Photo above: Tiffany Moore Simas, MD, MPH, Med, Chair of Obstetrics and Gynecology, UMass Memorial Health and Professor of Obstetrics & Gynecology, Pediatrics, Psychiatry, and Population & Quantitative Health Sciences, UMass Chan Medical School. Photo Credit: Matt Wright.
After the birth of her second child, Jennifer Ford found herself staring at a bottle of pain medication on her kitchen windowsill one day, wondering how long it would take — if she took all the pills — to fall unconscious, and for her husband, Andrew, to return home from work, find her and rush her to the hospital. If he did, she would surely have found an effective way to address her anguish.
“Then a light came on and I decided I would just tell my husband what I was feeling, which was an intense despair that my previous life was lost, that I would never feel better, that I didn’t want to do this,” Ford said. “Andrew locked up the pills and said, ‘we’re seeing the doctor.’”
Fortunately, her UMass Memorial Health obstetrician was familiar with her history of anxiety and depression and knew the next step to take. When she and Andrew arrived at his office, he offered her the Edinburgh Postnatal Depression Scale (EPDS) screening tool and connected her to services provided by the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms. Since July 2014, the first-in-the-nation Perinatal Psychiatry Access Program, funded by the Massachusetts Department of Mental Health, has offered providers immediate phone consultation with perinatal psychiatrists so that pregnant and postpartum individuals with mental health conditions have access to treatment.
“Over the phone, my doctor was able to change my medication to treat the postpartum depression and I was provided a social worker who arranged my regular visits with a psychiatrist and group therapy,” said Ford. “Right away, everything was done. We thought, that just doesn’t happen.”
A PARTNERSHIP IS BORN
It has been happening, thanks to the focused efforts of Tiffany Moore Simas, MD, MPH, MEd, and Nancy Byatt, DO, MS, MBA, DFAPA, FACLP.
Moore Simas is Chair of Obstetrics and Gynecology, UMass Memorial Health and Professor of Obstetrics & Gynecology, Pediatrics, Psychiatry, and Population & Quantitative Health Sciences, UMass Chan Medical School. She was MCPAP for Moms’ founding Obstetric Engagement Director and now serves as its Obstetric Engagement Liaison. Byatt is a perinatal psychiatrist with Women’s Mental Health Services at UMass Memorial Medical Center and Executive Director, Lifeline for Families Center and Lifeline for Moms Program, Department of Psychiatry, UMass Chan Medical School and Professor of Psychiatry, Obstetrics & Gynecology, and Population & Quantitative Health Sciences, UMass Chan Medical School. Byatt is the founding Medical Director of MCPAP for Moms and its current Director of Research and Evaluation. Together they founded the Lifeline for Moms program. (See sidebar: “Resources for Learning About and Integrating Perinatal Mental Health into Practice” with details about accessing the programs and their related efforts.)
Their partnership goes back more than 10 years, and their knowledge runs deep about how people like Jennifer Ford are susceptible to perinatal mental health conditions — those occurring during pregnancy and the first year after giving birth.
Most of their obstetrician-gynecologist colleagues don’t have this expertise, however, primarily due to lack of education and training in perinatal mental health during medical school, residency and beyond. “When Nancy and I started collaborating, obstetricians weren’t routinely screening and providing treatment for mental health conditions in their pregnant and postpartum patients. We wanted to increase the capacity and comfort of these frontline caregivers to do so,” said Moore Simas.
“If we think about diabetes in pregnancy as a parallel, not addressing it would never happen, right?” Byatt said. “Depression is twice as common as gestational diabetes. Yet without a system in place to help obstetric providers address depression, it often goes unaddressed. We have developed approaches for helping obstetric providers detect, assess and address depression just as we would any other medical problem.”
EVIDENCE ARRIVES
The need to manage perinatal mental health conditions has gained increasing attention over the past 15 years. In 2013, JAMA Psychiatry published “Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women With Screen-Positive Depression Findings,” by Katherine Wisner, MD, and colleagues. It concluded that 1 in 7 mothers who give birth may suffer from postpartum depression, a moderate to severe form of depression that occurs typically within three months of delivery.
The study identified several risk factors, including a history of depression, bipolar disorder or anxiety disorders; alcohol, drug or tobacco misuse; or having an unplanned pregnancy or mixed feelings about pregnancy. Problems resulting from personal relationships, money or housing circumstances also were shown to increase the chances of developing postpartum depression.
Shortly after the study’s publication, there was increasing consensus around screening for perinatal mental health within systems that facilitated access to assessment and treatment. From 2015 to 2017, recommendations were issued by the Council on Patient Safety in Women’s Health Care, U.S. Preventive Services Task Force (USPSTF) and American College of Obstetricians and Gynecologists (ACOG).
Alarming statistics and headlines have reinforced the threat posed by unaddressed perinatal mental health conditions not only to mothers, but also to the health and well-being of the baby and family. One in 5 women will experience a mental health condition during pregnancy or in the year after birth, according to the World Health Organization.
While not the only cases to have shocked the nation over the years, two recent Massachusetts examples have brought the issue of maternal mental health again to the forefront — one involving a mother who died by suicide four days after the birth of her twins and another in which a mother who was reportedly experiencing severe psychiatric illness was charged for the alleged murder of her young children.
“Perinatal mental health conditions are the leading cause of maternal mortality or pregnancy-related death in the U.S., yet, this is wholly preventable,” said Moore Simas. “We have the opportunity to do better and make education and resources easily available.”
STOP THE STIGMA
Since the launch of MCPAP for Moms, Byatt and Moore Simas and colleagues have continued to lead the way — from program expansions to adoption of clinical practice guidelines — designed to help obstetricians across the U.S. successfully integrate perinatal mental health care into their practices. Such integration goes beyond screening to encompass assessment, diagnosis, treatment, monitoring, and follow-up to ultimately improve patient outcomes. (See sidebar: “UMass Memorial Health-UMass Chan Innovations in Perinatal Mental Health Have National Impact.”)
By providing the education and resources to supplement obstetricians’ and their staffs’ minimal training in perinatal mental health, Byatt and Moore Simas are countering the stigma surrounding mental health conditions that can lead to serious consequences.
“Women should not die of mental health conditions in pregnancy and postpartum, certainly given all the contact with the medical community,” Moore Simas said in an American Medical Association webinar with Byatt in 2020. She noted that “women will have 12 to 15 visits in a nine-month period of time during pregnancy. They'll then have visits within the postpartum period, and visits with their pediatric provider for well-child visits…there is opportunity at all of those points to screen a woman and engage her in care.”
A MOTHER’S ADVICE
Jennifer Ford’s two girls, Addison and Mckinley, are now 11 and 9. She’s a real estate agent and the entire family tends to their farm in Oakham, Massachusetts where visitors can buy Thanksgiving turkeys and Christmas trees. From her own experience, Ford has developed a broader view of mental health care and when and for whom it should be applied.
“The advice I’d give to medical professionals: mental health care in general should be preventative. Start with a person in childhood, just like we do with vaccines. Provide routine mental health check-ins as that individual grows, and throughout the teen years. And have social workers in the practice and involved in all the cases, for evaluation and prevention. We should never have to fix people once they’re broken,” she said.
She believes the stigma surrounding mental health conditions would be reduced if, from a young age, people learn that this care is considered just as important by the medical community as any other treatment now provided as a matter of course.
After her battle with postpartum depression, Ford also offers advice to mothers that Byatt and Moore Simas would second. “Moms who are struggling while caring for a child — understand that you can’t pour from an empty cup. You have to take care of yourself, too. A healthy baby comes from a healthy mom.”
PERINATAL STRUGGLES
Ford probably never imagined she’d have to offer this advice, based on her experience with her first child. “That pregnancy was planned and anticipated. I was in a happy place in life, and I was content with one child.”
Then, Ford said, a series of events “left me to not be well during and after my second pregnancy.” These changes and their impact on Ford reflect certain risks factors for postpartum depression that have been discerned through research: having mixed feelings about pregnancy, as well as a history of anxiety and depression.
“A close friend’s child had died, which was devastating. Then my father-in-law was placed in hospice care.” Her husband Andrew was able to gain strength from his brothers during this time. “I started to think, why am I going to leave my older daughter without a sibling to lean on later in life if she needs to?” Ford remembers the day she threw her birth control away. “I learned I was pregnant the night after my father-in-law passed, five weeks later.”
This pregnancy was hard for the entire family; at certain points, Ford and her husband weren’t sure she would take the pregnancy to term. “I just didn’t feel the same way as the first time. I wasn’t too attached to the idea of it because of where we were in our lives,” Ford said.
Ford went into labor the day she and her doctor planned to discuss induction, after her due date had passed. “I pushed for a long time, the baby’s heart rate was dropping, and I needed an emergency c-section. Not having a vaginal birth added to my anguish.”
Ford felt fine in the hospital. She responded to the controlled and predictable environment, where her well-being was a priority, and she was attended to regularly. “I thrive on that, feeling things are in control. But as soon as I got home from the hospital, I felt the depression.”
Her bedroom in disarray for a planned renovation, clothes strewn across the bed, Ford said, “it hit me. I thought, I want to feel at home, in my own space, but this wasn’t home.” Worse, she felt the new baby wasn’t hers, as she looked nothing like her firstborn. “I felt no connection — wrong baby, wrong house.”
Within two weeks, Ford found herself staring at the bottle on the windowsill.
A THANKS TO CAREGIVERS
The help Ford received from MCPAP for Moms was supplemented with visits from family and friends, her husband’s unwavering support and the constant presence of her recently widowed mother-in-law. “In addition to mothers, we also need to recognize and take care of our partners and caregivers who are going through this mental health crisis with us,” she said.
“I have limited memory of that first year of recovery after Mckinley was born. But I do know that MCPAP for Moms was a well-oiled machine. So much was just made to happen behind the scenes. I didn’t have to think about it, I trusted it,” said Ford, adding, “I would not have known about MCPAP for Moms without my obstetrician.”
SPURRED TO ACT
One of Dr. James Wang’s first encounters with the tragic results of untreated severe postpartum depression was when a patient who had been seen in his obstetrics resident service later took her own life. “This was a sentinel event,” said Wang, MD, Assistant Professor of Obstetrics and Gynecology at UMass Chan – Baystate Regional Campus. “I needed to determine what I could do.”
Through research and familiarizing himself and his colleagues with the work of Byatt and Moore Simas, Wang increased access to vital resources in the hospital and clinic, including MCPAP for Moms. And he’s subsequently seen in real-time how it can make all the difference for patients.
“One of the residents was seeing a patient with bipolar disorder and severe depression and was uncertain of a treatment plan. Given the patient’s complex history, we called MCPAP for Moms,” said Wang. “Within a few minutes, we had a medication and follow-up plan. As the resident reviewed her options, the patient’s tension visibly melted.”
Applying perinatal mental health care in practice has been embraced with “open arms by our residents and physicians,” Wang said. The screening component is infused in everyday interactions with appropriate patients, and the broader team includes a perinatal psychiatrist and a psychiatric nurse practitioner focused on reproductive mental health.
As they have become more knowledgeable and practiced in perinatal mental health care, the practitioners are finding they resort to MCPAP for Mom services less often. “But knowing it’s available to us is always helpful.”
PERINATAL CARE IN PRACTICE
Wang explained their approach when perinatal mental health issues arise: “We use a standard screening tool, EPDS, with all patients at their first prenatal visit, at 28 weeks of pregnancy, immediately postpartum, and then at six weeks after birth. We also have patients schedule their annual gynecologic exams about six months postpartum, in action of the concept of the ‘fourth trimester’ of obstetric care, as advocated by ACOG.”
Wang noted that in “many cases of positive depression screens, we find we can talk through common issues with our patients. They may be sleep deprived or having difficulty adjusting to the new routine of parenthood – situational concerns. But if a patient is diagnosed with postpartum depression, we can refer them to our psychiatric team and offer close follow-up.”
He agrees that stigma around maternal mental health issues can be harmful for patients. “Society still holds mental health in a different category than other health conditions. A new parent may be reluctant to talk about being depressed for fear of being called weak or a bad parent, and some patients refuse medication to treat depression because of this.”
Some 50 to 70 percent of mothers develop postpartum blues, a form of mood disturbance in the first few weeks after delivery. “The more we talk about this as a health issue, a medical concern, then we normalize mental health as an aspect of the conversation and education,” Wang said.
ADVOCACY FOR MATERNAL HEALTH
A long-time advocate of perinatal mental health care and widespread access to services, Wang was recently at the Massachusetts Statehouse to meet with colleagues supporting passage of a new bill, An Act Establishing a Maternal Mental Health Equity Grant Program, that promises to help even more mothers in need.
The legislation would establish a grant program for community-based organizations addressing maternal mental health conditions or substance use disorders in areas experiencing high rates of adverse maternal health outcomes or significant racial or ethnic disparities in outcomes. Key components of the proposed bill that underscore the work of Byatt and Moore Simas include:
- Using grant funds to establish or expand maternity care programs to improve the integration of maternal mental health and behavioral health care services into primary care settings where pregnant individuals regularly receive services
- Addressing stigma associated with maternal mental health conditions and substance use disorders, with a focus on medically underserved populations
- Establishing or expanding programs to provide education and training to providers to identify warning signs for maternal mental health conditions or substance use disorders, and offering referrals to mental or behavioral health care professionals
This latest legislative effort builds upon what started in 2010 with then Massachusetts Governor Deval Patrick’s signing of An Act Relative to Postpartum Depression, authorizing the Massachusetts Department of Public Health to “develop a culture of awareness, destigmatization, and screening for perinatal depression” – and instituting the Edinburgh Postnatal Depression Scale, which Jennifer Ford took at her obstetrician’s office years ago.
The proposed new law reflects a focus on community-based partnerships and health systems that Moore Simas and Byatt are deeply invested in expanding to address inequities and close the gaps in perinatal mental health care that Byatt and Moore Simas are deeply invested in expanding. (See sidebar: “The Maternity Center’s Commitment to Improving Birth Equity” detailing UMass Memorial Medical Center’s programs focused on eliminating health disparities.)
A CURRICULUM FOR CARE
To help address a long-standing and critical issue that led Byatt and Moore Simas to develop their solutions — the dearth of psychiatrists trained in perinatal mental health — a joint effort of the National Task Force on Women’s Reproductive Mental Health and Marcé of North America has been underway since 2013. Led by Weill Cornell Medicine’s Lauren Osborne, MD; Sarah Nagle-Yang, MD, of the University of Colorado School of Medicine; and Kelsey Hannan, Johns Hopkins University School of Medicine, the National Curriculum in Reproductive Psychiatry has researched the state of education in reproductive psychiatry, aiming to move toward national standards.
The task force conducted surveys of residency and fellowship directors as part of the research. It found that other learners, such as ob-gyns, advanced practice nurses and general psychiatrists, as well as ob-gyn, pediatric and family medicine residents, would benefit from this training.
The result: a plan to create an interactive, web-based national curriculum that can be used in modular form for residency education, and in its entirety as a fellowship curriculum. The task force’s first six modules were piloted in nine residency programs in 2018-2019, with the remainder piloted in 2019-2020.
View resources for learning about and integrating perinatal mental health into practice.