Massachusetts is addressing under-diagnosis and lack of treatment for maternal depression by leveraging the time and expertise of the state’s few perinatal psychiatrists, who specialise in treating pregnant and postnatal women. The program consists of a telephone hotline to the few experts available, alongside mental health training for obstetricians and other frontline healthcare providers in regular contact with new and expecting mothers. More than one in seven women suffers from depression while pregnant or in the first year after birth. Furthermore, suicide is a leading cause of death among new mothers.
Results & Impact
In the first 18 months of the program, more than 1,100 pregnant women and new mothers were screened and treated for depression, with over 900 of these receiving expert psychiatric advice. Approximately 70% of obstetric practices in the state have now been trained and enrolled. One in seven women are known to suffer from depression while pregnant or in the first year after birth, but perinatal depression is still regularly under-diagnosed and left untreated.
Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms), Massachusetts Department of Mental Health, Massachusetts Behavioral Health Partnership, William James College INTERFACE, MotherWoman
The few perinatal psychiatry experts in the state have trained obstetricians, who have regular contact with pregnant women, in how to screen for and begin treating maternal mental health problems. The specialists have run one-hour, on-site training sessions across Massachusetts, and have created and distributed tool kits, which are evidence-based guidelines for depression screening and treatment. Any doctor or psychiatrist who identifies a woman with depression symptoms can call a free hotline to get expert advice. The caller is advised as to clinical treatment options and given details of local resources, such as support groups and therapists, which they can direct patients to. If the phone call is not sufficient to determine the next appropriate steps, the patient can attend a one-off, in-person consultation session with the expert. The database of available resources in the state has been developed and maintained by a separate organisation, the William James College INTERFACE. The central planning and administration of the program are also managed by a behavioural health company, the Massachusetts Behavioral Health Partnership.
Women and girls
Cost & Value
The program costs $600,000 (or $8 per mother) a year for approximately 70,000 births annually in the state, and it is paid for by the Massachusetts Department of Mental Health. The initial financing came from State Innovation Models grants under the Affordable Care Act.
Running since 2014
One challenge has been that regular psychiatrists are often uncomfortable prescribing medication to pregnant or breastfeeding women, as some medications pose health risks. However, part of the whole purpose of the program is to better train doctors and psychiatrists in which drugs to use and how to best weigh up risks. There could also be challenges replicating the program elsewhere: in areas with widely spread populations, face-to-face visits would be much harder, as there would be a need for sites across the state or country. The program also relies on the large pre-existing network of useful mental health resources in Massachusetts, such as support groups and child-at-risk prevention programs. In areas without such a network, the program would have less impact, and may be limited to helping primary care providers better prescribe medication. So far, there has also been little research on the clinical outcomes of the women treated under the scheme.
None yet, although several states run similar programs for access to child psychiatry based on Massachusetts’ model.
Massachusetts is tackling under-diagnosis and lack of treatment for pre- and post-natal depression through an innovative healthcare model. The idea is to disseminate the expertise of the few expert perinatal psychiatrists in the state so that everyone can get a minimum standard of care.
Maternal depression is a widespread challenge: one in every seven women are known to suffer from depression while pregnant or in the first year after birth. Mental ill health is linked to poor birth, infant and child outcomes. Yet it is still regularly under-diagnosed and left untreated. In the US, approximately 60% of women with symptoms are not diagnosed, and 50% of those with a diagnosis are not treated at all. Furthermore, suicide is a leading cause of death among new mothers.
Perinatal psychiatrists, specialists in treating pregnant and postnatal women, are too scarce to provide direct care for every woman in need, and women have few other avenues for care. Obstetricians and general practitioners are resistant to screening for perinatal depression if they do not have access to resources to treat it. Regular psychiatrists can be reluctant to treat pregnant or breastfeeding women, as they may not have adequate knowledge of the risks of medication.
Yet, in the first 18 months of Massachusetts’ program, more than 1,100 pregnant women and new mothers were screened and treated for depression, with over 900 of these receiving expert psychiatric advice.
“The problem, so to speak, was a lack of understanding of perinatal depression. Women were going without it being identified or treated because physicians don’t like to screen for something they don’t know what to do with,” said Marcy Ravech, Executive Director of Massachusetts’ Psychiatry Access Programs (MCPAP).
MCPAP for Moms involves two key mechanisms for leveraging specialists’ time and expertise. Expert psychiatrists have trained obstetricians, who have regular contact with pregnant and postnatal women, in how to screen for and begin treating mental health problems. This took place through one-hour, on-site training sessions and the distribution of tool kits: evidence-based guidelines for depression screening and treatment.
There is also a free telephone hotline meaning any doctor or psychiatrist who identifies a perinatal woman with depressive symptoms can call to get expert advice. When they call, they first speak to a coordinator who collects basic information to determine the nature and urgency of the case. This is followed by a consultation with the on-call perinatal psychiatrist who advises as to clinical treatment options. The coordinator then also passes on details of local resources, such as support groups and therapists, for frontline health workers to direct patients to.
Usually the phone call is sufficient to determine the next steps that should be taken, but if it is not, then the patient can attend a one-off, in-person consultation session with the expert. “If the psychiatrist doesn’t get enough information, or the issue is particularly complex, they can ask the woman to come in for face-to-face assessment. Recommendations are then given back to the health care provider about treatment,” said Ravech.
All mothers and providers caring for them have access to the program, regardless of their insurance status, and the program has now trained and enrolled approximately 70% of obstetric practices in the state. But more research needs to be done on the detailed clinical outcomes of the women treated under MCPAP.
The program is funded by the Massachusetts Department of Mental Health. The initial financing to set up the program came from State Innovation Models grants under the Affordable Care Act, which are aimed at transforming healthcare service to value- and outcome-based care. Costs are low, at $8 per pregnant woman per year, or $600,000 for over 70,000 deliveries annually in Massachusetts.
Replicating the program elsewhere would require an equivalent source of funding. “The legislature in a particular state has to want to do this. No one else we know has actually started a MCPAP for Moms,” said Ravech.
The central planning and administration of the state’s program are managed by a behavioural health organization, the Massachusetts Behavioral Health Partnership. Additionally, an extensive database of all mental health and maternity resources available in the state has been developed and is maintained by a separate organisation, the William James College INTERFACE.
In areas without such strong networks of resources, from support groups to therapists, such a program would have less impact, and may be limited to helping primary care providers better prescribe medication. “It’s not helpful to have a program like this if there is absolutely nowhere to refer people to,” said Ravech.
There could also be geographical challenges: in areas with widely-spread populations, face-to-face visits would be harder as there would be a need for sites all across the area. But insights from Massachusetts’ innovation in leveraging scarce health resources could still be adapted to different contexts. “If you don’t have the capacity to do the face-to-face visits, you could do a telephone-only model,” said Ravech.
(Picture Credit: Flickr/Or Reshef)