As a young woman, Jennifer Ford struggled with anxiety and depression. When she got pregnant, her physician advised her to stay on the antidepressant she took to manage her symptoms.
Her first pregnancy and childbirth went smoothly, she says, but things were different after she gave birth the second time. "It's when I hit my wall," Ford says.
She remembers feeling overcome by grief immediately after she got home.
"I couldn't even communicate a full sentence about how I was feeling," recalls Ford. "All I could do was cry."
She couldn't eat, sleep or take care of her newborn.
One afternoon, she was in her bedroom trying to take a nap but couldn't fall asleep — she felt overwhelmed by her emotions. "I wanted to take all of my pain meds and go to bed," she says. She wanted to put an end to her suffering.
Instead, she went into the kitchen and told her husband how she felt. "That was when he was like 'OK, obviously something needs to change here. We're going to get help. And we're going to get it now.' "
Her husband made an appointment with her OB-GYN, Dr. Christopher Conlan.
"She came in and I could immediately see in her face that she was having a very difficult time," Conlan remembers. "She needed help and didn't know where to turn."
Conlan gave Ford a standard depression questionnaire that confirmed that she had postpartum depression.
But he was at a loss as to how to treat her. Like most OBs, he wasn't trained to provide mental health care.
"At that point, the tools I have in my everyday practice were used," he recalls.
The story could have ended there. Around the country, an estimated 1 in 7 pregnant women and new mothers becomes clinically depressed during pregnancy or postpartum. But their primary points of contact in the medical system — their obstetricians — often lack the skills to address this common problem. As a result, few women get a diagnosis or treatment. According to one study, less than 20% of women get treated.
Luckily for Ford, her doctor had another resource to turn to. Recognizing the importance of the obstetrician's relationship with pregnant patients and new moms, a statewide program in Massachusetts offers support to obstetricians and gynecologists in screening for and treating depression in pregnant women and new moms.
"Every time a woman is seen by an obstetrics provider it is an opportunity to detect depression, educate them about it and to really engage them in treatment," says psychiatrist Nancy Byatt at the University of Massachusetts Medical School. Byatt helped launch a program called the Massachusetts Child Psychiatry Access Program for Moms, or MCPAP for Moms.
MCPAP for Moms holds training sessions and provides a toolkit for physicians, midwives and nurse practitioners in obstetrics practices across the state to help them identify symptoms of depression in pregnant and new moms. It also runs a helpline for practitioners to connect with psychiatrists for advice on their patients' symptoms and treatment.
So that day when Ford needed help, Conlan called the help line and got connected to an on-call psychiatrist. Before Ford left his office that day, he had set up help for her.
Since the program launched in 2014, "we've enrolled 74% of [OB] practices in the state, and that covers 80% of the deliveries," says Byatt.
And the program is the model for a national plan to address maternal mental health as part of the 21st Century Cures Act. Seven states, including Florida, Kansas and Louisiana, have received funding through the act to develop programs modeled after the one in Massachusetts.
The states of Washington and Wisconsin already have similar programs in place.
A lifeline for doctors
Women like Ford who have a history of depression have a higher risk of depression during pregnancy or after giving birth, what's known as perinatal depression.
Untreated perinatal depression affects not just the mother's health, but also her baby's and her entire family's social and emotional well-being. It can increase the risk of premature birth and low birth weight babies. And when a new mom is depressed, it affects her ability to take care of her baby and bond with it. That in turn can affect the baby's physical and emotional development and even puts the baby at a higher risk of having mental health problems later in life.
And there is a cost to not treating perinatal depression, says Dr. Tiffany Moore Simas, an associate professor of obstetrics and gynecology at the University of Massachusetts Medical School and the director of engagement with MCPAP for Moms.
One study estimated that untreated perinatal anxiety and mood disorders cost the state of California $2.4 billion for all births in 2017, when mother-infant pairs were followed for five years.
Despite the health care costs associated with untreated perinatal depression, a program like MCPAP for Moms is still rare. Ideally, pregnant women and new mothers with depression would have access to a psychiatrist, says Byatt. But there's a shortage of mental health care providers in the country — finding a provider and getting a timely appointment can be difficult and frustrating, especially when someone's depressed. Besides, the stigma around this kind of depression prevents women from seeking help.
For all these reasons, Byatt says medical authorities, including the American College of Obstetrics and Gynecology, recommend that OB-GYNs screen their patients for depression and help them get treatment.
When Byatt began her initial research into perinatal depression, she started conversations with OBs in the state to see if they were screening women. She quickly learned that most doctors did not feel comfortable screening, even though they wanted to help.
"They said 'We want to address this. We think it's so important. We don't know what to do. We haven't been trained, we don't have the resources,' " Byatt recalls.
Dr. David Klein, an OB-GYN in Shrewsbury, Mass., says he first began screening pregnant and postpartum women for depression about 12 years ago. "But it was more sporadic then," says Klein. "I kind of used it when I thought someone was having an issue [with depression]."
But, he says, it wasn't easy, because he wasn't trained to provide mental health care. If one of his patients screened positive for perinatal depression, "the issue became 'OK, now what do I do?' " he says. "To find someone to help me help her was very difficult."
Klein would have to make multiple calls to find a psychiatrist who was taking new patients and would accept his patient's insurance.
"It became a lot of effort on my part to find someone," says Klein. "Fortunately, over the years I found a small network I could use, but still, it was an effort to connect with those people and make sure the patient is being taken care of."
When Byatt spoke to OBs during her initial research, they told her they would be more willing to screen and treat perinatal depression if they had more training and support.
" 'We need a lifeline' is essentially what they said," says Byatt.
How it works
Byatt and her colleagues at the University of Massachusetts Medical School set out to create that lifeline. They launched the help line for doctors, held training sessions and provided a toolkit to educate physicians and nurse practitioners about perinatal depression and how to treat it.
A doctor who has a patient who screens positive for perinatal depression and who is not sure how to treat her can call the help line at 1-855-Mom-MCPAP (1-855-666-6272) Monday to Friday, 9 a.m. to 5 p.m., for a phone consultation with a psychiatrist. The goal is that "one of our psychiatrists will call them back within 30 minutes," says Byatt. "We essentially hold their hand and help them figure out how to help the patient."
When necessary, the psychiatrist does one-on-one consultation with the patient within a week or two. And the program's resource and referral specialist helps the patient find a longer-term mental health care provider — it can be for individual or group therapy sessions — and support groups close to her.
While the help line was created primarily for obstetrics providers, it is also open to pediatricians, primary care providers and even other psychiatrists. "Any provider from the state who's serving a pregnant and postpartum woman can call our program," says Byatt.
The program is funded by the Massachusetts Department of Mental Health. However, insurance companies are required by state law to pay part of the annual cost of the program, depending on how many of their clients use it, says Dr. John Straus, the founding director of the Massachusetts Child Psychiatry Access Program, which provided the blueprint for MCPAP for Moms and was designed to increase access to pediatric mental health care in the state.
They usually cover about 50% of annual costs, adds Byatt.
Until recently, the annual budget for MCPAP for Moms was about $850,000, says Byatt. In 2018, the program received an additional $175,000 annually to expand services for substance abuse disorders among pregnant women and new mothers. The program currently runs on $1 million per year, or about $1.16 per month for every woman served, notes Byatt.
A shift in attitudes
The help line has been a game changer for his practice, says Klein, the obstetrician in Shrewsbury, Mass. "I'll speak to a psychiatrist within two hours. We'll talk about the case, make a plan and the patient will be taken care of."
These days, he screens his patients regularly for perinatal depression. "To me it's like any other screening we do now," says Klein. "I'm very comfortable talking to women about their mental health."
This is true of OB practices across the state, says Moore Simas.
"We're finding that OBs are willing to prescribe drugs under the direction of our perinatal psychiatrist, during the time a patient is waiting to get to see a psychiatrist," she says.
And they have become increasingly comfortable treating more complex mental health issues in their patients, adds Byatt.
"We have several practices [where] if a patient has bipolar disorder, they're managing it, because it's hard to find a psychiatrist," she says.
And the change in attitude among physicians has raised awareness among women and broken down some of the stigma, says Klein.
"Patients don't feel embarrassed anymore ... to talk about it," he says. "They are very comfortable starting medication and they're very comfortable seeing a counselor."
Conlan, too, has noticed a shift in attitudes among his patients.
"Patients are now realizing that this is a very common issue, that they are not alone. And that it's better to speak up and we can help," he says. "They don't need to suffer in silence."
"There were people on my team"
After her second baby was born, Ford didn't even consider the possibility that she might be depressed and needed help, even though she'd experienced depression before and received treatment for it.
"It's very hard to admit that something's not right ... when you have a new baby in the house," she says. "It's supposed to be this wonderful happy time, and that's not how it was."
But when she went in to meet with Conlan, her physician, and he got hold of an on-call psychiatrist, the psychiatrist recommended that Conlan prescribe Ford a different antidepressant, and he made an appointment to see her in a couple of weeks.
By the time she left Conlan's office, Ford says she felt heartened by all the support. "I really felt like there were people on my team," she says, "that I wasn't alone in my room, feeling like I was a horrible person and a horrible mom."
MCPAP for Moms also connected her with a social worker, who helped her find a longer-term therapist and a local support group for moms with postpartum depression.
The changes in medication, the visit with the psychiatrist, the support group of mothers — all of it helped her manage her depression and eventually recover. She began to feel better within a couple of weeks.
"I was taking the time to blow-dry my hair, simple things," she recalls. "I was taking the time to sweep the floor, or to put my makeup or wear something other than pajama pants."
And she was starting to take care of her baby girl and bond with her.
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