Achieving Comprehensive Treatment in Perinatal Mental Health: Is Educating Obstetric Providers Sufficient?

Talk to a woman about her pregnancy, from your own mother to the Duchess of Sussex, and the resounding echo will affirm that the transition to motherhood is deeply intertwined with changes to the body, lifestyle, identity, and emotions, all of which increase vulnerability for mental health problems. Indeed, perinatal depression is one of the most common obstetric complications in the United States, with prevalence rates ranging from 10% to 15% in prior surveys of predominantly middle-class women of European decent ^1,2 to 30%–50% among women with lower-income ³ or black, indigenous, and other persons of color (BIPOC). ^{4 –6}

Unfortunately, these numbers mask the true severity of the problem, as the majority of women are underdiagnosed and left untreated ⁷ and, sadly, maternal suicidality is rising as a major contributor to maternal mortality. ⁸ Beyond this, perinatal mental health problems can impact bonding ^9,10 and parenting ¹¹ with ultimately negative consequences to infant ¹² and child ¹³ development. Given these statistics and consequences, there is urgency to act.

Pregnant and postpartum women have routine contact with obstetric providers, making these professionals ideally suited to screen, detect, and treat perinatal depression. However, obstetric providers often lack quality training and thus knowledge and skills to adequately address and treat their patients' perinatal depression. In this issue of the Journal of Women's Health, Byatt et al. ¹⁴ address this training deficit and propose a solution. The authors present pilot implementation data on an asynchronous interactive perinatal depression training module for obstetric providers.

The module tackles hands-on aspects of care, including topics such as perinatal depression screening, how to discuss illness and treatment options with patients, how to consider risks and benefits of different treatment modalities, and, finally, how to triage care according to severity with appropriate referrals to psychotherapy and/or initiation of safe and effective pharmacotherapy. The module was carefully crafted through an interactive process with input from obstetric providers (obstetricians, maternal-fetal medicine specialists, certified nurse midwifes, and nurse practitioners), and piloted with another set of 31 obstetric providers (of whom 19 completed the training). The pilot demonstrated an average 32% improvement in pre- to post-test scores on provider knowledge and confidence regarding perinatal depression care, in addition to high ratings of user satisfaction with the module, underscoring the potential power of provider training for advancing quality perinatal depression care.

The question, however, remains: Is educating obstetric providers sufficient to undo perinatal depression underdiagnosing, and undertreatment? I fear not.

First, in Byatt et al.'s ¹⁴ article only 19 of 31 finished (38% dropout rate), diminishing impact and highlighting the fact that perinatal providers face mounting demands on their time. ¹⁵ Moreover, as the authors themselves poignantly acknowledge “training [to diagnose and treat depression] is necessary but not sufficient to improve patient outcomes”. ¹⁴ Education alone is not sufficient to precipitate change, as education alone does not lead to behavior change. ¹⁶ Implementation scientists would argue that behavior change requires clinicians to unlearn prior biases before successfully implementing new information or skills; this suggests that a gain in knowledge is truly just one step toward long-standing change. ¹⁷ Byatt et al. ¹⁴ conclude that in addition to provider training other innovative approaches will be needed to overcome barriers to implementation of perinatal depression care in standard obstetric practice.

The discussion of how best to tackle perinatal mental health conditions in primary care is not new. ^{18 –23} For the past two decades the prevalence of perinatal mood and anxiety disorders (PMAD) ²⁴ and suicidality ⁸ among delivering women in the United States increased, and pleas for integrated medical and mental health care models for perinatal care amplified. In 2015, the Council on Patient Safety in Women's Health Care convened an interdisciplinary workgroup to develop an evidence-based patient safety bundle to address maternal PMADs. ²⁵ The workgroup developed guidelines for incorporating PMAD screening, intervention, referral, and follow-up into maternity care practice. A variety of collaborative and integrated perinatal mental health care models evolved after these guidelines, ^26,27 typically featuring a stepped care paradigm based on severity level. For patients with high complexity, telepsychiatry offers for the treating obstetrician and patient direct access to a perinatal mental health expert. ²⁸ For moderate to mild symptom-level patients, obstetric providers are encouraged to tap into the perinatal psychiatry access program resource (available across multiple states in United States), which offers same-day phone- or web-based perinatal psychiatry consultation on diagnostics, safe medications, and therapy options. ^29,30

Recently, novel technological patient-facing screening and treatment solutions have been developed, and perinatal women can use these for symptom monitoring, self-care, and therapy at their liberty. These technological solutions include but are not limited to pregnancy apps (e.g., The Bump, Ovia, and Glo), perinatal mental health chatbots to treat depression (e.g., Woebot and Poisera), ^{31 –33} and perinatal care management platforms (e.g., Mahmee). These technologies empower women to take charge of their perinatal wellness, promote honest disclosure, ³⁴ and are consistent with a growing peer-to-peer consumer empowerment movement. ³⁵ Pairing these patient-facing technological solutions with provider-facing perinatal consultations, for example, the perinatal access programs or collaborative stepped-care models, represents future innovation.

In Michigan, we are currently piloting this approach, crafting an integration between our perinatal psychiatry access program, MC3 Perinatal (www.mc3.depressioncenter.org) and a technology-based screening and service linkage tool, the High Touch, High Tech (HT2) App (https://www.ht-2.org). The “High Tech” element is an easy-to-use mobile app available to any clinic providing care to pregnant mothers in Michigan. Before a new intake appointment and at each prenatal care visit, the app screens for behavioral health risks and those who screen positive can agree to instantly view a brief motivational intervention shown on the app and are offered through the “High Touch” element same-day behavioral health telecounseling through remote behavioral health consultants. Upon completion of the web-based screener, and with patient consent, the app sends a detailed feedback report to the perinatal provider summarizing the patient's data and highlighting any behavioral health risks.

Our pilot data indicate that women are revealing significantly more risk than conventional screening and are interested in accessing needed care and resources by connecting with telecounseling. Our pilot data also show that perinatal providers appreciate the integrated MC3Perinatal-HT2 programming, as it provides ready access to consultation, training, and resourcing for their patients, while simultaneously promoting patient self-determination and instant access to care.

In the end, whether in inner-city Detroit, rural Alaska, or Buckingham Palace, perinatal women across the globe struggle with mental health issues, and access to safe and effective mental health care for all women is long overdue. In the United States alone, untreated perinatal mental health disorders lead annually to an additional 115,000 days spent in the hospital, 85,000 emergency department visits, 72,00 missed well-child visits, ³⁶ and $14 billion dollars a year in costs. ³⁶ We cannot afford these costs nor the unquantifiable human suffering caused by perinatal mental health disorders. Byatt et al. ¹⁴ offer an excellent first step toward overcoming the perinatal mental health crisis. Although fundamentally necessary for improving health outcomes among perinatal women, it is likely not sufficient unless it is viewed as one critical part of a greater paradigm shift of truly integrating mental health care with obstetric care, and empowering women through tools to actively shape and participate in their own perinatal mental health care.