Rapid increase seen in the diagnosis and treatment of perinatal mental health problems

Michigan Medicine - University of MichiganApr 1 2024

Mental health issues during pregnancy or the first year of parenthood have a much greater chance of getting detected and treated now than just over a decade ago, a trio of new studies suggests.

But the rise in diagnosis and care hasn't happened equally across different groups and states, leaving some pregnant or postpartum individuals more likely to suffer through treatable symptoms that can put themselves and their newborn at risk.

In general, the studies show rises in diagnoses of anxiety, depression and post-traumatic stress disorder during pregnancy and the first year after giving birth in Americans with private insurance from 2008 to 2020. Treatment – both with psychotherapy and medications – also rose in this population.

The findings, published in three papers in the April issue of the journal Health Affairs, come from a team at the University of Michigan who study mental health in the perinatal period.

Their analysis groups multiple conditions diagnosed during this period under the label PMAD, short for perinatal mood and anxiety disorders. In general, PMAD includes depressive and anxiety disorders that occur any time during pregnancy and the postpartum year.

Key findings from 2008 to 2020 in privately insured people age 15 to 44:

• The rate of perinatal PTSD diagnosis quadrupled, to nearly 2% of all those pregnant or postpartum in 2020. Most of the rise was among those also diagnosed with PMAD; PTSD is considered an anxiety disorder in reaction to trauma.
• The rate of PMAD diagnoses nearly doubled, with the greatest increases seen since 2015. By 2020, 28% of those pregnant or postpartum received a PMAD diagnosis.
• The rate of suicidal thoughts or acts among pregnant and recently delivered people more than doubled overall, based on information reported to insurance companies. But the rate dropped among all those who had received a PMAD diagnosis.
• The rate at which patients who were pregnant or postpartum received psychotherapy – any form of talk therapy paid for by their private insurance – more than doubled. The rate of psychotherapy among those diagnosed with a PMAD condition increased 16% across the entire study period, with a clear increase after 2014.
• The rate of antidepressant medication prescriptions during pregnancy and the postpartum period rose overall, but the rate rose fastest among those diagnosed with a PMAD during pregnancy. The rate of antidepressant prescribing rose especially sharply after multiple guidelines for clinicians treating PMAD came out in 2015 and 2016. By 2020, just under half of those diagnosed with a PMAD received a prescription for an antidepressant.

Taken together, these studies show a lot of movement in maternal mental health. The landscape is different, at least as far as our health care system's ability to pick up on conditions and help people get treatment for them."

Stephanie Hall, Ph.D., postdoctoral research fellow at the U-M Medical School Department of Psychiatry

Hall is first author of the new papers on PTSD diagnosis and antidepressant prescribing in the perinatal period, and a co-author on the paper on PMAD diagnosis.

"If anything, the rates we're documenting for diagnosis and treatment are a floor, not a ceiling, based on what other studies have suggested about who is experiencing these symptoms," said Kara Zivin, Ph.D., a professor in the Medical School and School of Public Health who also holds positions with the VA Ann Arbor Healthcare System and Mathematica. "It's important that those who are struggling get help, because not getting care has consequences."

Zivin has spoken and written publicly about her own experience with a mental health crisis during pregnancy, including in Health Affairs.

Impacts of policy and guideline changes

The researchers say their findings suggest that many of the changes in diagnosis and care happened after increased insurance coverage through mental health parity laws and the Affordable Care Act, and after updated guidelines for clinicians emphasized increased use of screening, psychotherapy and medication.

Relevant guidelines include those issued by the American College of Obstetrics and Gynecology and the U.S. Preventive Services Task Force.

But they also note that increased societal awareness and acceptance of mental health conditions and care likely contributed to the trends seen in the new findings.

Another factor that could explain changes in diagnosis and treatment: the rise of collaborative care models, under which psychiatrists can offer expert consultations and resources to primary care teams caring for people of all ages with mental health conditions.

Since 2013, for instance, clinicians caring for pregnant and recently delivered individuals anywhere in Michigan can get assistance from the MC3 program run by Michigan Medicine, U-M's academic medical center with funding from the state of Michigan.

The studies used data from private insurance companies, so they do not include people with low incomes covered by Medicaid, which covers about 40% of all births in the United States each year.

The data source also does not include those with other forms of government-funded insurance, those without insurance, and those with coverage by private insurance for less than two years.

So, the study findings mainly apply to those who have insurance through an employer (their own or that of another person who can cover them), and to those who bought private insurance individually, including after the launch of federal and state marketplaces under the ACA. The first marketplace plans offered coverage starting in 2014. 

The studies include data for the first nine months of the pandemic, and the researchers hope to include more recent data in future studies.

Disparities in diagnosis and care

All of the studies show differences between groups of individuals in rates of diagnosis and treatment.

For instance, white individuals with PMAD were much more likely to receive antidepressant prescriptions during pregnancy than those of Black, Hispanic or Asian heritage. They were also more likely to be diagnosed with PTSD during the entire perinatal period, even though other research has shown that actual incidence of PTSD during the perinatal period is higher in people of color.

On the other hand, Black individuals as a group had the largest increase in PMAD diagnosis in the study period.

Of all age groups, people in the youngest group (15 to 24) had the largest increases in both PMAD diagnoses and antidepressant prescriptions during the study period. Those aged 15 to 26 were more likely to be diagnosed with PTSD than members of older age groups.

The PMAD diagnosis study also shows wide variation between states in the rate of individuals diagnosed with PMAD after the Affordable Care Act, compared with before.

The team plans to continue their state-level analysis, with new funding that will fuel studies of data from mental health surveys of individuals during the perinatal period. Their new research will look at changes over time in states where policies regarding reproductive care have gone into effect in recent years, including changes in abortion-related policies since the Supreme Court case that overturned the Roe vs. Wade decision in the Dobbs v. Jackson Women's Health Organization case in June 2022.

The researchers also plan to study the potential impact of other policy and clinical guideline changes.

The impact of telehealth-based perinatal mental health care since 2020, especially for those living in areas with shortages of mental health providers, also represents another important area to study, they say.

"Perinatal mental health has broad implications for babies and families," said Zivin. "The changes we've documented in these studies will have ripple effects for years to come."

In addition to Hall and Zivin, the papers' authors are fellow members of the U-M Perinatal Mental Health Services and Policy Program including U-M faculty and staff Lindsay Admon, M.D., M.Sc., Sarah Bell, M.P.H., Anna Courant, M.S.N., Vanessa K. Dalton, M.D., M.P.H., Andrea Pangori, M.S., Amy Schroeder, M.A., Anca Tilea, M.P.H., and Xiaosong Zhang, as well as Ashlee Vance, Ph.D., of Henry Ford Health System, and Karen M. Tabb, Ph.D., M.S.W., of University of Illinois at Urbana-Champaign.

Zivin, Admon and Dalton are members of the U-M Institute for Healthcare Policy and Innovation.

The research was funded by the National Institute of Mental Health (MH120124) and the National Institute on Minority Health and Health Disparities (MD014958), both part of the National Institutes of Health.