Maternal mental illness

Science  15 Aug 2014:
Vol. 345, Issue 6198, pp. 755
DOI: 10.1126/science.1259614

In the United States, more than half a million women experience postpartum depression every year; among teens and low-income mothers, the rate is one in four. For many depressed mothers, symptoms begin during pregnancy and may also include disabling anxiety. In addition, maternal mental illness adversely affects infant brain development and subsequent social and emotional health as a result of inadequate prenatal care, poor birth outcomes, and impaired parenting practices. The broad implications of these disorders have led several states to require perinatal depression screening and/or education. Also, a provision of the U.S. Affordable Care Act calls for further research on screening and treatment. These policies are a good start, but laws already on the books must be adequately funded and evaluated. In addition, there are immediate policy actions that can be taken to improve the well-being of mothers and families.


The pathogenesis of perinatal depression is not yet fully understood, but human and animal studies have highlighted possible interconnected contributors, including hormonal dysregulation, abnormalities of the hypothalamic-pituitary-adrenal axis, genetic vulnerability, and epigenetic effects. Social and behavioral research has revealed sociodemographic predictors of perinatal depression, including history of depression, lower socioeconomic status, poor social support, and stressful life events. In 2006, New Jersey became the first U.S. state to mandate universal screening for postpartum depression. Unfortunately, this legislation did not improve detection and treatment for low-income mothers. This is because the law, and others like it, are undermined by challenges at three levels: the patient level (e.g., mental health stigma), the provider level (e.g., lack of awareness, time, and reimbursement for screening and treatment), and the system level (e.g., inadequate insurance systems and lack of care integration). It is at the system level where policy changes can have the largest effects.


Each year, up to 1 million U.S. women move in and out of health insurance coverage shortly after giving birth. State Medicaid programs finance 48% of U.S. births, but women with incomes above $32,000 (for a family of four) lose this coverage 60 days after giving birth when their “pregnancy” eligibility ends. The timing of this insurance disruption is especially cruel because anxiety and depression symptoms often worsen in the 2 to 3 months after childbirth. Policy-makers could help by requiring consistency in mental health benefits across the perinatal period and overlap of provider networks between Medicaid and private insurance plans.

In addition, screening must be bridged with coordinated, comprehensive treatment and support. The idea of “treatment” is often narrowly thought of as psychiatric medication or talk therapy, leaving out important community, peer, and family support. This is particularly important for women who frequently fall through the cracks: those who are low-income, drug-addicted, rural, racial/ethnic minorities, or immigrants. Increasing the use of patient-centered medical homes could bring together diverse teams (including doctors, social workers, nurses, community health workers, doulas, etc.) to meet these patients' needs. In the United Kingdom, for example, a coordinating health care professional is identified for each woman, routine services include both clinic and home visits, and all patient information is shared among the providers involved in her care, before and after childbirth.

“…U.S. families…deserve screening and comprehensive treatment for perinatal depression and anxiety…”


Beyond the realm of health insurance and care delivery systems, families with babies are further strained by the lack of paid maternity leave and affordable high-quality childcare. As President Obama recently commented, “…the United States is the only developed country in the world without paid maternity leave.” Policies to reduce family financial stressors contribute to maternal and child well-being. The 4 million U.S. families who will welcome a new baby this year deserve screening and comprehensive treatment for perinatal depression and anxiety, clinicians who embrace system-level change, and legislators who stand up for improved health for women and families.


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