At the OB/GYN practice, where I work part-time, we would refer patients back to their PCP (Primary Care Provider) or advise them to seek care with a local psychiatrist or referral to Morgantown (about a four-month wait) when they were experiencing mental health symptoms. I developed a passion for perinatal mental health after one of my patients insisted I could care for her and refused the options I gave her. In all honesty, what typically happened was that neither the local psychiatrist nor their PCP was comfortable prescribing medication during pregnancy and/or breastfeeding. I felt there had to be a better way to care for these women and their families, so I returned to school. Mountain Momma & Family Services LLC came about due to a class project that excited me about the possibilities of reaching more women across West Virginia.
Perinatal Mood and Anxiety Disorders, also known as PMADs, can occur anytime during pregnancy and for up to one year postpartum, thus defining perinatal. Mood can include depression, bipolar disorder, or psychosis. Anxiety symptoms include generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. The term disorder means it is interfering with the individual's daily functioning.
It has been reported that 1 in 5 to 1 in 7 women will experience symptoms of a mood and anxiety disorder, as well as 1 in 10 of their partners (Byatt et al., 2015; Luca et al., 2020). PMADs are the most common complication of pregnancy, yet they are the most undiagnosed and untreated complication, with as many as 75% of women experiencing symptoms not diagnosed or treated (MMHLA, 2020). March of Dimes (2022) reported the WV rate to be 19%, with the U.S. reporting a 14-20% national incidence rate (Byatt et al., 2015; Luca et al., 2020).
According to MMHLA (2023), the cost of untreated mental health is estimated at $32,000 per mother/infant pair. However, there are many risks to untreated mental illness during pregnancy and postpartum. For the mother, there is a risk of attempted or completed suicide, increased risk of miscarriage, preterm labor, pre-eclampsia, postpartum depression/psychosis, poor maternal-infant bonding, poor adherence to medical care, and substance use. For the infant, there is the risk of infanticide, preterm delivery, low birth weight, cognitive/emotional/language delays, and behavioral problems.
Some risk factors for PMADs are a history of mental illness, history of abuse, smoking, low education/income, no insurance or Medicaid insurance, and single or poor relationship quality (ACOG, 2018). Due to our inability to thoroughly evaluate every patient for these risk factors, we should not assume a patient does not have risk factors. Therefore, universal screening should be a priority in all practices that care for childbearing women and their families. I encourage Obstetrical providers to institute screening at the initial prenatal visit to help identify those women starting the pregnancy with mental health symptoms, at the glucola visit to identify those that develop during pregnancy, and again at postpartum visits to identify those that develop after delivery.
I prefer a reflex approach to screening. I start with the EPDS (Edinburgh Postnatal Depression Scale), and if it is positive, then I like to screen with the GAD7 and PHQ9. If the patient is interested in medication treatment, I also like to screen for bipolar disorder by either asking a few specific questions and/or having them complete the MDQ. All of these screeners are self-explanatory. Therefore, the provider does not have to be the one doing the screening. The screening questionnaires can be given to the patient by office staff during the rooming procedure.
In the next post, we will discuss what to do with a positive screen for perinatal mood and anxiety disorders.
