Position Statement 49: Perinatal Mental Health

Policy

Most women and many men experience mental health symptoms during the perinatal period before and after childbirth, when both parents are experiencing the stress of a major life change. Recent focus on perinatal anxiety and mood disorders has drawn attention to the mental health needs of perinatal women and their partners and the effects of this untreated condition on mothers, partners, infants, and children. Although “postpartum” depression is a more recognized term, this position statement uses the more comprehensive term “perinatal,” since symptoms may appear in either parent, both before and after the birth. Prevention, screening and treatment can be effective in lessening the symptoms of these disorders and the resulting impact on families.[1] Mental Health America (MHA) believes that a comprehensive system of prevention, outreach and response should be developed that responds to this need.

Background

Approximately 70 to 80% of all new mothers experience some negative feelings or mood swings during the first few days after giving birth. This is a self-limiting emotional state that generally occurs due to hormonal shifts and does not require treatment, although there are supports and dietary restrictions that can help.[2] Perinatal depression is not self-limiting, generally occurs later, and is the most common complication of childbirth.[3] It may include persistent sadness and hopelessness, inability to accept comfort or love, social withdrawal, feeling overwhelmed, impatience, irritability, restlessness, lack of energy, emptiness, fatigue, changes in sleeping and eating patterns, crying episodes, guilt, anxiety, panic attacks, frustration, irritability, lack of self-care, and neglect of the needs of the infant or other children in the home.[4] Onset can occur during pregnancy or at any time during the first year thereafter and often lasts for a year or more if untreated.

It is estimated that 7% to 20% of pregnant women are affected by depression during pregnancy. But women are more likely to develop depression and anxiety during the first year after childbirth than at any other time.[5] Perinatal mood and anxiety disorders greatly compromise parenting, which reinforces the underlying mental health condition and adversely affects the child’s physical and emotional development.

Perinatal Depression

While the exact rate of perinatal depression is unknown, websites compile[6] some generally agreed upon statistics regarding the incidence and the most common risk factors:

One recent Canadian study[7] found that 10-15% of women can expect to experience depression in the year following giving birth. The Postpartum Depression website estimates that the reported rate of clinical perinatal depression among women is between 10%-20% of all live births.[8]
With approximately 4 million live births occurring annually in the United States, this equates to approximately 600,000 women experiencing perinatal depression.
These statistics consider live births alone and do not take into account women who miscarry or have stillbirths. Considering these additional risks would increase the overall incidence of perinatal depression to up to 900,000 annually.
While perinatal depression can affect individuals of all backgrounds, low socioeconomic status, poor access to education and healthcare, adolescent age, African-American race and recent immigrant status are thought to lead to a postpartum depression rate of up to 25% in this population demographic. Lack of social support, perceived stress, prior history of depression, and a history of sexual or physical violence have been most frequently identified as potential risk factors for perinatal depression. Additional risk factors include the adolescent's perception of her pregnancy, family criticism, self-efficacy, self-esteem, substance use, parental stress, community violence, anxiety, and African-American ethnicity. Rates of up to 50% have been documented in African-American women.[9]
According to the Diagnostic and Statistical Manual published by American Psychiatric Association, women who give birth to preterm infants or infants with congenital anomalies or who experience a traumatic birth especially from an emergency cesarean section have an increased incidence of perinatal depression.[10] This risk factor is accentuated in the American obstetrical population due to the high incidence of cesarean births.
Some studies have shown that rates of perinatal depression in adoptive parents are comparable to rates in biological mothers. The stressors faced by adoptive parents are different than those faced by biological parents. Because there is still a societal stigma affecting adoptive families, the rates could be higher in adoptive parents as many suffer in silence with untreated symptoms.
Women with a history of depression, anxiety disorders or serious mood disorders such as bipolar disorder are 30%-35% more likely to develop perinatal depression.
If a woman has experienced depression with previous births, she is 10%-50% more likely to experience it again with subsequent births.
Recent policy changes have called for coordinated programs between mental health providers and primary care providers for screening, treatment and referral to promote early identification and treatment.[11]
Perinatal mood and anxiety disorders can be successfully treated with a variety of approaches including social support, lifestyle modifications, talk therapy, and medications.[12]

Perinatal Stress, Anxiety, and Psychosis

Perinatal mental health disorders are much broader than depressive symptoms alone, though too often the term “postpartum depression” is used to generalize these conditions. The spectrum of disorders includes:

Antenatal depression and anxiety
Postpartum depression and anxiety
Postpartum anxiety/panic disorder
Postpartum obsessive compulsive disorder
Postpartum post-traumatic stress disorder
Postpartum psychosis.

Only 40% of mothers with perinatal mood and anxiety disorders seek treatment.[13] Consequences for the mother and infant can be long term and life-threatening, and may lead to severe emotional problems and general medical problems in mothers, fathers and children if early appropriate treatment is not received.

Postpartum psychosis is a distinct disorder that is often erroneously referred to as postpartum depression. It is less common, occurs within the first two weeks after delivery, and is a medical emergency. Symptoms may include thought disturbances, delusions, hallucinations and disorganized speech or behavior. The prevalence of postpartum psychosis in the general population is one per 1,000 childbirths.[14] Bipolar disorder and schizophrenia appear to be closely correlated to an elevated prevalence of postpartum psychosis, so careful monitoring of mothers with pre-existing mental health conditions can provide timely diagnosis and treatment, thus improving outcomes for mothers and infants. Tragically, 10% of postpartum psychosis cases result in suicide or infanticide.

Causes of Perinatal Mood and Anxiety Disorders

Causes of perinatal mood and anxiety disorders appear to be multifactorial. The most likely hypothesis is that mental health changes are triggered by the significant changes in a woman's hormones during pregnancy.[15] Yet other studies have suggested there is no known correlation between hormones and postpartum mood and anxiety disorders, and hormonal treatment has not helped those experiencing such disorders. Sleep deprivation may play an important role in the severity of symptoms that may begin during pregnancy due to hormonal and other changes in the mother’s body and worsen after birth due to the demands of caring for an infant.[16]

Further, fathers, who are not undergoing profound hormonal changes, suffer perinatal mood disorders at relatively high rates. During the first postpartum year, the incidence of paternal depression ranged from 1.2% to 25.5% in community samples, and from 24% to 50% among men whose partners were experiencing perinatal mood disorders. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period.[17]

Effects

Any form of prenatal stress felt by the mother can have negative effects on various aspects of fetal development, which can cause harm to the mother and child. Commonly, symptoms involve how the patient views herself, how she feels about going through such a life changing event, the restrictions on the mother's lifestyle that motherhood will place, or how the partner or family feel about the baby. Pregnancy puts a lot of strain on a woman's body, so some stress, mood swings, sadness, irritability, pain, and memory changes are to be expected. Antenatal depression may lead to pre-eclampsia in pregnant women, preterm birth, and low birth weight infants with ongoing complex health needs.

MHA has previously endorsed the 2009 Institute of Medicine report on prevention of mental health and substance disorders in young people[18]. In the same year, the IOM issued a companion report that found that universal screening is beneficial during pregnancy and during the first twelve months after birth if mental health service follow-up is available.[19] This recommendation has recently been reinforced by the 2016 U.S. Preventative Services Task Force’s endorsement of screening for perinatal depression.[20] The American College of Obstetrics and Gynecology issued a 2015 committee report to the same effect.[21]

Call to Action

MHA advocates screening, treatment, support, occupational outreach, education, and research to address the problems identified in this position statement.

Screening is successful with any of several instruments; the PHQ-9 and the Edinburgh Postnatal Depression Scale (EPDS) are the most frequently used by clinicians. These screens can be completed by the mother or provider in any healthcare setting and reviewed by the provider for immediate follow-up by mental health care professionals[22] Screening may take place in mental health settings, obstetrical care settings, pediatric care settings, primary care, emergency departments, WIC offices or occupational health settings. Education about postpartum depression and about healthy parenting should be provided with screening. Screening for perinatal mood and anxiety disorders and follow up care should be a required element as part of health home and general medical and mental health integration in all health plans.

Parents and primary caregivers should also have access to effective supports to ensure successful transitions to the new roles as parents, mitigating potential distress and isolation for the parents and nurturing the healthy mental and emotional development of the child. This may also include connections to community-based services to meet health-related social needs that are required to treat depression and anxiety, such as financial counseling services or housing supports.

Maternal depression screening and intervention should be fully implemented in obstetrics and pediatrics, in addition to adult preventive care visits, as recommended by the U.S. Preventive Services Task Force (which mandates coverage of these services under the Affordable Care Act under most forms of public and private health insurance),[23] and the Centers for Medicare and Medicaid Services guidance on coverage under Medicaid.[24] Advocates should work with state Medicaid directors, health insurers, providers, and regulators to ensure that screening is consistent, both during pregnancy and in the postpartum period, and that positive screens are followed-up with timely and effective services. Mental health professionals should be co-located within the settings where screening is performed to provide immediate evaluation, diagnosis, and treatment of mothers with positive screening results. This approach will reduce barriers to care, improve compliance, and provide the best outcomes for mothers and infants. Where physical co-location is not feasible, virtual co-location by telehealth is a reasonable alternative, and other innovations, such as use of peer support specialists, primary care-led group-based interventions, or use of phone applications for peer support should be tested.
When mental health conditions are identified in obstetrical settings, providers and insurers should collaborate to ensure continuity of care postpartum in pediatrics and adult health treatment as these settings become more common points of contact after pregnancy ends. This builds on the American College of Obstetrics & Gynecology’s recommendation on optimizing postpartum care.[25]
Health care systems and insurers should offer evidence-based supports for parents. For example, Family Foundations is a group-based universal perinatal intervention that supports transitions into parenthood, and has been demonstrated to reduce perinatal mental health conditions and improve infant outcomes.[26] Advocates should encourage integration of evidence-based parenting supports into obstetrics and pediatrics as well as coverage by insurance, to improve outcomes for families over the long-term and potentially reduce overall health care costs.[27]
Obstetrics and pediatrics should screen for health-related social needs, such as financial insecurity or intimate partner violence, to identify risk factors that may precipitate or exacerbate mental health conditions. Two potential screening tools include the Safe Environment for Every Kid Parent Screen[28] and the Accountable Health Communities Screening Tool.[29] Health care systems and insurers should invest in building referral networks to ensure that needs identified are able to be met. Where community-based providers are not available to meet identified needs, advocates should push for additional funding for these services.
It is important that employers have occupational health programs to prevent and identify perinatal mood and anxiety disorders among employees, and provide support, accommodations, and referrals when needed.
Education about and resources for perinatal mood and anxiety disorders should be provided not only in the workplace but also during prenatal care, postpartum care, pediatric health care visits, and at discharge from hospitals after childbirth.
As mandated by the Affordable Care Act, “more research is needed on causes and incidence rates, differences in racial and ethnic groups, improved screening and diagnosis, and the development of new treatments” for perinatal mood and anxiety disorders.[30]

Effective Period

Mental Health America Board of Directors adopted this policy on December 8, 2018. It will remain in effect for a period of five (5) years and is reviewed as required by the Mental Health America Public Policy Committee

Expiration Date: December 31, 2023

[1] Yawn, B., Dietrich, A., Wollen, P., Bertram, S., Graham, D., Huff, J., Kurland, M., Madison, S. & Pace, W., “TRIPPD: A Practice –Based Network Effectiveness Study of Postpartum Depression Screening and Management, Annals of Family Medicine10(4):320-329 (2012). doi:10.1370/afm.1418, https://www.ncbi.nlm.nih.gov/pubmed/22778120

[2] http://americanpregnancy.org/first-year-of-life/baby-blues /

[3] Gaynes, B., Gavin, N., Metzger-Brody, S., et al., Depression: Prevalence, Screening Accuracy, and Screening Outcomes, Rockville, Maryland: Agency for Healthcare Research and Quality (2005). Retrieved from http://archive.ahrq.gov/downloads/pub/evidence/pdf/peridepr/peridep.pdf

[4] Id.

[5] Miller, L. & LaRusso, E., “Preventing Postpartum Depression,” Psychiatric Clinics of N Am. 34:53-65 (2011). Epub. Dec. 2010. doi:10.1016/j.psc.2010.11.010, https://www.sciencedirect.com/science/article/pii/S0193953X10001024?via%3Dihub

[6] https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml . https://www.postpartumdepression.org/resources/statistics/

[7] Lanes, A., Kuk, J.L., & Tamim, H. “Prevalence and Characteristics of Postpartum Depression Symptomatology among Canadian Women: A Cross-Sectional Study,” BMC Public Health 11;11:302 (2011). doi: 10.1186/1471-2458-11-302, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3118237/

[8] https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml . https://www.postpartumdepression.org/resources/statistics/

[9] Recto, P. & Champion, J.D., “Psychosocial Risk Factors for Perinatal Depression among Female Adolescents: A Systematic Review,” Issues Ment Health Nurs. 2017 Aug;38(8):633-642 (2017). doi: 10.1080/01612840.2017.1330908. Epub 2017, https://www.ncbi.nlm.nih.gov/pubmed/28650677

[10] Anomalies means neonatal birth defects (Down's Syndrome, cleft lip or palate, limb reduction defect, etc.) Traumatic birth refers to emergent cesarean sections which often lead to PTSD, anxiety or depression in the mother. The DSM5 is reference for this and specifically describes cesarean birth as the most common cause of PTSD from birth trauma.

[11] Selix, N. & Goyal, D. Recent Policy Changes in Perinatal Depression Screening and Treatment. Journal for Nurse Practitioners 14(2). 117-123 (2017) (no pub med reference found)