In the past decade, 10 states have created laws to promote screening for depression during pregnancy and the postpartum period. These laws are intended to increase awareness among doctors, women, and their families. Often, the legislation has been spurred by women who reached out to politicians after experiencing postpartum depression (PPD), or in response to tragic stories of women with postpartum depression and psychosis.
Last year, New York became the latest state to pass legislation when Governor Andrew Cuomo signed into law the Maternal Depression Bill on August 4, 2014. One component of the bill requires written guidelines to be distributed to healthcare providers about screening women for depression during and after pregnancy.
"If I had had one ob-gyn or one pediatrician on a child wellness visit spend just five minutes with me and ask me how I was doing, it would have saved me from going through the worst six months of my life," says Paige Bellenbaum, a New York-based clinical social worker who suffered PPD after the birth of her first child in 2006.
After she finally found help and began to recover, Bellenbaum collaborated with New York State Senator Liz Krueger to create the Maternal Depression Bill.
But very few studies have examined whether screening programs result in better access to treatment or improved mental health outcomes. This lack of evidence has led some experts to question whether screening laws actually help women – or may do more harm than good by creating confusion and distress when women who screen positive don't have access to care and support.
How screening works
Screening usually involves answering a 10-question test called the Edinburgh Postnatal Depression Scale (EPDS), which indicates whether a woman is at high risk of depression. Providers usually refer women who screen positive to a mental health specialist for a definite diagnosis and treatment.
A study of community-based health centers in North Carolina found that screening with the EPDS identified many more women at risk of depression at their six-week postpartum visit than healthcare providers did at a routine visit (35 percent compared to 6 percent). Another study found that among women who had previously exhibited signs of depression, ob-gyns and nurses identified only 26 percent as at risk during a regular prenatal visit.
But getting healthcare providers, such as ob-gyns and pediatricians, to screen is a challenge because they often feel unqualified to give mental health care, says Ilise Zimmerman, executive director of the Partnership for Maternal & Child Health of Northern New Jersey, an organization which trains perinatal care providers to screen women and help them find care.
New Jersey is one of three states (along with Illinois and West Virginia) that requires screening. In New Jersey, the law mandates that an obstetrician, nurse, or midwife screen women before they leave the hospital after giving birth and at several postpartum visits.
In the months before New Jersey passed the law in 2006, many doctors received training through a statewide initiative. Since then, three organizations in New Jersey, including Zimmerman's, have been responsible for training providers in hospitals and clinics. But Zimmerman says it is difficult to know if providers feel prepared to handle the screening results and actually are screening women at postpartum visits. (It's easier to track screening after hospital delivery because the state requires hospitals to note the patient's medical record that depression screening was performed.)
Even when clinicians do the screening, there is a danger that women who screen positive could feel alienated if clinicians don't explain the results in a way that women understand or feel comfortable with, says Linda Chaudron, MD, a psychiatrist at the University of Rochester School of Medicine and Dentistry. "But these risks can be minimized through provider education, and the benefits of identifying women who might otherwise go on suffering are great," she adds.
What the research says about screening
The main argument against PPD screening laws is the lack of research showing it results in more women getting treatment. There has been only one study on the impact of legislation, involving women on Medicaid in New Jersey between 2004 and 2007 – two years before and one year after the law was passed. Following the legislation, the study found no increase in the percentage of women who received a prescription for an antidepressant or had a mental health visit six months after giving birth. This suggests there was at least not an immediate improvement in care for postpartum depression.
However, in the years after that study, many programs and resources have been rolled out, which are helping women connect with treatment, says Susan Ellis Murphy, program coordinator for the Postpartum Wellness Initiative for South Jersey. Murphy runs the organization that trains obstetricians and pediatricians in southern New Jersey to screen women at postpartum visits. Since the law passed, Ellis's group implemented a system to receive information automatically on women who screen positive. This enables providers to contact the women to assess their mental health and make recommendations for care.
Another program that has become available in recent years is the Speak Up When You're Down helpline. Women anywhere in New Jersey can call the 24/7 number and get a list of maternal mental health care providers in their area for low cost. Women who are uninsured can find out about state agencies that provide care at no cost.
No studies have been done to evaluate the effects of these more recent efforts. Programs such as Murphy's put resources toward supporting providers and helping women, not tracking outcomes. Information is available on how many women are getting treatment through state subsidized programs, but independently funded researchers would be needed to analyze it.
Despite the lack of data that support screening on a statewide level, there are success stories from individual hospitals and groups of clinics. One study looked at the effect of training primary care doctors at 14 clinics across the United States to screen and treat women within the first three months postpartum.
Women at these clinics who screened positive received further evaluation and possibly medication or counseling. They had fewer depressive symptoms 6 and 12 months later, compared with women who went to one of the control clinics in the study where doctors had not been trained to screen and treat.
However, "the intervention clinics had to have a whole series of training on screening and diagnosis, and nurses had to be trained to do at least one follow-up call with women," says Barbara Yawn, MD, director of research at the Olmsted Medical Center in Minnesota, and lead author of the study. All these steps gave the clinics a lot of extra work and could be hard to maintain in the long run, says Yawn.
In Illinois, depression screening before and after pregnancy has been required by law since 2008. But years before the law, perinatal care doctors started receiving training on how to screen and help women at high risk. This "front-ending" approach was taken in part to avoid the problems that happened in New Jersey, where few support and treatment programs were in place when screening became required, says Laura Miller, MD, medical director of women's mental health at the Edward Hines, Jr. VA hospital in Illinois.
NorthShore University HealthSystem in Evanston, Illinois found that only 14 percent of women who screened positive actually made an appointment at a different clinic for evaluation and care. So administrators decided to staff ob-gyn clinics with psychiatrists and found that the rate jumped to 62 percent, says Jo Kim, PhD, director of NorthShore's Perinatal Depression Program. "A big barrier to mental health care in low-income populations is access, and uptake is going to be much greater if you can deliver the care to the same site," Kim adds.
Bringing mental health care providers into perinatal care clinics could be feasible throughout Illinois, says Miller, because doctors can be reimbursed by Medicaid for screening, and that money can go toward hiring mental health care providers.
However, the New York legislation would not reimburse doctors. Instead, the legislation mandates that the state department of health give maternal health providers referral information to distribute to women, including information on treatment options, treatment providers, and community resources. (Such resources would also be available online.)
For example, when doctors identify women at high risk of depression, they can refer the women to The Postpartum Resource Center of New York. This organization offers services including a helpline, and contact information for support groups.
Additional benefits of screening laws
There could be multiple benefits to laws that either require PPD screening or promote it (as in California, Massachusetts, Maine, Minnesota, Oregon, Washington, and now New York). "I haven't seen evidence that laws per se directly help, but they very effectively bring people together," says Miller. Clinical and advocacy groups, experts, and funders meet to discuss legislation, as was the case with the New York law, which can increase awareness among doctors and may even bring in funding.
"The best approach would be to make PPD screening a quality indicator, like BMI measurement and cervical cancer screening," says Yawn. This would mean providers get evaluated – and reimbursed – based on whether they screen. But before developing a quality indicator or law, Yawn stresses that we need more studies exploring any possible harms of PPD screening – namely, whether providers sacrifice other important exams to make time for screening, and whether it makes women feel stigmatized and guilty.
But raising public awareness of screening could help reduce that stigma, says Bellenbaum. A key aspect of the New York legislation that Bellenbaum helped create requires hospitals and birthing centers to give new mothers pamphlets about PPD after they deliver. And the bill encourages providers to give women the information in the presence of a family member, which could be especially important in communities where there is still a lot of stigma around mental health problems, says Bellenbaum.
"Some women are not going to open up if you screen them," Bellenbaum says. "As we chisel away at stigma, they will feel less threatened and more comfortable sharing."