Tuesday May 08, 2018
Moms Need Support, Not Legislated Medicine
A little more than four years ago, I sat on a couch in my friend's Queens apartment, watching the cold winter snow falling outside. As I held her newborn son, I listened to her worries about being a new mom, her struggles to get him to latch, her concerns about her husband -- who had already returned to work -- and her difficulties navigating who should sleep when and who was more "deserving" of that sleep.
She was exhausted, tearful and completely in love with her beautiful baby. She had a normal, healthy pregnancy and birth. In the months that followed, however, she struggled to find balance between her joy and the weight of her other emotions. Looking back, we agree that she had undiagnosed postpartum depression.
As family physicians, we are used to screening for depression. The U.S. Preventive Services Task Force gives depression screening a Grade B recommendation(www.uspreventiveservicestaskforce.org) in the general adult population, including pregnant and postpartum women.
In a recommendation supported by the AAFP, the task force says screening should be "implemented with adequate systems in place to ensure accurate diagnosis, effective treatment and appropriate follow-up."
Many of us screen postpartum moms for depression during well-child checks, knowing that sometimes the only time they make it to the doctor is when their child has an appointment.
During the past several years, there has been a growing body of research looking at postpartum depression and maternal mental health. Our understanding of the time period for susceptibility has broadened the definition -- it can start during pregnancy and can last at least a year after delivery -- and can include a range of symptoms and mood disorders, including anger, suicidal ideation and even psychosis. This has led to the more encompassing term of maternal mental health conditions. Although any woman is at risk, being a member of certain populations, such as those who are of lower socioeconomic status, have experienced violence, or are under significant stress, can be a predictor of maternal mental health conditions. Thus, certain measures may prevent or minimize the conditions.
But are we doing enough? Or as 2020 Mom, an organization that advocates for improvements in maternal mental health care, asks: Are we asking the right question?(www.2020mom.org)
Before my daughter was born, a two-article series in The New York Times offered both an in-depth look at several mothers' accounts of disturbing postpartum thoughts(www.nytimes.com) and the story of one mother's rapid spiral toward suicide.(www.nytimes.com)
After reading these articles, my husband and I discussed what we should to do if I were to start feeling symptoms of a maternal mood disorder. Having witnessed my friend's depression and that of a few patients, I did my best to take a variety of preventive measures, such as ensuring a good support network was in place and creating opportunities to get out of the house.
Worth noting is the fact that I had an option to voluntarily enroll in my health insurance's maternity management program and was assigned a nurse who scheduled a few phone calls during my pregnancy and postpartum to check on my mental health and offer advice.
Ultimately, I was fortunate and made it through that postpartum period relatively smoothly. Perhaps it was a combination of having two friends who were on maternity leave at the same time, my husband's flexible parental leave policies, relative ease with nursing and a healthy and fairly happy baby. But I also believe luck was involved. Luck that I had good health care coverage, parental leave and a job to return to, and luck that my hormones and brain chemistry behaved in such a way that I didn't feel depressed.
A postpartum mother in Sacramento earlier this year was not so lucky. After the birth of her second child, she realized that the thoughts and feelings she was having were not within the range of normal, and she presented to her doctor for evaluation, figuring she would be offered resources and support. Instead, she ended up with a police escort to the ER.(sacramento.cbslocal.com) Ultimately, she used this experience as an opportunity to bring attention to our broken system and the lack of resources available to mothers. It is frustrating to patients and physicians alike when we feel we are incapable of caring for our patients.
In an attempt to improve screening for maternal mental health conditions, bill AB 2193(leginfo.legislature.ca.gov) was introduced in February in the California State Assembly. The bill would make it the duty of licensed clinicians who treat or attend the mother, child, or both to screen the mother for maternal mental health conditions, as defined, at least once during pregnancy and once during the postpartum period and to report the findings of the screening to the mother's primary care physician if the health care practitioner is not the mother's primary care physician.
The bill would also make it the duty of any facility where those practitioners treat or attend the mother or child, or both in the first post-delivery appointment to ensure that those practitioners perform the required screening and report the findings. The bill would make a violation of its requirements grounds for disciplinary action by the licensee's licensing entity and would make the facility subject to punishment by its licensing entity.
The bill, which aims to improve the resources available for maternal mental conditions, also has the following provisions:
- Health care service plans and insurers would be required to develop, by July 1, 2019, a case management program that is available when a provider determines that patient may have a maternal mental health condition.
- Starting Jan. 1, 2019, health care service plan contracts and health insurance policies would be required to cover maternal mental health conditions and a case management program. Because a willful violation of this requirement would be a crime, the bill would impose a state-mandated local program.
- Case management programs would be required to meet specified standards, and plans and insurers would have to notify providers of the availability of the program and develop a quality management program to understand the effectiveness of the case management program.
Although the bill is well intended, mandating providers to screen for depression and other conditions regardless of whether appropriate support services are in place is at odds with USPSTF guidelines, and the penalties are disproportionately punitive. Several other states have enacted similar mandates; maternal health outcomes for these states have not been significantly impacted by these laws.(ps.psychiatryonline.org)
For these reasons, the California AFP's Legislative Affairs Committee has adopted an "oppose unless amended" position on the bill. The committee wants amendments removing the mandatory screening and medical board action against a physician's license.
The bill fails to recognize that, as physicians, once we screen or test for something, we are responsible for the results and for ensuring appropriate treatment thereafter. Understandably, many physicians are concerned about the idea that mandated screening will lead to positive results for which we cannot treat. On the other hand, simply not asking the screening questions does not mean the depression isn't there.
As family physicians, we are particularly poised to screen and manage our patients with maternal mental health conditions as we care for mothers and their families before, during and after pregnancy. Moreover, we are used to screening for and treating depression in our general adult patients. I would argue that we are responsible for advocating for our patient's mental health regardless of the whether there are recommendations to screen. This attempt to legislate medicine will not improve patient care; we need a comprehensive approach that puts into place the support our patients need when they are experiencing a range of mental health conditions.
As 2020 Mom points out, to screen or not to screen is perhaps not the right question. We have an obligation to participate in the process of advocating for stronger maternal mental health resources and to acknowledge our role in helping to assess the scope and prevalence of maternal mental health conditions.
Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services at community health centers in the San Francisco Bay Area, with a focus on providing evidenced-based care for underserved communities.
Posted at 09:00AM May 08, 2018 by Margaux Lazarin, D.O., M.P.H.