Oakham Jennifer Ford knew something was wrong after the birth of her second child, McKinley.
It was a difficult delivery and after a four-day stay in St Vincent’s Hospital following an emergency caesarean section, Ford returned to family life at his home in Oakham.
But within a few days his mood changed: “Suddenly that house didn’t feel like my home.”
Ford was having difficulty forming a relationship with McKinley, had frequent crying fits, and was depressed to the point of contemplating suicide: I felt like (my family) deserved better. Was entitled. That they would have been better off had I not been there.
She shared those feelings with her husband, Andrew, and he immediately sprang into action. The Fords’ obstetrician was called and the final diagnosis was postpartum depression.
Ford connected the mothers to the Massachusetts Child Psychiatry Access Program, which provided the mental health services they needed. Her medications were adjusted, she received immediate appointments with a psychiatrist and a social worker managed her care.
“After a few months, I noticed a change,” said Ford, who finally realized the joy of having her second child.
After three months, I started to think he (McKinley) was very sweet. It shocked me, wow, I can’t believe she’s 12 weeks old and that’s what I’m thinking right now.
At first, it was like seeing someone else’s child.
Willingness to talk about postpartum depression
Ford feels that it took about a year for his mood to return to normal. She doesn’t blame her gynecologist for her struggles, but she wishes there had been direct conversations during pregnancy about the risks of postpartum depression.
Depression is something Ford has struggled with intermittently over the years, and she wonders if her mood could change during and after pregnancy. But she did not properly understand the risks.
She talked to her obstetrician about continuing to take the medication Zoloft, prescribed for depression, during pregnancy. But she doesn’t remember discussing postpartum depression with a medical provider.
I was not adequately prepared for what would happen after pregnancy. There is a lack of discussion about mental health after pregnancy, Ford said. Later, I think, ‘Did I not put in enough effort to prepare? What did I and the doctor do wrong? I don’t know how to improve it.
Access to care is generally inadequate
Dr. Nancy Byatt, a perinatal psychiatrist at UMass Chan Medical School, said access to mental health care during and after pregnancy is generally inadequate.
To highlight the scope of the problem, Byatt said that even if a woman is identified as being depressed during a perinatal screen, less than 25% of those women get an initial mental health appointment. The perinatal period is generally defined as the weeks preceding birth and continuing through the child’s first year of life.
Another statistic that brings the challenge into focus is that according to the US Centers for Disease Control and Prevention, mental health conditions account for the largest percentage (23%) of pregnancy-related deaths in the US.
At Family Health Center in Worcester, patients face an increased risk for perinatal mental health conditions, said Stephanie Giraldo Earley, doctor of osteopathic medicine and primary care psychiatrist fellow.
Many of the center’s patients are low-income immigrants and refugees. Expectant mothers in this demographic may face socio-economic challenges that may predispose them to mental health conditions.
(Perinatal mental health) has been a big topic for a long time that is not getting as much attention as it should. But that is beginning to change, Eierle said.
Earley’s fellowship team is being trained in perinatal mental health. The team then trains primary care providers to screen, treat patients and connect them to needed resources.
‘Many barriers’ to care
There are “many barriers” to accessing mental health services during and after pregnancy, Byatt said.
Some patients are uncomfortable talking about their struggles. Byatt said some doctors don’t know what to do if they do follow them because they haven’t received proper training.
Supply and demand are at play. There are not enough psychiatrists and therapists to treat the number of women who need services. Even if the number of providers increased significantly, Byatt said, we are in such a bad shape that we will likely never be able to meet the demand.
Burnout is another cause, said Dr. Robert Zavosky, chief clinical officer of the Family Health Center. Some doctors left medicine or retired, exhausted even before the COVID-19 pandemic. When the pandemic hit, it compounded the problem.
Also, many students in medical school want work-life balance, so they choose specializations with manageable work hours and low stress. As a result, many students aren’t going into primary care or obstetrics, Zavosky said.
Additionally, there is little training in medical schools in perinatal mental health, Eierle said, and the same applies to residents in psychiatry.
There are also equity concerns involved. Patients with commercial insurance and those paying cash have better access to services than patients with public insurance, such as MassHealth, the state Medicaid insurance program, and this comes with lower copayments for care. As a result, many doctors don’t carry public insurance, Byatt said.
What are the solutions?
Byatt said parity is needed, so payments for mental health care match high-level payments for physical care. Policymakers, insurance companies and lawmakers will need to develop ways to do this, he said.
Senate Chairman of the Massachusetts Joint Committee on Mental Health, Senator John Velis, D-Westfield, was not available for comment. State Rep. Adrian Madaro, D-East Boston, co-chair of the committee, did not return a request for comment.
In the meantime, creative approaches are underway to promote access to mental health care. The Massachusetts Child Psychiatry Outreach Program for Moms is training providers across the state to better deliver mental health and substance use services. Bayat is the founding medical director of the program and training focuses primarily on obstetric practices.
This program, modeled on the Massachusetts Child Psychiatry Outreach Program for Mothers, has been replicated in 28 US states, funded by the federal Health Resources and Services Administration and state budgets.
In the following months of The Lancet, Byatt said the results of a research study would show improvements in depression symptoms among patients in maternity practices enrolled in the study. Byatt reported the study compared the Massachusetts Child Psychiatric Outreach Program for Mothers with programs that combined the Massachusetts Child Psychiatric Outreach Program for Mothers with depression care.
The study will also show higher cure rates than prior studies. Byte shared the results at this point:
In the Massachusetts Child Psychiatry Outreach Program for mothers with depression, 52% of patients initiated mental health treatment; 43% for the Massachusetts Child Psychiatry Outreach Program for Mothers. The earlier percentages compared to Byatt’s show that even if a woman is identified as being depressed during a perinatal screen, less than 25% of those women get an initial mental health appointment.
The study also showed follow-up rates of 25% for the Massachusetts Child Psychiatry Outreach Program for mothers with depression care and 20% for the Massachusetts Child Psychiatry Outreach Program for mothers with depression.
There’s still room for improvement, Byatt said, but it’s much more than what we’ve seen in previous studies.
Meanwhile, Byatt is part of a $21 million study funded by the Patient-Centered Outcomes Research Institute. This is based on a study published in The Lancet. Among the details: Mothers from eight of the 28 states that use the Massachusetts Child Psychiatry Outreach Program will be trained to use the interventions in the study. The results will be compared with interventions that also include peer support in obstetric practices.
In brief, a health care model will be compared to a health care model that involves so-called “community partnerships” that provide peer support.
Grateful and ready for the future
Ford is grateful that she had a solid family support system to help her deal with postpartum depression. She plans to study nursing at Mount Wachusett Community College next year and is considering a career that will help postpartum mothers.
Ford’s advice for all moms is to not be afraid to ask for help if depression sets in during pregnancy.
The first thing you need to do to be an excellent mother is to make sure all your needs are met. This is the only way,” she said.
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