New Guidelines For Perinatal Depression Are Important, But Barriers Remain
New JAMA Pediatrics editorial highlights new guidelines.

New Guidelines for Perinatal Depression are Important, but Barriers Remain

New recommendations from the U.S. Preventive Services Task Force (USPSTF) suggest that clinicians should provide or refer pregnant and postpartum women who are at increased risk of perinatal depression to counseling interventions. These recommendations are “an important step forward in improving the health of mothers and families affected by perinatal depression,” wrote research scientists and doctors at Kaiser Permanente, in an editorial for the journal JAMA Pediatrics.

The editorial, titled: “Preventing Perinatal Depression to Improve Maternal and Child Health- a Health Care Imperative,” was published February 12 in the journal JAMA Pediatrics.

The Division of Research’s Lyndsay Avalos, PhD, the editorial’s lead author.

“USPSTF recommendations are important because they are used by insurance companies to make coverage decisions, so they could ultimately decrease the number of women suffering from perinatal depression and improve the health of women and their infants and children,” said lead author Lyndsay Avalos, PhD, MPH, a research scientist at Kaiser Permanente Northern California’s Division of Research. “However, the recommendations also highlight the need to overcome barriers to screening and preventive interventions for depression, and the need for further research on other preventive interventions that may be easier for health systems to implement and for new mothers — and mothers-to-be — to access.”

The USPSTF recommendations mark a shift in focus from identification and treatment to prevention, a core principle of public health, the authors wrote. Depression is the most common complication of pregnancy: it is estimated that up to 20 percent of pregnant and postpartum women suffer from perinatal depression.

Prenatal depression (depression during pregnancy) has been linked to preterm delivery and other adverse neonatal outcomes. Postpartum depression (depression in the year after the birth of a child) may interfere with mother-child attachment and bonding, thus creating an environment that adversely affects the infant’s development. Infants of mothers with postpartum depression are at increased risk of failure to thrive, attachment disorders, developmental delays, and other negative effects on cognitive development, social-emotional development, and behavior.

“Given the importance of maternal mental health well-being and the healthy development of the child, interventions to prevent perinatal depression are important to primary care obstetrical, pediatric, and adult and family medicine clinicians,” said Tracy Flanagan, MD, Director of Women’s Health and obstetrician and gynecologist at Kaiser Permanente in Northern California.

The editorial highlights many challenges to the implementation of the USPSTF recommendations: Providing primary care clinicians with the resources needed to screen and refer patients; integration and collaboration between primary care medicine and behavioral health services; lack of an accurate screening tool to identify women at risk of perinatal depression coupled with the limited knowledge of the best way to identify women at risk; patient-level barriers such as cost, lack of accessibility, and lack of community awareness and education about depression and the availability of effective treatments and preventive interventions.

Solutions to these challenges could come from decision support tools built into electronic health records that help clinicians identify women at high risk by triggering alerts, and screeners such as the Patient Health Questionnaire to quantify depression symptom severity. However, the editorial calls for future research to identify a tool and scoring system that could incorporate a constellation of risk factors and/or symptom severity scores, in order to identify women at risk of perinatal depression and thus facilitate initiation of prevention care.

The authors acknowledge that it is important to note that successful referral of all women presenting with increased risk of perinatal depression would put enormous pressure on existing mental health resources that are already suffering from a shortage of providers. Evidence-based research on other preventive interventions that may not involve intense health care system resources, such as mindfulness programs, mobile health interventions, physical activity, telephonic care, and peer support, is urgently needed, the authors wrote.

Addressing perinatal depression is a priority area for Kaiser Permanente Northern California, which has implemented a universal perinatal depression screening program. Avalos and colleagues at the Division of Research have found that with the universal screening program, many more women with perinatal depression were able to be identified, leading to more women receiving treatment.

“Given the challenges to implementation of — and barriers to receipt of — counseling services for women at risk of perinatal depression, we look forward to future evidence-based research on other preventive interventions which will provide women and clinicians a variety of options for effective preventive interventions,” added Avalos.

Other co-authors of the editorial include De-Kun Li, MD, PhD, research scientist at the Division of Research.

Avalos’s time preparing this editorial was funded by the National Institute of Mental Health.

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