Financial Toll of Untreated Perinatal Mood and Anxiety Disorders Among 2017 Births in the United States

Economic evaluation of Be a Mom, a web-based intervention to prevent postpartum depression in high-risk women alongside a randomized controlled trial

BACKGROUND

Postpartum depression (PPD) poses significant challenges, affecting both mothers and children, with substantial societal and economic implications. Internet-based cognitive behavioral therapy interventions (iCBT) offer promise in addressing PPD, but their economic impact remains unexplored. This study aimed to evaluate the cost-utility of Be a Mom, a self-guided iCBT intervention, compared with a waiting-list control among postpartum women at high risk of PPD.

METHODS

This economic evaluation was conducted alongside a 14-month randomized controlled trial adopting a societal perspective. Participants were randomized to Be a Mom (n = 542) or a waitlisted control group (n = 511). Self-report data on healthcare utilization, productivity losses, and quality-adjusted life years (QALYs) were collected at baseline, post-intervention, and 4 and 12 months post-intervention. Incremental cost-effectiveness ratios (ICERs) were calculated, and cost-effectiveness acceptability curves were generated using nonparametric bootstrapping. Sensitivity analyses were conducted to assess result robustness.

RESULTS

Over 14 months, Be a Mom generated a QALY gain of 0.0184 (0.0022, 0.0346), and cost savings of EUR 34.06 (-176.16, 108.04) compared to the control group. At a willingness to pay of EUR 20,000, Be a Mom had a 97.6 % probability of cost-effectiveness.

LIMITATIONS

Results have limitations due to self-selected sample, potential recall bias in self-reporting, missing data, limited follow-up, and the use of a waiting-list control group.

CONCLUSIONS

This study addresses a critical gap by providing evidence on the cost-utility of an iCBT intervention tailored for PPD prevention. Further research is essential to identify scalable and cost-effective interventions for reducing the burden of PPD.

The cortisol awakening response is blunted in healthy women early postpartum

INTRODUCTION

The dynamic capacity of the hypothalamic-pituitary-adrenal (HPA) axis supports healthy adaptions to stress and play a key role in maintaining mental health. Perinatal adaptations in the HPA-axis dynamics in terms of the Cortisol Awakening Response (CAR), may be involved in dysregulation of perinatal mental health. We aimed to determine if CAR and absolute evening cortisol early postpartum differed from non-perinatal women and evaluate the association between the CAR and maternal mental well-being.

METHODS

The CAR was computed as the area under the curve with respect to increase from baseline from serial home-sampling of saliva across 0-60 minutes from awakening. We evaluated differences in CAR and absolute evening cortisol between postpartum women (N=50, mean postpartum days: 38, SD: ±11) and non-perinatal women (N=91) in a multiple linear regression model. We also evaluated the association between CAR and maternal mental well-being in a multiple linear regression model.

RESULTS

We found that healthy postpartum women had a blunted CAR (p<0.001) corresponding to 84% reduction and 80% lower absolute evening cortisol (p<0.001) relative to non-perinatal healthy women. In the postpartum group, there was a trend-level association between lower CAR and higher scores on the WHO Well-Being Index (WHO-5) (p=0.048) and lower Edinburgh Postnatal Depression Scale (EPDS) scores (p=0.04).

CONCLUSION

Our data emphasize the unique hormonal landscape during the postpartum period in terms of blunted CAR and lower absolute evening cortisol in healthy women early postpartum compared to non-perinatal. Our findings show a potential association between a reduced CAR and improved mental well-being during early motherhood, which suggests that reduced CAR might reflect healthy adjustment to early motherhood.

Association of perinatal depression and postpartum contraception intent, choice, and actual use

OBJECTIVES

Depression is common during pregnancy and the year following childbirth (the perinatal period). This study assessed the association of depressive symptoms and contraception decisions in perinatal individuals.

STUDY DESIGN

We conducted a secondary analysis using data from the PRogram in Support of Moms (PRISM) study, a cluster randomized controlled trial of active interventions which aimed to address perinatal depression. This analysis included 191 individuals aged 18-45 who screened positive for depression on the Edinburgh Postnatal Depression Scale (EPDS, score ≥10) during pregnancy or up to 3 months postpartum. We assessed contraception intent and method choice at 1-3 months postpartum. At 5-7 months postpartum, we assessed contraceptive method used and EPDS depression scores. We used logistic regressions to examine the relationship between depression and contraceptive use/method.

RESULTS

At 1-3 months postpartum, the majority of participants (76.4%) expressed an intention to use contraception. Of those, over half (53.4%) indicated a preference for higher effectiveness contraception methods. Participants with persistent depression symptoms (positive EPDS) at 5-7 months were significantly less likely to report using higher effectiveness contraceptive methods (aOR = 0.28, 95% CI = 0.11-0.70) compared to those without. Among participants with persistent depressive symptoms, 21.1% reported using a contraception method of lower effectiveness than had originally intended.

CONCLUSION

Perinatal individuals with persistent depressive symptoms at 5-7 months postpartum reported greater use of less-effective contraception methods than originally planned.

IMPLICATIONS

We found associations between perinatal depression and use of less effective contraception use. Provider discussions regarding contraception planning is important, particularly in those with perinatal depression symptoms.

Association of Postpartum Mental Illness Diagnoses with Severe Maternal Morbidity

Background: This study aimed to determine whether birthing people who experience severe maternal morbidity (SMM) are more likely to be diagnosed with a postpartum mental illness. Materials and Methods: Using the Massachusetts All Payer Claims Database, this study used modified Poisson regression analysis to assess the association of SMM with mental illness diagnosis during the postpartum year, accounting for prenatal mental illness diagnoses and other patient characteristics. Results: There were 128,161 deliveries identified, with 55.0% covered by Medicaid. Of these, 3.1% experienced SMM during pregnancy and/or delivery hospitalization, and 20.1% had a mental illness diagnosis within 1 year postpartum. In adjusted regression analyses, individuals with SMM had a 10.6% increased risk of having any mental illness diagnosis compared to individuals without SMM, primarily due to an increased risk of a depression or post-traumatic stress disorder diagnosis among people with SMM than those without SMM. Conclusions: Individuals who experienced SMM had a higher risk of a mental illness diagnosis in the postpartum year. Given increases in SMM in the United States in recent decades, policies to mitigate mental health sequelae of SMM are urgently needed.

Barriers to help-seeking for postpartum depression mapped onto the socio-ecological model and recommendations to address barriers

Postpartum depression affects nearly a quarter of women up to a year after childbirth. Although it is treatable, significant barriers to help-seeking prevent women from being treated. This paper assesses key literature on the barriers for help-seeking among women with postpartum depression. The barriers identified have been mapped onto the socio-ecological model in addition to potential recommendations that professionals can use to address barriers on individual, interpersonal, organizational, community and societal levels. The recommendations provided are meant to serve as leverage points for professionals in efforts to create appropriate support and interventions. As such, this paper serves as a mapping tool for healthcare and public health professionals to assess obstacles to women's help-seeking and to guide multi-pronged interventions on various levels of the socio-ecological model that may increase help-seeking among women with postpartum depression. Holistically and comprehensively providing support to women will require significant effort throughout all sectors of society as opposed to isolated, siloed interventions.

An Evaluation of the Health Economics of Postnatal Depression Prevention and Treatment Strategies in China: A Cost-Effectiveness Analysis

OBJECTIVE

The primary objectives of this study are to assess the cost-effectiveness of early postnatal screening and prenatal psychological interventions for the prevention and treatment of postpartum depression (PPD) among Chinese pregnant women. Additionally, we aim to explore the most cost-effective prevention and treatment strategies for PPD in China.

METHODS

We used TreeAge 2019 to construct a decision tree model, with the model assuming a simulated queue size of 10,000 people. The model employed Monte Carlo simulation to assess the cost-effectiveness of PPD prevention and treatment strategies. Transfer probabilities were derived from published studies and meta-analyses. Cost and effectiveness data were obtained from published sources and relevant studies. Incremental cost-effectiveness ratios (ICERs) were used to describe the results, with willingness-to-pay (WTP) thresholds set at China's gross domestic product (GDP) per capita.

RESULTS

Compared to the usual care group, the cost per additional quality-adjusted life year (QALY) for the early postnatal screening group and the prenatal psychological interventions is USD 6840.28 and USD 3720.74, respectively. The cure rate of mixed treatments for PPD has the greatest impact on the model, while patient participation in treatment has a minor impact on the cost-effectiveness of prevention and treatment strategies.

CONCLUSION

Both early postnatal screening and prenatal psychological interventions are found to be highly cost-effective strategies for preventing and treating PPD in China. Prenatal psychological interventions for pregnant women are the most cost-effective prevention and treatment strategy. As such, from the perspective of national payers, we recommend that maternal screening for PPD be implemented in China to identify high-risk groups early on and to facilitate effective intervention.

Developing consensus to enhance perinatal mental health through a model of integrated care: Delphi study

Perinatal mental illness is an important public health issue, with one in five birthing persons experiencing clinically significant symptoms of anxiety and/or depression during pregnancy or the postpartum period. The purpose of this study was to develop a consensus-based model of integrated perinatal mental health care to enhance service delivery and improve parent and family outcomes. We conducted a three-round Delphi study using online surveys to reach consensus (≥75% agreement) on key domains and indicators of integrated perinatal mental health care. We invited modifications to indicators and domains during each round and shared a summary of results with participants following rounds one and two. Descriptive statistics were generated for quantitative data and a thematic analysis of qualitative data was undertaken. Study participants included professional experts in perinatal mental health (e.g., clinicians, researchers) (n = 36) and people with lived experience of perinatal mental illness within the past 5 years from across Canada (e.g., patients, family members) (n = 11). Consensus was reached and all nine domains of the proposed model for integrated perinatal mental health care were retained. Qualitative results informed the modification of indicators and development of an additional domain and indicators capturing the need for antiracist, culturally safe care. The development of an integrated model of perinatal mental health benefitted from diverse expertise to guide the focus of included domains and indicators. Engaging in a consensus-building process helps to create the conditions for change within health services.

Harnessing Consumer Wearable Digital Biomarkers for Individualized Recognition of Postpartum Depression Using the All of Us Research Program Data Set: Cross-Sectional Study

BACKGROUND

Postpartum depression (PPD) poses a significant maternal health challenge. The current approach to detecting PPD relies on in-person postpartum visits, which contributes to underdiagnosis. Furthermore, recognizing PPD symptoms can be challenging. Therefore, we explored the potential of using digital biomarkers from consumer wearables for PPD recognition.

OBJECTIVE

The main goal of this study was to showcase the viability of using machine learning (ML) and digital biomarkers related to heart rate, physical activity, and energy expenditure derived from consumer-grade wearables for the recognition of PPD.

METHODS

Using the All of Us Research Program Registered Tier v6 data set, we performed computational phenotyping of women with and without PPD following childbirth. Intraindividual ML models were developed using digital biomarkers from Fitbit to discern between prepregnancy, pregnancy, postpartum without depression, and postpartum with depression (ie, PPD diagnosis) periods. Models were built using generalized linear models, random forest, support vector machine, and k-nearest neighbor algorithms and evaluated using the κ statistic and multiclass area under the receiver operating characteristic curve (mAUC) to determine the algorithm with the best performance. The specificity of our individualized ML approach was confirmed in a cohort of women who gave birth and did not experience PPD. Moreover, we assessed the impact of a previous history of depression on model performance. We determined the variable importance for predicting the PPD period using Shapley additive explanations and confirmed the results using a permutation approach. Finally, we compared our individualized ML methodology against a traditional cohort-based ML model for PPD recognition and compared model performance using sensitivity, specificity, precision, recall, and F1-score.

RESULTS

Patient cohorts of women with valid Fitbit data who gave birth included <20 with PPD and 39 without PPD. Our results demonstrated that intraindividual models using digital biomarkers discerned among prepregnancy, pregnancy, postpartum without depression, and postpartum with depression (ie, PPD diagnosis) periods, with random forest (mAUC=0.85; κ=0.80) models outperforming generalized linear models (mAUC=0.82; κ=0.74), support vector machine (mAUC=0.75; κ=0.72), and k-nearest neighbor (mAUC=0.74; κ=0.62). Model performance decreased in women without PPD, illustrating the method's specificity. Previous depression history did not impact the efficacy of the model for PPD recognition. Moreover, we found that the most predictive biomarker of PPD was calories burned during the basal metabolic rate. Finally, individualized models surpassed the performance of a conventional cohort-based model for PPD detection.

CONCLUSIONS

This research establishes consumer wearables as a promising tool for PPD identification and highlights personalized ML approaches, which could transform early disease detection strategies.

Examining racial/ethnic inequities in treatment participation among perinatal individuals with depression

OBJECTIVE

A cluster randomized controlled trial (RCT) of two interventions for addressing perinatal depression treatment in obstetric settings was conducted. This secondary analysis compared treatment referral and participation among Minoritized perinatal individuals compared to their non-Hispanic white counterparts.

METHODS

Among perinatal individuals with depression symptoms, we examined rates of treatment 1) referral (i.e., offered medications or referred to mental health clinician), 2) initiation (i.e., attended ≥1 mental health visit or reported prescribed antidepressant medication), and 3) sustainment (i.e., attended >1 mental health visit per study month or prescribed antidepressant medication at time of study interviews). We compared non-Hispanic white (NHW) (n = 149) vs. Minoritized perinatal individuals (Black, Asian, Hispanic/Latina, Pacific Islander, Native American, Multiracial, and white Hispanic/Latina n = 157). We calculated adjusted odds ratios (aOR) for each outcome.

RESULTS

Minoritized perinatal individuals across both interventions had significantly lower odds of treatment referral (aOR = 0.48;95% CI = 0.27-0.88) than their NHW counterparts. There were no statistically significant differences in the odds of treatment initiation (aOR = 0.64 95% CI:0.36-1.2) or sustainment (aOR = 0.54;95% CI = 0.28-1.1) by race/ethnicity.

CONCLUSIONS

Perinatal mental healthcare inequities are associated with disparities in treatment referrals. Interventions focusing on referral disparities across race and ethnicity are needed.

A pilot acceptability evaluation of MomMind: A digital health intervention for Peripartum Depression prevention and management focused on health disparities

Health disparities cause significant strain on the wellbeing of individuals and society. In this study, we focus on the health disparities present in the condition of Peripartum Depression (PPD), a significant public health issue. While PPD can be managed through therapy and medication, many women do not receive adequate PPD treatment due to issues of social stigma and limited access to healthcare resources. Digital health technologies can offer practical tools for PPD management. However, current solutions do not integrate behavior theory and are rarely responsive to the transient information needs stemming from women's unique sociodemographic, clinical and psychosocial profiles. We describe a pilot acceptability evaluation of MomMind, a health-disparities focused digital health intervention for the prevention and management of PPD. A crucial MomMind advantage is its basis on behavior change theory and patient engagement as enabled by the Digilego digital health framework. Following an internal usability evaluation, MomMind was evaluated by patients through cross-sectional acceptability surveys, pre-and-post PPD health literacy surveys, and interviews. Survey respondents included n = 30 peripartum women, of whom n = 16 (53.3%) were Hispanic and n = 17 (56.7%) of low-income. Survey results show that 96.6% of participants (n = 29) approved and welcomed MomMind, and 90% (n = 27) found MomMind to be an appealing intervention. Additionally, significant improvements (p< = 0.05) were observed in participants' PPD health literacy, specifically their ability to recognize PPD symptoms and knowledge of how to seek PPD information. Interview main themes include MomMind's straightforward design and influence of others (family members, providers) on use of technology. Results suggest that enhancement of a digital health framework with health literacy theory can support production of digital health solutions acceptable to vulnerable populations. This study incorporates existing theories from different disciplines into a unified approach for mitigating health disparities, and produced a novel solution for promotion of health in a vulnerable population.

Outcomes at the Motherhood Center: A Comparison of Virtual and On-Site Versions of a Specialized Perinatal Partial Hospitalization Program

OBJECTIVES

Remotely administered mental health care is becoming increasingly common for treatment of a range of psychiatric disorders; however, there is a dearth of literature overviewing direct comparisons between remote and in-person interventions for treatment of Perinatal Mood and Anxiety Disorders (PMADs). The sudden advent of the Covid-19 pandemic in New York City forced an abrupt conversion for an intensive day treatment program for new mothers with PMADs, from an on-site to a remote program.

METHODS

The current report compares outcomes of 81 women who completed the program in-person to those of 60 women who completed the program remotely.

RESULTS

Improvement in depression scores was statistically superior in the remote program, and improvement in mother-infant bonding was statistically equivalent between the on-site and remote programs.

DISCUSSION

These findings indicate that specialized partial hospitalization treatment for individuals with moderate to severe psychiatric illness can be effectively provided via telehealth, thus offering improved convenience, accessibility, and safety without compromising care. We conclude that remotely administered group psychotherapy is an effective intervention for women with moderate to severe PMADs.

The perceived mental health experiences and needs of postpartum mothers living in the United Arab Emirates : A focus group study

BACKGROUND

After childbirth, mothers are particularly vulnerable to mental health problems including anxiety and depression, which often remain undetected and untreated. In the United Arab Emirates (UAE), recent figures revealed a substantial prevalence of postpartum depression. However, postpartum mental health remains largely understudied in the country's clinical and research settings. Therefore, given the paucity of literature in the UAE and building upon previous epidemiological findings, this study aimed to explore the perceived mental health experiences and needs of mothers during the postpartum period to guide the development of targeted interventions that address mothers' unique mental health challenges.

METHODOLOGY

Four focus groups were conducted, involving a total of 27 Emirati and multicultural expatriate mothers aged 32.47 ± 4.56 years old, living in the UAE and within their first year postpartum. Descriptive interpretive thematic analysis was employed to analyze the data.

ANALYSIS

Six themes were generated that capture the mothers postpartum experiences and mental health needs: (1) distinct postpartum experiences of primiparous and multiparous mothers, (2) experiences of emotional distress in the initial postpartum stage, (3) multifaceted challenges in breastfeeding, (4) multifactorial influences on postpartum mental health, (5) postpartum social support resources and providers, and (6) the need for formal and informal resources.

CONCLUSIONS

The findings highlight the importance of considering the unique cultural and societal factors that impact maternal mental health in the UAE, given its diverse population. A collaborative multidisciplinary approach, integrating culture sensitivity, is vital to address the mental health needs of postpartum mothers and to guide the development of tailored evidence-based interventions.

Disparities in Utilization and Delivery Outcomes for Women with Perinatal Mood and Anxiety Disorders

Perinatal mood and anxiety disorders (PMAD), which include depression and/or anxiety in the year before and/or after delivery, are common complications of pregnancy, affecting up to one in four perinatal individuals, with costs of over $15 billion per year in the US. In this paper, we provide an overview of the disparities in utilization and delivery outcomes for individuals with perinatal mood and anxiety disorders in the US. In addition, we discuss the current US screening and treatment guidelines as well as the high societal costs of illness of PMAD for both perinatal individuals and children. Finally, we outline opportunities for quality improvement of PMAD care in the US, including leveraging increased engagement with healthcare system during prenatal care, working toward a more cohesive national strategy to address PMAD, leaning into evidence-based policymaking through collaboration with a panel of experts, and generating state-level profiles focused on PMAD.

The Social Context of Pregnancy, Respectful Maternity Care, Biomarkers of Weathering, and Postpartum Mental Health Inequities: A Scoping Review

Background: Mental health disorders are the number one cause of maternal mortality and a significant maternal morbidity. This scoping review sought to understand the associations between social context and experiences during pregnancy and birth, biological indicators of stress and weathering, and perinatal mood and anxiety disorders (PMADs). Methods: A scoping review was performed using PRISMA-ScR guidance and JBI scoping review methodology. The search was conducted in OVID Medline and Embase. Results: This review identified 74 eligible English-language peer-reviewed original research articles. A majority of studies reported significant associations between social context, negative and stressful experiences in the prenatal period, and a higher incidence of diagnosis and symptoms of PMADs. Included studies reported significant associations between postpartum depression and prenatal stressors (n = 17), socioeconomic disadvantage (n = 14), negative birth experiences (n = 9), obstetric violence (n = 3), and mistreatment by maternity care providers (n = 3). Birth-related post-traumatic stress disorder (PTSD) was positively associated with negative birth experiences (n = 11), obstetric violence (n = 1), mistreatment by the maternity care team (n = 1), socioeconomic disadvantage (n = 2), and prenatal stress (n = 1); and inverse association with supportiveness of the maternity care team (n = 5) and presence of a birth companion or doula (n = 4). Postpartum anxiety was significantly associated with negative birth experiences (n = 2) and prenatal stress (n = 3). Findings related to associations between biomarkers of stress and weathering, perinatal exposures, and PMADs (n = 14) had mixed significance. Conclusions: Postpartum mental health outcomes are linked with the prenatal social context and interactions with the maternity care team during pregnancy and birth. Respectful maternity care has the potential to reduce adverse postpartum mental health outcomes, especially for persons affected by systemic oppression.

Association of blood metals with anxiety among adults: A nationally representative cross-sectional study

BACKGROUND

Previous evidence demonstrated the inconsistent associations between metals and anxiety. The purpose of this study was to evaluate the individual and joint effects of blood lead (Pb), cadmium (Cd), mercury (Hg), selenium (Se) and manganese (Mn) on anxiety in the general population.

METHODS

Data of 4000 participants (aged≥20 years) in the study were retrieved from the National Health and Nutrition Examination Survey (NHANES) 2011-2012. Multiple logistic regression, restricted cubic splines (RCS) logistic analysis, and weighted quantile sum (WQS) regression were fitted to explore the possible effects of single and mixed metal exposures on anxiety. Moreover, this association was assessed by smoking group.

RESULTS

In the study, 24.60 % of participants were in an anxiety state. In logistic regression, blood Pb, Cd, Hg, Se and Mn were not significantly associated with anxiety in all participants. After stratified by smoking group, blood Cd was positively associated with anxiety in the current smoking group [P = 0.029, OR (95 %): 1.708(1.063, 3.040)], whereas not in other groups. In RCS regression, we observed a linear dose-response effect of blood Cd on anxiety stratified by smoking group. In WQS analysis, mixed metal exposures were positively associated with anxiety [P = 0.033, OR (95 %): 1.437(1.031, 2.003)], with Cd (33.69 %) contributing the largest weight to the index.

CONCLUSIONS

Our study showed that excessive exposure to Cd is a significant risk factor for anxiety, and the co-exposures to Pb, Cd, Hg, Se and Mn were positively related with the risk of anxiety in current smokers.

Extended Postpartum Medicaid In Colorado Associated With Increased Treatment For Perinatal Mood And Anxiety Disorders

Perinatal mood and anxiety disorders (PMAD), a leading cause of perinatal morbidity and mortality, affect approximately one in seven births in the US. To understand whether extending pregnancy-related Medicaid eligibility from sixty days to twelve months may increase the use of mental health care among low-income postpartum people, we measured the effect of retaining Medicaid as a low-income adult on mental health treatment in the postpartum year, using a "fuzzy" regression discontinuity design and linked all-payer claims data, birth records, and income data from Colorado from the period 2014-19. Relative to enrolling in commercial insurance, retaining postpartum Medicaid enrollment was associated with a 20.5-percentage-point increase in any use of prescription medication or outpatient mental health treatment, a 16.0-percentage-point increase in any use of prescription medication only, and a 7.3-percentage-point increase in any use of outpatient mental health treatment only. Retaining postpartum Medicaid enrollment was also associated with $40.84 lower out-of-pocket spending per outpatient mental health care visit and $3.24 lower spending per prescription medication for anxiety or depression compared with switching to commercial insurance. Findings suggest that extending postpartum Medicaid eligibility may be associated with higher levels of PMAD treatment among the low-income postpartum population.

Improving parental mental health in the perinatal period: A review and analysis of quality improvement initiatives

Parental mental health is an essential sixth vital sign that, when taken into consideration, allows clinicians to improve clinical outcomes for both parents and infants. Although standards exist for screening, referral, and treatment for perinatal mood and anxiety disorders (PMADs), they are not reliably done in practice, and even when addressed, interventions are often minimal in scope. Quality improvement methodology can accelerate the implementation of interventions to address PMADs, but hurdles exist, and systems are not well designed, particularly in pediatric inpatient facilities. In this article, we review the effect of PMADs on parents and their infants and identify quality improvement interventions that can increase screening and referral to treatment of parents experiencing PMADs.

Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model

Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.

Are Providers Adequately Screening for Anxiety Symptoms During Pregnancy?

OBJECTIVE

To examine the difference in prevalence of self-reported anxiety symptoms throughout pregnancy compared to clinical diagnosis of an anxiety disorder by a provider.

DESIGN

Secondary data analysis of a prospective cohort study of 50 pregnant individuals.

SETTING/LOCAL PROBLEM

Pregnant individuals commonly experience heightened anxiety symptoms, which are associated with adverse perinatal outcomes. However, a diagnosis of an anxiety disorder by a health care provider is less common, which may result in insufficient mental health intervention.

PARTICIPANTS

Pregnant individuals were recruited at their first prenatal appointment and followed until birth.

INTERVENTION/MEASUREMENTS

We examined anxiety symptoms using the Edinburgh Postnatal Depression Scale Anxiety subscale. We conducted a medical record review to examine if pregnant individuals were clinically diagnosed with an anxiety disorder.

RESULTS

Based on an Edinburgh Postnatal Depression Scale Anxiety subscale cutoff score of ≥5, 40% (n = 20) of individuals experienced anxiety symptoms during pregnancy. However, only 16% (n = 8) of participants were diagnosed with an anxiety disorder by a health care provider.

CONCLUSION

Anxiety symptoms are prevalent throughout pregnancy and may be underdiagnosed by health care providers. An intervention to increase clinical diagnosis of an anxiety disorder and subsequent referral to a mental health specialist may be indicated.

The Pressing Need to Integrate Mental Health into Obstetric Care

Mental health and substance use conditions are prevalent among perinatal individuals. These conditions have a negative impact on the health of perinatal individuals, their infants, and families, yet are underdiagnosed and undertreated. Populations that have been marginalized disproportionately face barriers to accessing care. Integrating mental health into obstetric care could address the perinatal mental health crisis. We review perinatal mental health conditions and substance use, outline the impact associated with these conditions, and describe the promise and potential of integrating mental health into obstetric settings to improve outcomes for patients receiving obstetric and gynecologic care.

Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment

Psychological birth trauma and childbirth-related posttraumatic stress disorder represent a substantial burden of disease with 6.6 million mothers and 1.7 million fathers or co-parents affected by childbirth-related posttraumatic stress disorder worldwide each year. There is mounting evidence to indicate that parents who develop childbirth-related posttraumatic stress disorder do so as a direct consequence of a traumatic childbirth experience. High-risk groups, such as those who experience preterm birth, stillbirth, or preeclampsia, have higher prevalence rates. The main risks include antenatal factors (eg, depression in pregnancy, fear of childbirth, poor health or complications in pregnancy, history of trauma or sexual abuse, or mental health problems), perinatal factors (eg, negative subjective birth experience, operative birth, obstetrical complications, and severe maternal morbidity, as well as maternal near misses, lack of support, dissociation), and postpartum factors (eg, depression, postpartum physical complications, and poor coping and stress). The link between birth events and childbirth-related posttraumatic stress disorder provides a valuable opportunity to prevent traumatic childbirths and childbirth-related posttraumatic stress disorder from occurring in the first place. Childbirth-related posttraumatic stress disorder is an extremely distressing mental disorder and has a substantial negative impact on those who give birth, fathers or co-parents, and, potentially, the whole family. Still, a traumatic childbirth experience and childbirth-related posttraumatic stress disorder remain largely unrecognized in maternity services and are not routinely screened for during pregnancy and the postpartum period. In fact, there are gaps in the evidence on how, when, and who to screen. Similarly, there is a lack of evidence on how best to treat those affected. Primary prevention efforts (eg, screening for antenatal risk factors, use of trauma-informed care) are aimed at preventing a traumatic childbirth experience and childbirth-related posttraumatic stress disorder in the first place by eliminating or reducing risk factors for childbirth-related posttraumatic stress disorder. Secondary prevention approaches (eg, trauma-focused psychological therapies, early psychological interventions) aim to identify those who have had a traumatic childbirth experience and to intervene to prevent the development of childbirth-related posttraumatic stress disorder. Tertiary prevention (eg, trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing) seeks to ensure that people with childbirth-related posttraumatic stress disorder are identified and treated to recovery so that childbirth-related posttraumatic stress disorder does not become chronic. Adequate prevention, screening, and intervention could alleviate a considerable amount of suffering in affected families. In light of the available research on the impact of childbirth-related posttraumatic stress disorder on families, it is important to develop and evaluate assessment, prevention, and treatment interventions that target the birthing person, the couple dyad, the parent-infant dyad, and the family as a whole. Further research should focus on the inclusion of couples in different constellations and, more generally, on the inclusion of more diverse populations in diverse settings. The paucity of national and international policy guidance on the prevention, care, and treatment of psychological birth trauma and the lack of formal psychological birth trauma services and training, highlight the need to engage with service managers and policy makers.

OpenAI's Narrative Embeddings Can Be Used for Detecting Post-Traumatic Stress Following Childbirth Via Birth Stories

Free-text analysis using Machine Learning (ML)-based Natural Language Processing (NLP) shows promise for diagnosing psychiatric conditions. Chat Generative Pre-trained Transformer (ChatGPT) has demonstrated preliminary initial feasibility for this purpose; however, whether it can accurately assess mental illness remains to be determined. This study evaluates the effectiveness of ChatGPT and the text-embedding-ada-002 (ADA) model in detecting post-traumatic stress disorder following childbirth (CB-PTSD), a maternal postpartum mental illness affecting millions of women annually, with no standard screening protocol. Using a sample of 1,295 women who gave birth in the last six months and were 18+ years old, recruited through hospital announcements, social media, and professional organizations, we explore ChatGPT's and ADA's potential to screen for CB-PTSD by analyzing maternal childbirth narratives. The PTSD Checklist for DSM-5 (PCL-5; cutoff 31) was used to assess CB-PTSD. By developing an ML model that utilizes numerical vector representation of the ADA model, we identify CB-PTSD via narrative classification. Our model outperformed (F1 score: 0.82) ChatGPT and six previously published large language models (LLMs) trained on mental health or clinical domains data, suggesting that the ADA model can be harnessed to identify CB-PTSD. Our modeling approach could be generalized to assess other mental health disorders.

Prenatal mood and anxiety disorders and associated cytokine changes

BACKGROUND

We examined whether women with prenatal mood and anxiety disorders would exhibit differential pro- and anti-inflammatory marker trajectories during the prenatal and postpartum periods compared to women without these disorders.

METHODS

Approximately 179 pregnant women participated in a longitudinal study conducted in two urban areas. Blood samples for inflammatory markers were collected at six study visits. The Structured Clinical Interview for the DSM-IV (SCID) was administered to participants scoring above cutoffs on anxiety and depression. Pregnant women with SCID Axis I diagnoses of mood and/or anxiety disorders were compared to other participants on inflammatory markers. Multilevel modeling tested associations between SCID diagnoses and within-person interleukin (IL)6 and IL10 trajectories.

RESULTS

Prenatal SCID diagnoses were associated with linear, quadratic and cubic change in IL6 from prenatal to postpartum timepoints. Women with a prenatal SCID diagnosis had steeper decreases and increases in IL6 during prenatal and postpartum periods. SCID diagnoses were associated with lower IL10 in mid-pregnancy to postpartum (b = -0.078, SE = 0.019; p = .015).

LIMITATIONS

Future studies would benefit from a larger sample size and a larger number of participants with SCID diagnoses. Future research should also examine whether different prenatal Axis 1 diagnoses are associated with different patterns of immune response in pregnancy.

CONCLUSIONS

Pregnant women with prenatal mood and anxiety disorders had greater fluctuations in IL6 across prenatal and postpartum periods and lower IL10 through pregnancy and postpartum. They may have different proinflammatory states that remain after birth without a reciprocal anti-inflammatory response.

What's next for the field of multigenerational mental health? The need for deep behavioral phenotyping via a prenatal mental health registry

From its inception, development and psychopathology theorists have sought to uncover the earliest forms of risk for mental health challenges in children, to prevent the development of more severe, intractable manifestations of psychopathology. Large familial risk registries have advanced our understanding of early, potentially modifiable factors that could prevent or mitigate the expression of challenging symptoms of neurodevelopmental conditions, and similar registries have been proposed to advance understanding of ADHD and related phenotypes. Data from single-site studies, largely focused on perinatal exposure to maternal mood disorders, reveal that a robust predictor of child psychopathology is parental psychopathology. However, early developmental trajectories of psychopathology risk may be better captured using transdiagnostic approaches in pregnancy, capturing the full range of mental health symptoms. We describe here the need for a parental mental health registry that begins prenatally that includes deep behavioral phenotyping across a range of transdiagnostic indicators of mental health risk to prevent psychopathology in children. This registry has the potential to uncover pathways to psychopathology risk in childhood and support the discovery of novel mechanisms to be targeted for prevention and intervention.

Societal costs of untreated perinatal mood and anxiety disorders in Vermont

PURPOSE

To estimate the societal costs of untreated perinatal mood and anxiety disorders (PMADs) in Vermont for the 2018-2020 average annual birth cohort from conception through five years postpartum.

METHODS

We developed a cost analysis model to calculate the excess cases of outcomes attributed to PMADs in the state of Vermont. Then, we modeled the associated costs of each outcome incurred by birthing parents and their children, projected five years for birthing parents who do not achieve remission by the end of the first year postpartum.

RESULTS

We estimated that the total societal cost of untreated PMADs in Vermont could reach $48 million for an annual birth cohort from conception to five years postpartum, amounting to $35,910 in excess societal costs per birthing parent with an untreated PMAD and their child.

CONCLUSION

Our model provides evidence of the high costs of untreated PMADs for birthing parents and their children in Vermont. Our estimates for Vermont are slightly higher but comparable to national estimates, which are $35,500 per birthing parent-child pair, adjusted to 2021 US dollars. Investing in perinatal mental health prevention and treatment could improve health outcomes and reduce economic burden of PMADs on individuals, families, employers, and the state.

Use of Behavioral Health Treatment Among Parenting Women With Opioid Use Disorder in the United States

OBJECTIVE

To examine use of mental health treatment, substance use disorder treatment, and perceived barriers to treatment by whether a major depressive episode occurred during the past year among parenting women with opioid use disorder.

DESIGN

Secondary analysis of survey data from the National Survey on Drug Use and Health, 2015-2019.

SETTING

United States.

PARTICIPANTS

Women aged 18 to 44 years with opioid use disorder and at least one child in the household.

METHODS

We computed descriptive statistics for demographic characteristics, treatment by major depressive episode status, and barriers to treatment by major depressive episode status. We conducted multinomial logistic regression to examine associations among demographic characteristics, major depressive episode status, and type of treatment.

RESULTS

Of the 36% of respondents in our weighted sample (N ≈ 254,300) who experienced major depressive episode, 35% received substance use disorder and mental health treatment, and 27% did not receive any form of treatment. We found that identification as a person of color was significantly associated with a lower relative risk of receiving any type of treatment. Frequently reported barriers to treatment included affordability, access, and stigma.

CONCLUSION

Respondents with opioid use disorder and co-occurring major depressive episode did not obtain necessary treatment. Barriers to treatment, including affordability, access to treatment, and stigma, need to be addressed, particularly among women of color.

Association between trajectories of maternal depressive symptoms and length of hospital stay, hospitalization costs, and adverse maternal and infantile outcomes: A longitudinal observational study

This study aimed to determine the trajectories of perinatal depression and their relationship with length of hospital stay (LOS), hospitalization costs, and adverse maternal and infantile outcomes. This longitudinal observational study included 525 participants. Perinatal depressive symptoms were assessed at four waves (from the first trimester to the postpartum period). LOS, hospitalization costs, and adverse maternal (sleep, fatigue, anxiety, perceived stress, and memory problems) and infantile outcomes of participants were obtained from medical records and self-reported questionnaires. Trajectories of perinatal depressive symptoms were explored with latent class growth analysis. Associations between trajectories and adverse maternal and infant outcomes were explored with multiple linear regression and binary logistic regression models. The participants' average age was 29.6 ± 3.9 years. Five heterogeneous developmental trajectories of perinatal depressive symptoms were identified as follows: high-level (7.05%), moderate-increasing (12%), remission (15.05%), moderate-level (37.14%), and low-level (28.76%). The average LOS was 5.78 ± 2.13 days, and the average hospitalization costs were 12,695.27 ± 5457.51 yuan. Compared with the trajectory of low-level depressive symptoms, the LOS, hospitalization costs, and likelihood of adverse outcomes of women with high-level and moderate-increasing depressive symptom trajectories increased. The findings capture the heterogeneity of perinatal depression in Chinese women. Women in the moderate-increasing and high-level trajectory groups had longer LOS, more hospitalization costs, and poor birth outcomes. Elucidating the trajectories of perinatal depression and their relationship with maternal and infant health outcomes provides important insights into the development of person-centred care planning for women during pregnancy and postpartum.

Screening and Follow-Up Care for Perinatal Mood and Anxiety Disorders at a Rural Obstetric Clinic

OBJECTIVE

To improve screening for perinatal mood and anxiety disorders (PMAD) and follow-up care while balancing team workload.

DESIGN

Four rapid plan-do-study-act cycles were implemented over 8 weeks.

SETTING/LOCAL PROBLEM

At baseline, only 2% of patients with PMAD were identified at a rural obstetric clinic, and none (n = 0 of 50) received screening with a validated tool. Of the 12 patients who had a current or prior history of PMAD, 92% (n = 11) were not screened for self-harm, and 67% (n = 8) received no referral. The clinic had no standardized care for PMAD.

PARTICIPANTS

Patients (n = 253) screened at initial pregnancy intake, early in the third trimester, and at the 6-week postpartum visit.

INTERVENTION/MEASUREMENTS

Following the screening, brief intervention, and referral to treatment model, patients were screened using the Edinburgh Postnatal Depression Scale, and brief intervention and referral to treatment were used with a point-of-care checklist. Data were collected three times weekly for run chart analysis, and team surveys measured workload.

RESULTS

At the end of 8 weeks, effective screening for PMAD and follow-up care were achieved for 98% of patients and included screening, education, shared decision-making for management, referral, and clinic and phone follow-up to support mental health care uptake.

CONCLUSIONS

Standardizing screening and follow-up care can increase identification of PMAD and increase uptake of mental health care. For sustainability, a decision aid can streamline patient-provider communication and reduce visit length.

Racial Disparities in Diagnosis of Postpartum Mood and Anxiety Disorders Among Symptomatic Medicaid Enrollees, 2012-2015

OBJECTIVE

This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis.

METHODS

Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race).

RESULTS

The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively).

CONCLUSIONS

Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.

The cost-effectiveness of zuranolone versus selective serotonin reuptake inhibitors for the treatment of postpartum depression in the United States

AIMS

The objective of this research is to evaluate the cost-effectiveness of zuranolone, the first oral treatment indicated for postpartum depression (PPD) in adults approved by the United States Food and Drug Administration.

METHODS

Zuranolone and selective serotonin reuptake inhibitor (SSRI) trial-based efficacy was derived from an indirect treatment comparison. Long-term efficacy outcomes were based on a large longitudinal cohort study. Maternal health utility values were derived from trial-based, short-form 6-D responses. Other inputs were derived from literature and economic data from the US Bureau of Labor Statistics. We estimated costs (2023 US dollars) and quality-adjusted life-years (QALYs) for patients with PPD treated with zuranolone (14-day dosing) or SSRIs (chronic dosing). The indirect costs and QALYs of the children and partners were also estimated.

RESULTS

The incremental cost-effectiveness ratio for zuranolone versus SSRIs was $94,741 per QALY gained over an 11-year time horizon. Maternal total direct medical costs averaged $84,318 in the zuranolone arm, compared to $86,365 in the SSRI arm. Zuranolone-treated adults averaged 6.178 QALYs compared to 6.116 QALYs for the SSRI arm. Costs and utilities for the child and partner were also included in the base case. Drug and administration costs for zuranolone averaged $15,902, compared to $30 for SSRIs over the studied time horizon. Results were sensitive to the model time horizon.

LIMITATIONS

As head-to-head trials were not available to permit direct comparison, efficacy inputs were derived from an indirect treatment comparison which can be confounded by cross-trial differences. The data used are reflective of a general PPD population rather than marginalized individuals who may be at a greater risk for adverse PPD outcomes. The model likely excludes unmeasured effects for patient, child, and partner.

CONCLUSIONS

This economic model's results suggest that zuranolone is a more cost-effective therapy compared to SSRIs for treating adults with PPD.

Overcoming training bottlenecks: mixed-methods evaluation of digital training for non-specialists in postnatal depression self-help treatment

OBJECTIVES

This mixed-methods study evaluated the feasibility, acceptability and preliminary effectiveness of an interactive digital training programme for non-specialist supporters providing a guided self-help intervention for postnatal depression (PND).

METHODS

A total of 49 non-specialist trainees participated. Six digital training modules were flexibly delivered over a 5-week period. Training included a chatroom, moderated by a supervised assistant psychologist. Quantitatively, feasibility was assessed via participation and retention levels; acceptability was examined using course evaluation questionnaires; and effectiveness was measured pre-test-post-test quantitatively using a self-report questionnaire and pre-post using scenario questions. Participant focus groups explored feasibility, acceptability and effectiveness.

RESULTS

The training was feasible; 41 completed the course and 42 were assessed at follow-up. Quantitative course evaluation and thematic analysis of focus group feedback demonstrated high training acceptability. RANOVAs indicated training significantly improved knowledge and confidence pre- to post-test. There were demonstrable increases in specific skills at post-test as assessed via clinical scenarios.

CONCLUSION

This training is a feasible, acceptable and effective way to upskill non-specialists in supporting treatment for PND, however supervised practice is recommended to ensure participants embed knowledge competently into practice. The training offers an effective first step in upskilling non-specialist supporters to support women with PND treatment at scale.

Prenatal and postpartum depression diagnosis in a large health system: prevalence and disparities

BACKGROUND/OBJECTIVES/INTRODUCTION

Depression during pregnancy or postpartum carries the same risks as general depression as well as additional risks specific to pregnancy, infant health and maternal well-being. The purpose of this study is to document the prevalence of depression symptoms and diagnosis during pregnancy and in the first 3 months postpartum among a cohort of women receiving prenatal care in a large health system. Secondarily, we examine variability in screening results and diagnosis by race, ethnicity, language, economic status and other maternal characteristics during pregnancy and postpartum.

PATIENTS/MATERIALS AND METHODS

A retrospective study with two cohorts of patients screened for depression during pregnancy and postpartum. Out of 7807 patients with at least three prenatal care visits and a delivery in 2016, 6725 were screened for depression (87%) at least once during pregnancy or postpartum. Another 259 were excluded because of missing race data. The final sample consisted of 6523 prenatal care patients who were screened for depression; 4914 were screened for depression in pregnancy, 4619 were screened postpartum (0-3 months). There were 3010 screened during both periods who are present in both the pregnancy and postpartum cohorts. Depression screening results are from the Patient Health Questionnaire (PHQ-9) and diagnosis of depression was measured using ICD codes. For patients screened more than once during either time period, the highest score is used for analysis.

RESULTS

Approximately, 11% of women had a positive depression screen as indicated by an elevated PHQ-9 score (>10) during pregnancy (11.3%) or postpartum (10.7%). Prevalence of depression diagnosis was similar in the two periods: 12.6% during pregnancy and 13.0% postpartum. A diagnosis of depression during pregnancy was most prevalent among women who were age 24 and younger (19.7%), single (20.5%), publicly insured (17.8%), multiracial (24.1%) or Native American (23.8%), and among women with a history of depression in the past year (58.9%). Among women with a positive depression screen, Black women were less than half as likely as White women to receive a diagnosis in adjusted models (AOR 0.40, CI: 0.23-0.71, p = .002). This difference was not present postpartum.

CONCLUSIONS

Depression symptoms and diagnoses differ by maternal characteristics during pregnancy with some groups at substantially higher risk. Efforts to examine disparities in screening and diagnosis are needed to identify reasons for variability in prenatal depression diagnosis between Black and White women.Key messagesWomen who were young, single, have public insurance, and women who identify as multiracial or non-Hispanic (NH) Native American were most likely to have a positive depression screen or a diagnosis for depression.After adjustment for confounders, NH Black women with a positive depression screen were about half as likely to have a diagnosis of depression during pregnancy as NH White women.Awareness of the differing prevalence of depression risk screening results, diagnoses and potential for variation in diagnosis may identify opportunities to improve equity in the delivery of essential mental health care to all patients.

Reducing the Adverse Effects of Birth Trauma Among Birth Companions

Birth trauma affects the entire family, yet limited attention has been directed to how nurses influence the experiences of birth companions. Therefore, the purpose of this article is to increase awareness of birth trauma among birth companions and provide nursing strategies to reduce the adverse effects of traumatic childbirth among birth companions. I review background information describing birth companions' perceptions of childbirth as traumatic and the implications of birth trauma. I then present protective nursing strategies before, during, and after birth, followed by a discussion on implications. Lastly, I offer a summary of protective nursing strategies, an example of postnatal debriefing using the adapted ASSIST communication tool, and available online birth companion resources.

A systematic review of clinical psychological guidance for perinatal mental health

BACKGROUND

Guidelines on psychological and/or psychosocial assessment and intervention in the perinatal period can provide beneficial practice guidance for healthcare professions to reduce maternal distress and potential mortality. As little is known about the similarities in recommendations across guidelines, which could impact the quality of therapeutic intervention women receive, this systematic review was conducted to draw out the consistent guidance for perinatal psychological and/or psychosocial therapeutic input.

METHOD

Eight literature and two guideline databases were searched alongside guideline development institutions, and organisations of maternity or perinatal mental health care. All relevant guidance was searched for and extracted before guideline quality was assessed using the AGREE-II instrument. Included guidelines had a primary or secondary focus on psychological assessment and therapeutic intervention for perinatal mental health difficulties. Using a narrative synthesis approach, recommendation consistencies and inconsistencies were outlined.

RESULTS

From the 92 records screened, seven guidelines met the inclusion criteria. Only two guidelines were rated high (> 80%) across all assessed domains, with the other guidelines scoring between poor and excellent across domains. Highest rated domains across all seven guidelines were clarity of presentation (75%) and scope and purpose (70%). Recommendations for structured psychological assessment and intervention were most commonly reported in the guidelines; however, the level of detail and depth of information varied across guidelines. Whilst assessment and intervention recommendations for mother-infant dyad and partners were considered, research into working therapeutically with these client groups in perinatal mental health services is only just emerging. Hence, guideline recommendations for working with the mother-infant dyad and partners were based on consensus of expert opinion.

CONCLUSION

Perinatal mental health guidelines were consistent in scope but showed considerable variability in quality and depth of recommendations, which could have implications for standards of clinical practice. However, there is still a need to improve the evidence underpinning recommendations in perinatal mental health guidelines to advance the implementation of psychological and/or psychosocial interventions. High quality interventions in the perinatal period could improve outcomes for women and their families.

Effects of perioperative use of esketamine on postpartum depression risk in patients undergoing cesarean section: A randomized controlled trial

BACKGROUND

Postpartum depression (PPD) is a prevalent public health issue. Although ketamine has prophylactic effects on PPD in women undergoing cesarean section, the effects of esketamine on PPD remain unclear. This trial aimed to evaluate the efficacy of perioperative esketamine infusion on PPD risk by assessing Edinburgh Postnatal Depression Scale (EPDS) scores and blood biomarkers.

METHODS

A total of 150 participants undergoing elective cesarean section were randomly allocated to receive either esketamine or normal saline. Since 27 participants were excluded due to consent withdrawal or loss to follow-up, 123 patients were included. The primary outcome was the prevalence of PPD risk. Secondary outcomes included the prevalence of postpartum anxiety (PPA) risk, levels of biomarkers, postoperative pain intensity, and cumulative sufentanil consumption.

RESULTS

The prevalence of PPD and PPA risk at 3 days, 42 days, 3 months, and 6 months postpartum did not differ between the two groups. Furthermore, EPDS scores, pain intensity at rest, and during coughing on postoperative days (POD) 1 and 2 did not differ between the two groups. Sufentanil consumption during 0-12 h, 12-24 h, 0-24 h, and 0-48 h postoperatively were significantly lower in the esketamine group compared to the control group. Blood biomarkers did not differ between the two groups on POD 3.

LIMITATIONS

The sample size was small. PPD risk was simply screened, not diagnosed.

CONCLUSIONS

Perioperative administration of esketamine did not decrease the incidence of PPD risk in women after elective cesarean section. However, esketamine reduced opioid consumption.

Harnessing consumer wearable digital biomarkers for individualized recognition of postpartum depression using the All of Us Research Program dataset

Postpartum depression (PPD), afflicting one in seven women, poses a major challenge in maternal health. Existing approaches to detect PPD heavily depend on in-person postpartum visits, leading to cases of the condition being overlooked and untreated. We explored the potential of consumer wearable-derived digital biomarkers for PPD recognition to address this gap. Our study demonstrated that intra-individual machine learning (ML) models developed using these digital biomarkers can discern between pre-pregnancy, pregnancy, postpartum without depression, and postpartum with depression time periods (i.e., PPD diagnosis). When evaluating variable importance, calories burned from the basal metabolic rate (calories BMR) emerged as the digital biomarker most predictive of PPD. To confirm the specificity of our method, we demonstrated that models developed in women without PPD could not accurately classify the PPD-equivalent phase. Prior depression history did not alter model efficacy for PPD recognition. Furthermore, the individualized models demonstrated superior performance compared to a conventional cohort-based model for the detection of PPD, underscoring the effectiveness of our individualized ML approach. This work establishes consumer wearables as a promising avenue for PPD identification. More importantly, it also emphasizes the utility of individualized ML model methodology, potentially transforming early disease detection strategies.

Economic Burden Associated With Untreated Mental Illness in Indiana

Importance

There is a paucity of systematically captured data on the costs incurred by society-individuals, families, and communities-from untreated mental illnesses in the US. However, these data are necessary for decision-making on actions and allocation of societal resources and should be considered by policymakers, clinicians, and employers.

Objective

To estimate the economic burden associated with untreated mental illness at the societal level.

Design, Setting, and Participants

This cross-sectional study used multiple data sources to tabulate the annual cost of untreated mental illness among residents (≥5 years old) in Indiana in 2019: the US National Survey on Drug Use and Health, the National Survey of Children's Health, Indiana government sources, and Indiana Medicaid enrollment and claims data. Data analyses were conducted from January to May 2022.

Main Outcomes and Measures

Direct nonhealth care costs (eg, criminal justice system, homeless shelters), indirect costs (unemployment, workplace productivity losses due to absenteeism and presenteeism, all-cause mortality, suicide, caregiver direct health care, caregiver productivity losses, and missed primary education), and direct health care costs (disease-related health care expenditures).

Results

The study population consisted of 6 179 105 individuals (median [SD] age, 38.0 [0.2] years; 3 132 806 [50.7%] were women) of whom an estimated 429 407 (95% CI, 349 526-528 171) had untreated mental illness in 2019. The economic burden of untreated mental illness in Indiana was estimated to be $4.2 billion annually (range of uncertainty [RoU], $2.1 billion-$7.0 billion). The cost of untreated mental illness included $3.3 billion (RoU, $1.7 billion-$5.4 billion) in indirect costs, $708.5 million (RoU, $335 million-$1.2 billion) in direct health care costs, and $185.4 million (RoU, $29.9 million-$471.5 million) in nonhealth care costs.

Conclusion and Relevance

This cross-sectional study found that untreated mental illness may have significant financial consequences for society. These findings put into perspective the case for action and should be considered by policymakers, clinicians, and employers when allocating societal resources and funding. States can replicate this comprehensive framework as they prioritize key areas for action regarding mental health services and treatments.

Development of an Implementation Science Telehealth Toolkit to Promote Research Capacity in Evaluation of Telehealth Programs

Background

The field of telehealth is rapidly growing and expanding access to quality health care, although there have been varied implementation outcomes in telehealth modalities. Dissemination and implementation (D&I) research can provide a systematic approach to identifying barriers and facilitators to telehealth implementation processes and outcomes.

Methods

An interdisciplinary research and clinical team developed an implementation science telehealth toolkit to guide D&I evaluations of new and existing telehealth innovations.

Results

The toolkit includes a separate section to correspond to each step in the D&I evaluation process. Each section includes resources to guide evaluation steps, telehealth specific considerations, and case study examples based on three completed telehealth evaluations.

Discussion

The field of telehealth is forecasted to continue to expand, with potential to increase health care access to populations in need. This toolkit can help guide health care stakeholders to develop and carry out evaluations to improve understanding of telehealth processes and outcomes to maximize implementation and sustainability of these valuable innovations.

The protective value of trait mindfulness for mothers' anxiety during the perinatal period

OBJECTIVES

Anxiety is highly prevalent in the perinatal period and can have negative consequences for the mother and the child. Extensive research has been done on risk factors for anxiety during the perinatal period, but less is known about protective factors. The current study aims to determine the relative contribution of trait mindfulness as a protective factor for anxiety.

METHODS

A longitudinal study design was used, with four measurement points: 12, 22, and 32 weeks of pregnancy (T0, T1, and T2, respectively), and 6 weeks postpartum (T3). General anxiety was measured at T1, T2, and T3, pregnancy-specific distress was measured at T1 and T2, mindfulness facets (acting with awareness, non-reacting, and non-judging) and partner involvement were measured at T1, and other known risk factors for anxiety were measured at T0. Multilevel regression models were used for statistical analyses.

RESULTS

Mindfulness facets measured at T1 were negatively associated with anxiety at T1, T2, and T3, and pregnancy-specific distress at T1 and T2. Of the mindfulness facets, non-judging was shown to have the largest protective effect against anxiety and pregnancy-specific distress. Also compared to partner-involvement and known risk factors, non-judging showed the largest effect on anxiety and pregnancy-specific distress.

CONCLUSIONS

For pregnant women who are at risk for developing or experiencing high levels of anxiety, it may be beneficial to participate in a mindfulness training with special attention for the attitudinal aspects of mindfulness.

Comparing the factor structures and reliabilities of the EPDS and the PHQ-9 for screening antepartum and postpartum depression: a multigroup confirmatory factor analysis

To evaluate and compare the factor structure and reliability of EPDS and PHQ in antepartum and postpartum samples. Parallel analysis and exploratory factor analysis were conducted to determine the structure of both scales in the entire sample as well as in the antepartum and postpartum groups. McDonald's omega statistics examined the utility of treating items as a single scale versus multiple factors. Multigroup confirmatory factor analysis (MCFA) was utilized to test the measurement invariance between the antepartum and postpartum groups. Two-factor models fit best for the EPDS in both the antepartum and postpartum groups; however, the most reliable score variance was attributable to a general factor for each scale. MCFA provided evidence of weak invariance across groups regarding factor loadings and partial invariance regarding item thresholds. PHQ-9 showed a two-factor model in the antepartum group; however, the same model did not fit well in the postpartum group. EPDS should be preferred to PHQ-9 for measuring depressive symptoms in peripartum populations. Both scales should be used as a single-factor scale. Caution is required when comparing the antepartum and postpartum scores.

A Pregnant Pause: System-Level Barriers to Perinatal Mental Health Care

Perinatal mood and anxiety disorders, defined as mood and anxiety disorders during pregnancy and the year following birth, affect one in five pregnant and postpartum individuals in the United States and are associated with substantial morbidity and mortality for both pregnant individuals and their infants. Despite this tremendous prevalence and associated disease burden, the overwhelming majority of those affected do not receive treatment. Although prior research has identified several patient-level barriers to effective treatment, the contributions of system-level factors have been underappreciated. We present a pilot study using a simulated patient approach to describe the accessibility and affordability of mental health care through the 18 clinics affiliated with U.S. reproductive psychiatry fellowship programs. Based on our experience, a prospective patient seeking care from these 18 clinics without a prior referral would only have been successful half of the time-and even then may have to wait as long as 2 months for an initial appointment. These data underscore the need for clinicians, public health professionals, and institutions to address system-level barriers that undermine effective referrals for care, including implementing "warm-handoffs" to mental health providers and ending practices that restrict appointments to existing patients within a health care system. They also reinforce the importance of contemporary federal policy efforts to address maternal health, particularly among low-income and racially minoritized communities. Key policies include expanding postpartum insurance coverage, which plays a critical role in reducing insurance disruptions that can undermine the accessibility of mental health care and other vital health services.

Study protocol for the ROSE Scale-Up Study: Informing a decision about ROSE as universal postpartum depression prevention

PURPOSE

To examine the effectiveness, cost-outcome, equity, scalability, and mechanisms of the Reach Out, Stay strong, Essentials for mothers of newborns (ROSE) postpartum depression prevention (PPD) program as universal versus selective or indicated prevention.

BACKGROUND

The United States Preventive Services Task Force (USPSTF) currently recommends PPD prevention for pregnant people at risk of PPD (i.e., selective/indicated prevention). However, universal prevention may be more scalable, equitable, and cost-beneficial.

DESIGN

Effectiveness of ROSE for preventing PPD among people at risk is known. To assess ROSE as universal prevention, we need to determine the effectiveness of ROSE among all pregnant people, including those screening negative for PPD risk. We will enroll 2320 pregnant people, assess them with commonly available PPD risk prediction tools, randomize everyone to ROSE or enhanced care as usual, and assess ROSE as universal, selective, and indicated prevention in terms of: (1) effectiveness (PPD prevention and functioning), (2) cost-benefit, (3) equity (PPD cases prevented by universal prevention that would not be prevented under selective/indicated for minority vs. non-Hispanic white people), (4) quantitative and qualitative measures of scalability (from 98 agencies previously implementing ROSE), (5) ROSE mechanisms across risk levels. We will integrate results to outline pros and cons of the three prevention approaches (i.e., universal, selective, indicated).

CONCLUSION

This will be the first trial to assess universal vs. selective/indicated PPD prevention. Trial design illustrates a novel, efficient way to make these comparisons. This trial, the largest PPD prevention trial to date, will examine scalability, an understudied area of implementation science.

Social determinants of perinatal mental health during the COVID-19 pandemic

OBJECTIVE

We sought to clarify relevant social-structural determinants of perinatal mental health-material and social resources, as well as pandemic employment-related stressors, in White and BIPOC child-bearers-toward building comprehensive risk screening and prevention/intervention models that can alleviate health disparities. Each of these determinants was hypothesized to contribute to perinatal symptoms in ways that disproportionately benefit White child-bearers.

METHOD

A community sample of Illinois child-bearers (n = 409 pregnant, 122 new parents) completed online questionnaires from May 2020-June 2021. Relations between composite measures of child-bearers' material resources, social resources, and pandemic employment-related stressors and mental health symptoms were tested in multiple regression models. Main effects of social determinant composites and moderated effects by race/ethnic identification were tested.

RESULTS

All social determinants displayed significant unique associations with mental health in the sample, with social resources carrying the greatest weight. Although no moderated effects of composite resource measures were found, the relation between pandemic employment-related reduced resources and symptoms proved stronger in BIPOC compared to White child-bearers.

CONCLUSIONS

Both stable social-structural determinants and acute crisis-related shifts contribute to perinatal mental health, with higher levels and/or impacts of resources helping to explain racial/ethnic disparities. These findings can inform more comprehensive screening and prevention protocols and policy recommendations that improve perinatal health outcomes.

Postpartum Mood and Anxiety Disorders: A Lexicon of Metaphors

Undiagnosed and untreated postpartum mental health disorders represent a silent health crisis. The aim of this paper was to develop a lexicon of metaphors women use to describe their postpartum mood and anxiety disorders to assist holistic nurses in recognizing as early as possible these struggling mothers. Mothers may not know the medical terminology to articulate their mental health problems and may turn to using metaphors. The metaphors included in this lexicon were obtained from the author's earlier qualitative studies of metaphors women used to describe their experiences of postpartum depression, postpartum panic disorder, and posttraumatic stress disorder due to traumatic childbirth. In this lexicon these metaphors are organized by these three mental health disorders and includes a table of definitions of each metaphor along with examples of the context of the metaphors represented by quotes from the mothers. Metaphors can be keys that open and unlock doors that stand between holistic nurses and their patients. Being attentive to metaphorical language women use to describe how they are feeling after giving birth can be an innovative approach holistic nurses can use to identify these vulnerable women and provide an opportunity to nurture and empower new mothers.

Promoting the Mental Health of Parents and Children by Strengthening Medicaid Support for Home Visiting

As state and federal policy makers seek to improve mental health, many aim to boost upstream approaches to prevent or mitigate diagnosable conditions. Home visiting offers a wholistic approach for new parents and children at home through health education, parenting support, and other services. Evidence of its benefits has accumulated across a growing number of home visiting models, some of which have demonstrated direct mental health outcomes, such as improved access to mental health services and reductions in family stress and maternal depression. Despite growing federal investments, home visiting reaches only a small fraction of families who might benefit. Public and private grant funding has successfully built and expanded home visiting in every state, but the current landscape of programs remains limited. As the nation's largest single coverage source for children, Medicaid, along with the Children's Health Insurance Program, has unsurpassed reach, to more than 40 million children and millions more families annually. Medicaid offers a natural vehicle to scale home visiting programs to promote early childhood development and address the mental health of both mothers and young children. To scale home visiting and reach far more families across the country who could benefit, federal policy makers should establish home visiting as a required Medicaid benefit and make additional investments to help states build capacity as the approach is scaled.

Chronic Pb Exposure Induces Anxiety and Depression-like Behaviors in Mice via Excitatory Neuronal Hyperexcitability in Ventral Hippocampal Dentate Gyrus

Lead (Pb) is a widespread neurotoxic pollutant. Pb exposure is associated with mood disorders, with no well-established neural mechanisms elucidated. In the present study, we aimed to investigate whether excitatory neurons in the dentate gyrus subregion of the ventral hippocampus (vDG) played a key role in Pb-induced anxiety and depression-like behaviors. C57BL/6 mice were exposed to 100 ppm Pb starting on day 1 of pregnancy until experiments were performed using the offspring. Behavioral studies suggested that chronic Pb exposure triggered anxiety and depression-like behaviors. A combination of electrophysiological, optogenetic, and immunohistochemistry experiments was conducted. Results showed that Pb exposure resulted in excitatory neuronal hyperexcitability in vDG and that the behavioral deficits caused by Pb exposure could be rescued by inhibition of excitatory neuronal activity. Moreover, it was found that the action potential (AP) threshold of excitatory neurons was decreased by electrophysiological recordings. Our study demonstrates a significant role for excitatory neurons in vDG in Pb-induced anxiety and depression-like behaviors in mice, which is likely a result of decreased AP threshold. These outcomes can serve as an important basis for understanding mechanisms of anxiety and depression under environmental Pb exposure and help in the design of therapeutic strategies.

The integration of behavioral health consultants within a state-wide psychiatry consultation program: a community case study

This paper describes the integration and role of masters-prepared behavioral health consultants (BHCs) within a state-wide psychiatry consultation program for children, adolescents, and perinatal women. Data from the Michigan Clinical Consultation and Care (MC3) program are reviewed, with attention to the role that BHCs play in the consultation process, integrated care, screening, and their dual roles with Community Mental Health Services Programs (CMHSPs) in Michigan. Approximately 82% of MC3 services are provided by the BHCs and involve resources or integrated care. BHCs play a role in managing provider consultations and connecting patients and providers to resources in the MC3 program.