Evaluating Tenets of Comprehensive Maternal Mental Healthcare

September 12, 2023 - Earlier this year, the Policy Center for Maternal Mental Health released its 2023 Inaugural Maternal Mental Health State Report Card, giving the United States a D overall in maternal mental health. Of all 50 states, California had the highest score of a B–, representing the only state to exceed a C+. These failing scores indicate a need for more comprehensive maternal mental healthcare.

It is no secret that maternal, mental, and women’s healthcare have fallen by the wayside in the US healthcare system.

“In general, access to mental health care is abysmal, but healthcare professionals have seen insufficient attention paid to maternal mortality. Mental health issues during pregnancy and after childbirth are the number one complication of childbirth and the leading cause of maternal mortality. Yet, they remain unaddressed.,” said Sarah Oreck, MD, a reproductive psychiatrist and co-founder of Mavida Health.

Reproductive psychiatry is a niche sector that specializes in the relationship between female reproductive hormones and mental health, uniquely positioning Oreck to provide information on comprehensive reproductive mental health. Oreck sat down with LifeSciencesIntelligence to discuss extensive maternal mental healthcare tenets.

Reasons for Poor Maternal Mental Health

The mental health state report card analyzed states in three primary domains:

1. Providers and programs
2. Screening and screening reimbursement
3. Insurance coverage and payment

Provider and programs were scored based on multiple factors, including perinatal mental health certified provider-to-patient ratios, maternal mental health prescriber-to-patient ratios, inpatient perinatal mental health treatment programs, outpatient intensive or partial hospitalization programs, maternal mental health task force or commissions, and community-based organizations providing direct maternal mental health services.

Screening requirements and reimbursement evaluations were based on requirements for maternal mental health screenings, Medicaid reimbursements, billing, and insurance coverage. Finally, insurance coverage and treatment payment assessed Medicaid expansion, postpartum Medicaid extension, and maternal mental health quality management programs.

LifeSciencesIntelligence asked Oreck to explain the reasons behind these abysmal rates.

“It's multifactorial. There are a lot of social and political issues that have to do with this,” explained Oreck.

She describes what she calls “the myth of motherhood” in America, where women are expected to be able to handle motherhood on top of their other responsibilities on their own. In addition to a lack of federal leave policies, unaffordable childcare and the expenses of motherhood place an additional burden on mothers and caregivers.

“COVID-19 increased rates of perinatal mood and anxiety disorders to one in three women or birthing people,” explained Oreck. “That number may be back down to one in five, but COVID was a huge stressor because people lost all support.”

Although there is no clear or precise reason why states score so low on maternal mental health, Oreck echoes the voices of many other healthcare professionals and advocates, noting that women’s mental health and female-centered health are highly neglected areas of healthcare.

Strategies for Improving Maternal Mental Healthcare

While women’s health is neglected across the board, other similarly developed countries continue to have lower maternal mortality rates and mental illnesses. LifeSciencesIntelligence asked Oreck to explain what strategies have worked to improve maternal mental health and outcomes.

“Maternal leave is critical, but some other countries implement nurses that go to homes and check in postpartum,” added Oreck. “During pregnancy, women and pregnant people see physicians and encounter the medical system more than they do in their entire lives. Yet, in the postpartum period, sometimes they see a doctor or their midwife once, six weeks after birth. So, they get all the attention in the world during pregnancy, and then it's just shut off afterward when there is such a huge risk. Six weeks is just unacceptable.”

While some societies have updated postpartum appointments to occur at two or four weeks, other medical systems have implemented new ways to check in on mothers and provide an extra layer of support to mothers.

“Universal childcare is a concept in other places but might not be possible in our country,” explained Oreck.

Although that may not be attainable, there are multiple small steps that the healthcare system can take to improve maternal health outcomes. For example, including check-ins for postpartum individuals and doing their check-ups before six weeks can help ensure a new parent’s well-being and analyze their risk for depressive disorders or postpartum psychosis.

Postpartum Depression Screenings

Postpartum depression screenings are mandated in about ten states; however, some additional states require providers to ask questions about mood, depression, and anxiety. Although screenings are excellent for identifying mental health conditions, such as postpartum depression, screening without treatment is futile.

Many pediatricians conduct the Edinburgh Postpartum Depression Screening (EPDS) when mothers bring their newborns in for their checkups; however, they are not equipped to handle mental health issues in these mothers.

“That means asking individuals who are not mental health professionals and already have limited time with their patients to manage postpartum depression,” Oreck clarified.

Pediatrics, primary care obstetrics, gynecology, and midwifery are not trained to handle mental health issues. While they may be able to provide some treatment options, most patients must obtain a referral to a mental health expert for a comprehensive treatment plan.

Therapy

Oreck explained that the current gold standard for postpartum depression is therapy, including individual or group therapy. Although many obstetricians and gynecologists have taken to providing selective serotonin reuptake inhibitors (SSRIs) to manage postpartum depression, evidence-based research points to therapy as the right place to start.

“Modalities that are most well-studied include cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT), but a lot of different types of psychotherapies can be utilized. At Mavida, CBT and IPT are the primary focus,” she noted. “ Group settings have been known to be beneficial for this type of treatment because there is often a sense of isolation experienced by new mothers. Connecting with others in similar situations can be both helpful and healing.”

Therapy can also be an excellent tool for managing other reproductive mental issues disorders, including perinatal depression, pregnancy loss, stress during the perinatal period, premenstrual dysphoric disorder, and mental health issues related to infertility preconception.

In addition to group therapy, lifestyle, and behavioral interventions can impact reproductive mental health. Most of the time, new parents need extra sleep or support. Simple things like reassuring them it is okay to supplement breastfeeding with formula or tapping into their network to take a break can make a significant difference.

“These are typically the initial approaches considered. If they prove insufficient, the use of medications is then explored,” explained Oreck.

Medications

Oreck explained that before the most recent approval for postpartum depression drugs, brexanolone was used to manage mild-to-moderate postpartum depression. However, in a broader scope, mood and anxiety disorders were managed through psychotherapy.

"The gold standard currently is SSRIs, both in pregnancy and postpartum. There is excellent safety data on those medications. In fact, it boasts the most robust data set compared to any other medication during pregnancy," she added. "It can be surprising for some, as medications like insulin or blood pressure medication are not as well-studied in pregnancy, which can be quite shocking to people."

Pregnant individuals are often excluded from drug studies and clinical trials, meaning that most of the data available is based on outcomes in men or retrospective studies. However, data analysis has shown minimal SSRI concentrations get into breast milk during breastfeeding, making it a safe alternative.

Despite the standard use of SSRIs to manage postpartum depression, these medications can take a long time to be effective and don’t always work for all patients.

“When typically putting someone on an SSRI in the postpartum, it is important to inform them, 'This medication may not take effect for four to 12 weeks. Additionally, if dealing with severe depression, it might be necessary to continue this treatment for at least six months to a year.' SSRIs are not medications that provide immediate results after a few days,” explained Oreck.

Although some people taking SSRIs may experience some long-standing changes, they are nothing compared to the effects of zuranolone.

However, the recent approval of zuranolone for severe postpartum depression by the US Food and Drug Administration (FDA) has changed the landscape for treating PPD.

“It's just a 14-day course, and then the researchers kept seeing results up to 45 days and maybe even longer,” explained Oreck.

“That is impactful, especially because SSRIs come with side effects. For some people, it's fatigue,” stated Oreck “Across the board, SSRIs have many issues, specifically with women's sexual functioning. About 80–90% of women will have sexual side effects, such as decreased interest in sex and inability to orgasm.”

It is unheard of for postpartum depression medications to be effective that quickly. The only treatments in psychiatry that have gotten close are ketamine treatments, electroconvulsive therapy, and transcranial magnetic stimulation.

Zuranolone Concerns

However, there are some limitations to zuranolone.

"In the study, zuranolone excluded anyone who was nursing or asked the patients to stop nursing. Thus, there is uncertainty about its safety for breastfeeding," Oreck clarified. "It is recognized that breastfeeding can play a mitigating role in postpartum depression and be beneficial if successful."

To date, zuranolone has only been tested and approved in patients with severe depression. No evidence indicates how it works in patients with other psychiatric disorders, such as mild-to-moderate symptoms or postpartum obsessive–compulsive disorder (OCD).

"Perinatal anxiety and mood disorders serve as an umbrella term encompassing birth PTSD, postpartum PTSD, and anxiety, which is far more common than postpartum depression," she continued. "There is hope for similar modulation for other maternal psychiatric illnesses, particularly when considering the potential hormonal component involved in these conditions."

Unfortunately, the cost of zuranolone is still unknown as the drug was just approved.

“I have concerns right off the bat that zuranolone may be inaccessible to many populations in need of it, particularly those not receiving specialized care in other areas,” Oreck explained.

More Comprehensive Care

Without medications to manage mild-to-moderate postpartum depression and other maternal mental health disorders, mental health professionals have reverted to their standard of targeted therapy and SSRIs.

Beyond that, Oreck and her team at Mavida Health are working toward developing a sense of community among postpartum individuals and promoting comprehensive changes that improve maternal mental health.

“Getting more sleep, moving your body, mindfulness practices, therapy, and support are also important. Humans need all those things.  Social-political advocacy should not be overlooked, even with the introduction of a shiny new medication,” emphasized Oreck.

Beyond zuranolone, other treatments, such as community support, therapy, and peer support, must be available across all communities. Mavida Health hopes to provide comprehensive care to birthing individuals, partners, and the entire family.

Moving Forward

Although new developments like zuranolone and other tools are expanding the toolkit for pregnant women and individuals, Oreck maintains that there needs to be more research that focuses on female hormonal health.

"Excitement surrounds zuranolone's hormonal basis and its potential to shed light on the distinct mechanisms of postpartum depression compared to major depression," she said. "Consideration extends to the next phase in a woman's life, marked by numerous mental health challenges during perimenopause, which we believe are hormonally influenced. There is anticipation to see if zuranolone or other agents through research could offer assistance in this context."

Other research could focus on the mental health changes throughout the menstrual cycle, lactation, menopause, and other female hormonal transitions.