Maternal Mental Health: Moving Mental Health Care Upstream

Nearly three decades ago, a senior official of the World Health Organization asked me what I would do if I had only $1 to spend on mental health care. I replied that I would use the dollar to provide mental health care for a pregnant woman with depression and/or an addiction problem. I would give that same answer today.

In this column, I have partnered with Dr. Amritha Bhat, an expert in perinatal mental health care, to review the potential benefits of providing effective collaborative care to mothers at high risk for mental health and substance use problems.—Jürgen Unützer, M.D., M.P.H.

Most people with a mental health or substance use problem experience the first symptoms of illness during childhood, adolescence, or early adulthood, but it often takes more than a decade to get effective mental health care. This is a critical period in life, and we need to think about what we can do to intervene earlier on, perhaps even to prevent mental illness altogether. In other words, we need to look for opportunities to “move care upstream.”

Let’s take the case of Ms. C., who is pregnant with her second child and anticipates a difficult postpartum period. She epitomizes high risk for postpartum depression—two episodes of major depression (one of which was in her first postpartum period), recent separation from her abusive husband, low social support, and a strong family history of mood disorders. She’s receiving weekly psychotherapy, is building her resilience, and will receive services from a home visiting nurse in the postpartum period, reducing her risk of postpartum depression by up to 44 percent.

What if Ms. C.’s mother had received similar services? Would Ms. C.’s trajectory have been different? Her mother had a tumultuous history of multiple depressive episodes, suicide attempts, and hospitalizations. Even when not in a depressive episode, she alternated between being distant and overly intrusive. Ms. C. inherited some risk for developing depression. Ms. C.’s child will inherit that same risk, but she or he will have a mother whose depression is adequately treated. Because of this, Ms. C.’s baby may not have the 39 percent to 49 percent higher risk of preterm birth or low birth weight, the 1.34 times higher odds of developmental delay, or the three times higher odds of externalizing disorders and adolescent depression. Addressing prenatal risk factors, including maternal mental health, brings us as close to primary prevention as we can get in the field of mental health care. Ms. C.’s treatment plan is mental health immunization for her baby.

Home-visiting programs and school-based mental health care are good examples of moving health care out of hospitals and into communities. What if we moved care further upstream? In the context of perinatal mental health, moving care upstream might imply comprehensive identification and adequate treatment of perinatal mental health disorders and parenting support for caregivers suffering from mental health problems. We need to deliver effective mental health care to pregnant and postpartum women—women are more likely to contact health service systems than men and are more motivated to receive treatment in the perinatal period. It is crucial that these services are easily accessible to women at highest risk—in primary care or obstetric settings and in patients’ homes, rather than in specialty mental health settings.

Over the past decade, studies have demonstrated it is both effective and cost-effective to integrate perinatal mental health care into obstetric and primary care settings. Real-world practice experience from a county-funded collaborative care program for high-risk mothers in 13 community health clinics demonstrated that collaborative care leads to substantially improved depression outcomes. A case management program targeting high-risk moms with addiction problems also showed encouraging results. Several initiatives are working to improve detection of perinatal mental health problems, such as recommendations for perinatal depression screening, and an Early and Periodic Screening, Diagnostic, and Treatment Medicaid provision to screen for maternal depression as a pediatric risk factor. Other programs are supporting prenatal providers in the delivery of evidence-based mental health treatments. Ensuring maternal mental health gives children a head start on optimal physical, emotional, and cognitive development. By delivering perinatal mental health treatments in primary care and prenatal settings, we are integrating care not only across health care settings, but across generations.

Perinatal collaborative care for moms and babies presents an enormous opportunity for psychiatrists and other behavioral health care professionals to improve mental health at a population level and, perhaps, even to prevent mental illness altogether. ■