consent of the Center.

The Center for Dignity, Recovery & Empowerment at the Mental Health Association of San Francisco was established to advance effective mental health supports grounded in hope and human dignity through integration of policy, research and community-based practices.

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STATEMENT OF ISSUE Maternal mental health conditions such as depression and anxiety are the most common complications of childbirth, impacting approximately 15-20% of pregnant and postpartum women.1 When untreated, these conditions can have severely adverse long-term effects on the health of the whole family, including the mother, partner, and child2 and potentially lead to eventual self-harm and suicidal ideation. Women experiencing symptoms of maternal depression and anxiety face significant challenges in adequately caring for the needs of their infants as well as themselves,3 and may have difficulty functioning in the workplace and among social peers.4 They are also likely to engage in high-risk behaviors including alcohol and substance abuse.5 6 Fetal and neonatal outcomes of perinatally depressed mothers can be significantly adverse and include increased risk for premature delivery, low gestational and birthweight, and unhealthy fetal activity and behavior.7 8 Infants and young children of women with postpartum conditions are at high risk for experiencing serious cognitive, developmental, and emotional delays or impairments up to adolescence.9 Women across age groups, socioeconomic status, educational levels, races, cultures, and ethnicities are at risk for developing maternal mental health conditions. Certain risk factors strongly contribute to the likelihood of developing maternal depression and anxiety, including: history of psychopathology and psychosocial adversities, history of abuse, low levels of social support, experiencing stressful life events, substance misuse, and negative cognitive style.10 11 The prevalence of depression and anxiety is nearly twice as high in vulnerable groups;12 low-income and minority mothers experience stressors that increase their likelihood of becoming depressed and face greater barriers to having symptoms detected and accessing treatment than

1  Postpartum  Support  International  (2014).  Perinatal  Mood  &  Anxiety  Disorders  Overview.  Retrieved  from  http://www.postpartum.net/Get-the-Facts.aspx 2  Xu,  F,  Austin,  M,  Reilly,  N.,  Hilder,  L.,  Sullivan,  E.A.  (2012).  Major  depressive  disorder  in  the  perinatal  period:  using  data  linkage  to  inform  perinatal  mental  health  policy.  Archives  of  Women’s  Mental  Health,  15(5).  Retrieved  from    http://link.springer.com/article/10.1007/s00737-012-0289-8# 3  Oregon  Health  Authority  (n.d.).  Maternal  Mental  Health.  Retrieved  from  https://public.health.oregon.gov/HealthyPeopleFamilies/Women/MaternalMentalHealth/Pages/index.aspx 4  Maternal  and  Child  Public  Health  Leadership  Training  Program  (2007).  Preventing  Perinatal  Depression.  Northwest  Bulletin,  21(2).  Retrieved  from    http://depts.washington.edu/nwbfch/PDFs/NWBv21n2.pdf 5  Chapman,  S.L.C.,  Wu,  L.  (2013).  Postpartum  substance  use  and  depressive  symptoms:  a  review.  Women’s  Health,  53(5).  Retrieved  from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3742364/ 6  National  Institute  for  Health  Care  Management  Foundation  (2010).  Identifying  and  treating  maternal  depression:  strategies  &  considerations  for  health  plans.  NIHCM  Foundation  Issue  Brief.  Retrieved  from  http://www.nihcm.org/pdf/FINAL_MaternalDepression6-7.pdf 7  Kinsella,  M.T.,  Monk,  C.  (2009).  Impact  of  maternal  stress,  depression,  and  anxiety  on  fetal  neurobehavioral  development.  Clinical  Obstetrics  and  Gynecology,  52(3).  Retrieved  from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710585/   8  Muzik,  M.,  Borovska,  S.  (2010).  Perinatal  depression:  implications  for  child  mental  health.  Mental  Health  Family  Medicine,  7(4).  Retrieved  from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083253/ 9  Stein,  A.,  et  al.  (2014).  Effects  of  perinatal  mental  disorders  on  the  fetus  and  child.  The  Lancet,  384(9956).  Retrieved  from  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61277-0/fulltext#article_upsell 10  Howard,  L.,  et  al.  (2014).  Non-­‐psychotic  mental  disorders  in  the  perinatal  period.  The  Lancet,  384(9956).  Retrieved  from  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961276-9/abstract 11  Leigh,  B.,  Milgrom,  J.  (2008).  Risk  factors  for  antenatal  depression,  postnatal  depression  and  parenting  stress.  BMC  Psychiatry,  8(24).  Retrieved  from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2375874/ 12  Chaudron,  L.,  et  al.  (2010).  Accuracy  of  depression  screening  tools  for  identifying  postpartum  depression  among  urban  mothers.  Pediatrics,  125(3).  Retrieved  from  http://www.ncbi.nlm.nih.gov/pubmed/20156899

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the general population.13 Despite the high prevalence of maternal depression and anxiety across the US, only 15-20% of mothers eventually receive treatment. Among low-income women, this rate is considerably lower.14 Women experiencing symptoms of perinatal/postpartum depression and anxiety often remain undiagnosed and untreated due to ‘practical barriers’ to care (not knowing where and how to access services, family responsibilities, lack of time, lack of knowledge on issues) and ‘social barriers’ to care (shame, fear of stigma, fear of stereotypes on what motherhood should include or look like).15 16 While women with fewer resources are especially affected by practical barriers, a majority of women across economic means report the following significant challenges: difficulty in accessing screening services, lack of flexibility of treatment location and treatment options, and lack of overall awareness, support, and education which lead to fear and doubt about treatment effectiveness.17 Low-income women tend to face additional logistical, structural, and personal barriers, including: lack of routine and systematic screening-and-referral mechanisms in primary care or other settings, finding affordable services and childcare, misunderstanding of treatment options, and cultural preferences.18 BACKGROUND Since 2000, maternal mental health conditions have received increased attention from federal and state agencies. Federal support for screening, early identification, and treatment of perinatal depression rose in the early 2000s until, in 2003, the first federal legislation on perinatal depression was introduced in response to the suicide of Melanie Blocker-Stokes, who suffered from postpartum psychosis to her death. The Melanie Blocker Stokes MOTHERS Act or “Moms Opportunity To access Health, Education, Research and Support” finally became incorporated into the Patient Protection and Affordable Care Act, which passed in 2010. This Act includes research provisions and includes additional provisions on directing the future actions of the National Institute of Mental Health, authorizing grants to support the establishment, operation, and delivery of effective and cost-efficient systems for providing clinical services to women with, or at risk for, postpartum depression or psychosis, and appropriates money to study the benefits of screening. However, due to federal budget issues and a challenging political climate surrounding the Affordable Care Act, no funds have been allocated toward the Act by Congress since its passage.

13  Boyd,  R.  Mogul,  M.,  et  al.  (2011).  Screening  and  referral  for  postpartum  depression  among  low-­‐income  women:  a  qualitative  perspective  from  community  health  workers.  Depression  Research  and  Treatment,  Article  ID  320605.  Retrieved  from  http://www.hindawi.com/journals/drt/2011/320605/cta/ 14  Retrieved  from  http://opinionator.blogs.nytimes.com/2014/10/16/treating-­‐depression-­‐before-­‐it-­‐becomes-­‐postpartum 15  Muzik,  M.,  Borovska,  S.  (2010).  Perinatal  depression:  implications  for  child  mental  health.  Mental  Health  Family  Medicine,  7(4).  Retrieved  from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083253/ 16  Barnes-­‐Higgs,  K.  (2012).  Behavioral  health  care  for  maternal  mental  health  in  Philadelphia.  Maternity  Care  Coalition.  Retrieved  from  http://maternitycarecoalition.org/wp-content/uploads/2012/02/Perinatal-Depression-Barriers-and-Recommendations.pdf 17  Muzik,  M.,  Borovska,  S.  (2010).  Perinatal  depression:  implications  for  child  mental  health.  Mental  Health  Family  Medicine,  7(4).  Retrieved  from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083253/ 18 Pooler, J. (2013). Postpartum depression, low-income women, and WIC: examples of integrated screening and referral efforts. Altarum Institute. Retrieved from http://altarum.org/health-policy-blog/postpartum-depression-low-income-women-and-wic-examples-of-integrated-screening-and-referral-efforts

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Several states have passed laws mandating screening and education, but a number of these mandates have not been strictly enforced. In 2006, New Jersey became the first U.S. state to pass a law mandating universal screening, education and referral for postpartum depression. In 2007, Illinois passed a law requiring that licensed health care professionals provide education about perinatal mental health disorders as part of prenatal education and invite women to complete a screening questionnaire. Many states including California, Virginia, Texas, and Pennsylvania have launched innovative statewide training, campaign, and systemic treatment access programs. Outreach, screening, education, and treatment practices have vastly improved in recent years across various settings of care. Despite improvements, however, outreach and screening practices remain inconsistent, especially for low-income women. Providers present inadequate or no education to women due to limited training. Finally, while treatment addressing maternal mental health conditions is largely effective, women who do receive referrals for treatment face significant barriers in accessing treatment. This is largely due to the fact that providers are typically not co-located with location of treatment access and/or do not have strengthened mechanisms in place to ensure follow-up of services. POLICY RECOMMENDATIONS

PROVIDER SETTING

• Mental health professionals trained in the area of treating maternal depression and anxiety should be co-located in settings where women undergo screening and evaluation. Improved coordination of care and co-location of treatment access at obstetrics clinics or gynecology clinics have been shown to enable treatment-seeking behavior and ensure follow-up and obtainment of appropriate services.

• Early screening and secondary prevention mandates are imperative to preventing the

potential onset of additional symptoms and/or providing women with an additional net of preventive support to build sustained resiliency against possible development of new conditions. Additionally, it is recommended that women who present 1) a previous history of psychopathology and psychosocial challenges and/or 2) one or more risk factors for developing depression or anxiety should be offered opportunities for close monitoring and evaluation throughout the perinatal and postpartum periods.

• To better address barriers to detection and treatment of maternal mental health

conditions for low-income women, community-based health workers should be actively engaged in mandated, routine screening and warm handoff referral processes to culturally and linguistically sensitive treatment services, ideally co-located at local clinics, agencies, and health centers.

• Primary care physicians and staff working with pregnant and postpartum women should

complete comprehensive trainings on best practices in the delivery of destigmatizing and culturally sensitive education, screenings, and treatment knowledge to reach the need at scale.

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• Diagnostic evaluation must be mandated to follow all positive screenings to confirm diagnoses, as screenings can produce a high rate of false positives and existing screening instruments vary in overall efficacy, sensitivity, and specificity, and to-date are not culturally sensitive.

SYSTEMS SETTING

• Workplace policies and occupational health programs should be revised to promote ongoing wellness and recovery for mothers with mental health conditions and provide supports for successful continuation or re-entry to work. This can include provision of prevention, support, flexibility, and referral measures for prenatal, perinatal, and postpartum women.

• Local and state agencies must allocate substantial funding and resources toward the

development and sustained support of stigma-reducing public information and awareness campaigns with the goal of shifting culture and societal expectations surrounding motherhood. Agencies should work closely with a diverse range of community-based organizations and field leaders to develop sensitive, destigmatizing messaging and advance evidence-based stigma reduction activities.

• Local and state public health agencies must collaborate with community partners –

such as workplaces, hospitals, wellness centers, childcare centers, and clinics – and existing programs such as Maternal, Infant, and Early Childhood Home Visiting Programs, WIC, and Early Head Start to ensure extensive access to culturally and linguistically sensitive maternal mental health education and resources.

• Continued advocacy for funding allocation toward the Affordable Care Act-approved

Melanie Blocker Stokes MOTHERS Act is imperative to the ongoing development of innovation and research in this field. This Act, which was passed in 2010 to establish a federal commitment to expand research efforts, public awareness, and education initiatives on postpartum depression, has remained stagnant due to Congress’ lack of financial commitment.