Perinatal Depression: Giving Birth to New Hope

"My depression meds aren't working and the psychiatrist is booked for another 2 months. I just don't know what to do. Can you help me?" I first heard these words as an intern caring for patients in our outpatient obstetrics clinic. Although this patient eventually received treatment, she endured unnecessary suffering owing to the lack of availability of perinatal mental health care. Sadly, she would not be my last patient to encounter the same difficulties.

Through my experience practicing as an obstetrics and gynecology resident in Flint, Michigan, a small postindustrial midwestern city, I anticipate a scarcity of certain subspecialty services. Expectant mothers whose pregnancies are complicated by unique maternal life-threatening conditions or by severe fetal anomalies often require integrated care with or transfer to quaternary care centers in the more populated and resource-rich sections of our state. Pediatric neurosurgeons and cardiothoracic surgeons understandably do not populate a city of less than 100,000 inhabitants. Although these physicians treat conditions that are too rare to merit dedicated and specialized care in every town, there is one condition that is unfortunately both common and underaddressed: perinatal depression.

Currently, about one of every 11 expectant mothers in the United States meets diagnostic criteria for depression (1). Untreated depression carries significant consequences for perinatal maternal and fetal health. Maternal effects include increased substance abuse and postpartum depression. Fetal effects include inadequate nutrition and prematurity (1,2). Despite the ubiquity of perinatal depression, access to its treatment remains scarce. Numerous factors contribute to poor access to mental health care for pregnant patients. These factors include patient and physician concerns about antidepressant use in pregnancy, a limited number of psychiatrists willing to provide perinatal mental health care, and an overall lack of patient care coordination between primary care physicians, psychiatrists, and obstetricians.

Evidence-based medicine helped bury the false perception that pregnancy was protective against depression (3). However, regulations regarding the enrollment of expectant mothers in pharmaceutical trials paradoxically limit the amount of data about which psychotropic medications are safe in pregnancy (3). This may contribute to the undertreatment of depression in pregnancy. Up to 46% of pregnant patients who take medications prescribed for depression prematurely cease those medications because of concerns about their effects on the fetus (4). Moreover, many of these patients' physicians have validated those concerns, partially due to their inexperience in caring for pregnant individuals and partially due to fears regarding medical liability (4). In one study of 25 depressed pregnant women who had prior depression, 41% received instructions from their physician to cease psychotropic medications entirely (4). Frustratingly, the medications that many women discontinue (either independently or after consulting with their primary care physician) are often medications that are actually safe to continue in pregnancy (4). Primary care physicians need more training on the safety profile of psychotropic medications, including those known to be relatively safe, such as sertraline and escitalopram, in order to better counsel their patients and reduce gaps in treatment during pregnancy.

Even when pregnant patients are referred to physicians who are experienced with and willing to treat mental disorders, other barriers prevent pregnant patients from obtaining that care (5). The most significant of these is the extremely limited supply of mental health specialists willing to provide perinatal mental health care (6). The lack of psychiatrists and psychotherapists results in gaps in treatment that can culminate in acute episodes, leading to inpatient psychiatric admission or to subtler but nonetheless harmful physical and socioeconomic effects on expectant mothers and their families. In recognition of the need to treat pregnant patients with depression, the American College of Obstetrics and Gynecology now formally recommends that obstetricians should be prepared to either initiate medical therapy for patients who screen positive for depression or refer them to appropriate mental health resources (1). This recommendation, however, does not address issues pertaining to gaps in treatment or the limited supply of perinatal mental health specialists. For example, although obstetricians are able to prescribe psychotropic medications that are safe in pregnancy, usually several weeks have passed between the time a patient learns that she is pregnant and the time she presents to an obstetrician for prenatal care (7). During this time, the patient may have stopped taking her previously prescribed antidepressant medications (4). Furthermore, some expectant mothers have depression that is refractory to medications, requiring specialized psychiatric care that may not be available because of the lack of appropriate perinatal mental health resources.

In response to the lack of perinatal mental health specialists, several American hospital systems have created psychiatric fellowship programs devoted to women's mental health. Psychiatrists who receive such advanced training become experts in the provision of perinatal mental health care. These subspecialty-trained psychiatrists are crucial in expanding perinatal mental health access. An added benefit of these fellowship programs is the exposure that they provide to psychiatric residents in training. In this way, general psychiatrists who train where such programs exist can comfortably draw from their experiences in residency and co-manage perinatal depression in pregnant patients with their obstetricians.

Increased co-management of perinatal depression is essential to improving perinatal mental health; however, it is only one component of a more expansive solution: an integrated health care model involving primary care physicians, obstetricians, and psychiatrists. For some patients, primary care physicians are the first health care professionals they see after learning about a new pregnancy (8). Primary care providers are thus uniquely positioned to screen for depression and, if needed, connect patients with obstetricians for managing the pregnancy and psychiatrists for managing complicated cases of depression. Early care coordination may eliminate treatment gaps and improve perinatal health outcomes (8).

There is also ample opportunity for the creation and expansion of government-sponsored programs that integrate perinatal and mental health care. One model, the Massachusetts Child Psychiatry Access Program for Moms, is a statewide initiative that provides training to health care providers, telephone access to expert perinatal psychiatric consultants, and referrals to community mental health resources (9). The integration of these perinatal mental health components has helped increase timely access to evidence-based perinatal mental health care in Massachusetts. The program may serve as an excellent roadmap for other states and municipalities (9).

Whether expectant mothers reside in the smallest prairie towns or the largest coastal cities, depression in pregnancy is a serious condition that no one should face alone. Much work is needed to improve primary care physician education regarding the safe use of antidepressant medications in pregnancy, to increase psychiatric trainees' exposure to and comfort with perinatal mental health care, and to implement an integrated health care model that guides expectant mothers with depression through their pregnancies. In this manner, more expectant mothers in America may benefit from unhindered access to perinatal mental health care.

Key Points/Clinical Pearls