April 12, 2024

Rapid increases observed in the diagnosis and treatment of perinatal mental health problems

Mental health problems during pregnancy or the first year of parenthood are now much more likely to be detected and treated than just over a decade ago, a trio of new studies suggest.

But the increase in diagnosis and care has not happened equally across groups and states, leaving some pregnant or postpartum individuals more likely to suffer from treatable symptoms that could endanger themselves and their newborn.

Overall, the studies show an increase in the number of diagnoses of anxiety, depression and post-traumatic stress disorder during pregnancy and the first year after giving birth among Americans with private insurance between 2008 and 2020. Also treatment – ​​both with psychotherapy and medicines – increased during this period. population.

The findings are published in three articles in the April issue of the journal Health matterscome from a team at the University of Michigan investigating mental health in the perinatal period.

Their analysis groups several 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 at any time during pregnancy and the postpartum year.

Key findings from 2008 to 2020 among privately insured people aged 15 to 44:

  • The number of perinatal PTSD diagnoses quadrupled to nearly 2% of all pregnant or postpartum patients in 2020. Most of the increase occurred among those who had also been diagnosed with PMAD; PTSD is considered an anxiety disorder in response to trauma.
  • The number of PMAD diagnoses has nearly doubled, with the largest increase since 2015. In 2020, 28% of those who were pregnant or postpartum received a PMAD diagnosis.
  • The number of suicidal thoughts or actions among pregnant women and people who have recently given birth has more than doubled overall, based on information reported to insurance companies. But the rate dropped among everyone who had received a PMAD diagnosis.
  • The number of patients who were pregnant or postpartum receiving psychotherapy — any form of talk therapy paid for by their private insurance — more than doubled. The rate of psychotherapy among those diagnosed with PMAD increased by 16% over the entire study period, with a marked increase after 2014.
  • Prescriptions for antidepressants during pregnancy and the postpartum period increased overall, but the rate increased most rapidly among those diagnosed with PMAD during pregnancy. The number of prescriptions for antidepressants has increased sharply after several guidelines for doctors treating PMAD were released in 2015 and 2016. In 2020, just under half of those diagnosed with 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 in terms of our health care system’s ability to pick up conditions and help people get treatment for them.”

Stephanie Hall, Ph.D., postdoctoral fellow in the UM Medical School Department of Psychiatry

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

“The numbers we document for diagnosis and treatment are certainly a floor and not a ceiling, based on what other studies have suggested about who experiences these symptoms,” said Kara Zivin, Ph.D., a professor in the Medical School and School of Public Health, who also holds positions at the VA Ann Arbor Healthcare System and Mathematica. “It is important that those who are struggling get help, because not getting care has consequences.”

Zivin has spoken and written publicly about her own experiences with a mental health crisis during pregnancy Health matters.

Impact of policy and guideline changes

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

Relevant guidelines include those of the American College of Obstetrics and Gynecology and the US Preventive Services Task Force.

But they also note that increased societal awareness and acceptance of mental health issues 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, where psychiatrists can provide expert advice and resources to primary care teams caring for people of all ages with mental illness.

Since 2013, physicians caring for pregnant and recently delivered individuals anywhere in Michigan have been able to receive assistance from the MC3 program at Michigan Medicine, UM’s academic medical center, with funding from the State of Michigan.

The studies used data from private insurance companies so that low-income people are not 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 private insurance coverage for less than two years.

The research results are therefore mainly applicable to those who have insurance through an employer (their own employer or that of another person who can cover it), and to those who have individually purchased private insurance, even after the launch of federal and state marketplaces under the ACA. . The first marketplace plans offered coverage from 2014.

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

Differences in diagnosis and care

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

For example, white people with PMAD were much more likely to be prescribed antidepressants during pregnancy than people of black, Hispanic or Asian descent. They were also more likely to be diagnosed with PTSD during the entire perinatal period, even though other research has shown that the 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 diagnoses during the study period.

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

The PMAD Diagnosis Survey also shows large differences between states in the number of individuals diagnosed with PMAD after the Affordable Care Act, compared to before.

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

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

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

“Perinatal mental health has broad implications for babies and families,” says Zivin. “The changes we documented in these studies will have ripple effects for years to come.”

In addition to Hall and Zivin, the authors of the articles are fellow members of the UM Perinatal Mental Health Services and Policy Program, including UM faculty and staff Lindsay Admon, MD, M.Sc., Sarah Bell, MPH, Anna Courant, MSN, Vanessa K. Dalton, MD, MPH, Andrea Pangori, MS, Amy Schroeder, MA, Anca Tilea, MPH, and Xiaosong Zhang, as well as Ashlee Vance, Ph.D., of Henry Ford Health System, and Karen M. Tabb, Ph.D., MSW, from the University of Illinois at Urbana-Champaign.

Zivin, Admon and Dalton are members of the UM 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.


Michigan Medicine – University of Michigan

Magazine reference:

Hal, S.V., et al. (2024) Perinatal posttraumatic stress disorder diagnoses increased among commercially insured people, 2008-2020. Health matters. doi.org/10.1377/hlthaff.2023.01447.

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