From Data to Action: Using Science to Transform Perinatal Mental Health Care

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Introduction

This summary outlines key insights regarding the challenges and advancements in integrating mental health care into perinatal settings, based on the provided audio excerpts. The speaker's passion for this work is deeply rooted in a powerful personal history involving transgenerational trauma stemming from her grandmother's untreated psychiatric illness after her mother's birth. This experience highlighted the critical importance of maternal mental health and its potential transgenerational impact. As a perinatal psychiatrist, the speaker witnessed firsthand the unmet needs of patients in obstetric settings, who were not being screened for or receiving adequate treatment for mental health conditions despite obstetric clinicians' desire to help. This reality motivated the speaker to pursue research aimed at leveraging the existing relationship between obstetric clinicians and patients to improve mental health outcomes.

The Challenge: Common, Undertreated Disorders with Significant Impact

Perinatal depression and anxiety are common, affecting at least one in five individuals during this period. These disorders have a negative impact on birth, child, and infant outcomes. Despite their prevalence, they are significantly undertreated. A systematic review found that only one in four individuals who screen positive for depression reach an initial mental health appointment. Crucially, mental health conditions, combined with substance use disorders, are now the leading underlying cause of maternal deaths in the United States, accounting for 23% of deaths, significantly higher than other medical causes like hemorrhage or preeclampsia. Other perinatal mental health conditions discussed include substance use disorders (at least 5%), anxiety disorders (as high as one in five), OCD symptoms (up to 17%), PTSD (1.1%, likely an underestimate), bipolar disorder (specific increase in risk), and postpartum psychosis (one to two in a thousand), which can be associated with tragic outcomes like infanticide and suicide. These disorders are increasingly recognized as a major public health issue.

Barriers to Care and the Need for Integrated Systems

Despite professional organizations like ACOG and AIM recommending screening, assessment, treatment, and follow-up for mood and anxiety disorders during the perinatal period, implementation is challenging. Recommendations have evolved from screening at least once to screening twice in pregnancy and once postpartum for depression and anxiety, plus screening at least once for bipolar disorder, especially with a positive depression screen. However, screening is just the first step and must be coupled with adequate systems for diagnosis, effective treatment, and follow-up.

Focus groups with patients and clinicians revealed significant barriers:

• Patients felt uncomfortable discussing symptoms or seeking care.
• Clinicians didn't know what to say or were afraid to screen if they couldn't offer resources.
• Systems were not integrated, and community-based interventions were not being accessed.
• Referrals often resulted in frustration, as there were insufficient mental health providers available to treat the volume of patients needing care, leading to long wait times. Modeling an OB practice with 1000 patients, if 200 have symptoms and 150 need treatment, the limited availability of treatment slots means only a fraction can be seen.

This situation of patients not disclosing symptoms/seeking care and clinicians being unprepared with limited resources directly leads to low treatment uptake and negative outcomes.

Developing Solutions: Access Programs and Capacity Building

To overcome these multi-level health system barriers, the focus shifted to building capacity within obstetric settings. This led to the development of MCPAP for Moms (Massachusetts Child Psychiatry Access Program for Moms), a model aimed at leveraging psychiatric resources to support perinatal clinicians in providing care. This model, similar to Texas's Perry Pan program, has three core components:

1. Perinatal Consultation: Provides access to a perinatal or reproductive psychiatrist via phone to answer clinician questions. Consultation is considered the engine of these programs. Examples include advising on medication management (e.g., bupropion vs. sertraline in pregnancy).
2. One-Time Assessments: For more complex cases where diagnosis or management is unclear, the program can see patients for a one-time consultation (often within two weeks), provide recommendations back to the requesting clinician, and help manage bridge treatment until longer-term care is secured. This is frequently used to differentiate bipolar disorder from other conditions.
3. Education and Toolkits: Provides resources and training for clinicians.
4. Resource and Referrals: Helps navigate the complex mental health system, including referrals to community resources.

The goal is for the perinatal clinician to treat the patient with support from the access program, increasing available treatment capacity by leveraging existing clinical relationships. Data from MCPAP for Moms shows that over time, this model builds clinician capacity to treat more complex illnesses, with calls shifting from primarily depression to more bipolar disorder cases.

Advocacy, Funding, and Reach

The development and funding of these programs were significantly driven by lived experience and advocacy. In Massachusetts, lived experience stories were crucial in advocating for legislation and securing state funding. Federally, advocacy led to legislation (championed by Congresswoman Katherine Clark) to fund these programs nationwide through the 21st Century CARES Act. The principle that "the people closest to the pain should be closest to power" was central to this movement. Currently, there are 30 such programs across the U.S., with the potential to cover over 70% of U.S. births. Some are federally funded by HRSA, while others like Texas's Perry Pan receive state funding.

Addressing perinatal mental health is also financially beneficial. Untreated mood or anxiety disorders cost an estimated $32,000 per parent-child dyad per year. In contrast, the MCPAP for Moms program costs less than $14 per person covered per year. Advocacy also led to legislation requiring health plans to pay a surcharge proportional to their covered patients, making the programs more sustainable.

Evolving Implementation Strategies

While access programs provide reactive support, integrating mental health care into perinatal settings requires more proactive approaches. Early focus was on the healthcare system (screening, education, resources, consultation, workflow integration). However, challenges remained in ensuring treatment was sustained and symptoms remitted. Building on the access program model, strategies evolved to provide clinic-level implementation guidance to help practices integrate the mental health care pathway. This guidance involves assessing current practice against guidelines, setting goals, developing workflows, and using Plan-Do-Study-Act cycles for sustainment. It also often includes a navigator to help patients access appointments. This approach aligns with the pillars of perinatal quality collaboratives (collaborative learning, rapid response data, QI science support). The guidance essentially provides the "how" to implement the "what" provided by guidelines like the AIM bundle.

Research trials have evaluated these implementation strategies:

• Prism Trial: Assessed whether adding implementation guidance to the statewide MCPAP for Moms program improved outcomes. While depression symptoms improved in both groups (MCPAP alone and MCPAP plus implementation guidance), the implementation guidance group showed higher, though not statistically significant, rates of treatment initiation and sustainment (52% initiation vs. 43%, 25% sustainment vs. 20%). PTSD symptoms also decreased in both groups, with greater improvement seen in the implementation guidance group. The study design primarily focused on depression symptoms, but the quality of care improved more in the implementation guidance practices, including screening more people.
• Self-Guided Implementation Study: Revised the implementation guide to be self-guided or require only two meetings. This study found that participation in implementation guidance (with e-learning) improved bipolar disorder screening rates (from 0% to 30%) and overall quality of care. However, the two-meeting format was insufficient for some practices, indicating that most practices need more guidance, particularly for full workflow integration. Current studies, including collaboration with Baylor sites, are tailoring guidance to practice settings and recognizing the need for more intensive support for workflow integration.

Future Directions: Community Partnerships and a Non-Traditional Workforce

While progress has been made, many individuals still lack access to mental health treatment and support. The impact of interventions is a product of both reach (how many patients get the intervention) and effectiveness (do symptoms improve). Future studies are explicitly focusing on maximizing both.

A key learning is the need to go beyond the healthcare system. Healthcare systems are often strapped for resources. Therefore, healthcare community partnerships are essential to leverage community resources and ensure all individuals interacting with perinatal individuals are prepared to support mental health.

The current Pathway Study (in which Baylor's generalist clinic is participating) is testing whether implementing recommended care works better when partnering with the community to add community-based mental health support. One arm uses the healthcare system approach (implementation guidance integrated with access programs like Perry Pan), while the other arm adds community-based supports. In this second arm, Postpartum Support International (PSI) peer mentors with lived experience will deliver behavioral activation, an 8-10 session short-term therapy, and navigation services virtually. These peer mentors are being trained by the developer of the behavioral activation model. This model combines evidence-based peer support with a specific behavioral intervention to make it more robust. The partnership involves integrating PSI into implementation meetings to facilitate referrals and cross-communication between healthcare practices and community support. This approach emphasizes a trauma-responsive approach and focuses on the relationship with patients.

Broader recommendations for the future include:

• Shifting from reactive, crisis-driven resource allocation to proactive, upstream care focused on treating people while they are at risk.
• Promoting healthy and resilient families, which includes developing and integrating prevention strategies, potentially leveraging digital therapeutics.
• Focusing on the patient-clinician relationship, being trauma-responsive, and asking questions in a way that builds trust rather than focusing solely on problems. Simple changes in communication can be impactful.
• Developing practical and scalable approaches to integrating mental health care not just in perinatal settings, but also in pediatric and other care settings.
• Embedding mental health support into existing infrastructure and creating a non-traditional workforce. Relying solely on referrals to psychiatrists and psychotherapists is not a scalable solution. The non-traditional workforce could include peer support specialists, doulas, home visitors, and potentially digital interventions that extend human connection and provide support between visits. The speaker believes it will be "all of the above" - a puzzle with many pieces in different settings.

A powerful parallel is drawn between the current challenge in perinatal mental health and the historical challenge of childhood cancer treatment. In the 1970s, the death rate from acute lymphoblastic leukemia (ALL) was 90%, despite effective chemotherapy existing. The key was not a lack of treatment, but a failure in implementing that treatment effectively. By developing networks and childhood cancer centers focused on how to implement care, the death rate dropped to 10%. Similarly, effective treatments exist for perinatal mental health, but people aren't getting them due to implementation challenges. The goal is to improve implementation to achieve similar transformative changes in outcomes.

Regarding concerns about federal funding, the speaker clarified that the Pakori funding for the Pathway study is not at risk as Pakori is not a federal agency and is on a 10-year funding cycle. Federally funded access programs receive their funding at the start of the year, so no immediate lapse is expected, although communications regarding required language changes are being reviewed.

In summary, transforming perinatal mental health care requires recognizing the significant impact of untreated disorders, addressing multi-level barriers through system capacity building (access programs), implementing evidence-based care pathways, and critically, building healthcare community partnerships and utilizing a non-traditional workforce to increase reach and provide comprehensive, accessible support. The focus must shift towards proactive, preventative, and relationship-centered care to achieve widespread improvement in outcomes.

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