To Screen or Not to Screen? Doctors Debate Post Partum Depression Testing

Wendy Root Askew struggled with postpartum anxiety after her son was born. She is pictured here with her husband Dominick, and their son and dog on vacation in 2015. (Courtesy of Wendy Root Askew)

Lawmakers will begin debate next month on a bill that would require doctors to screen new moms for mental health problems – once while they’re pregnant and again, after giving birth.

But a lot of doctors don’t like the idea. Many obstetricians and pediatricians are afraid to screen new moms for depression and anxiety.

“What are you going to do with those people who screen positive?” said Laura Sirott, an OB/GYN who practices in Pasadena. “Some providers have nowhere to send them.”

Of women who screen positive for postpartum depression, 78 percent don’t get mental health treatment, according to a 2015 study review published in the journal Obstetrics & Gynecology. Dr. Sirott’s patients have told her the range of reasons why they don’t take her up on a referral to a psychologist.

“Oh, they don’t take my insurance. Or my insurance pays for three visits. I can’t take time off of work to go to those visits. It’s a three-month wait to get in to that person,” she said.

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And, it’s hard to find a psychiatrist who is trained in the complexities of prescribing medications to pregnant or breastfeeding women, and who is willing to treat them, especially in rural areas.

“So it’s very frustrating to ask patients about a problem and then not have any way to solve that problem,” Sirott said.

But moms are frustrated, too. After the baby comes, no one asks about them anymore. Wendy Root Askew struggled for years to get pregnant, and when she finally did, her anxiety got worse. She couldn’t stop worrying that something would go wrong.

“And then after I had my son, I would have these dreams where someone would come to the door and they would say ‘Well, you know, we’re just going to wait two weeks to see if you get to keep your baby or not,’” she said. “And it really impacted my ability to bond with him.”

She likes the bill, AB 2193, because it goes beyond mandated screening. It requires health insurance companies to set up case management programs to help moms find a therapist, and to connect obstetricians or pediatricians with a psychiatric expert.

“Just like we have case management programs for patients who have diabetes or sleep issues or back pain, a case management program requires the insurance company to take some ownership of making sure their patients are getting the treatment they need to be healthy,” said Root Askew, who is now advocating for the bill on behalf of the group 2020 Mom.

Health insurance companies haven’t taken a position on the legislation. It’s unclear how much it will cost them to comply, because some already have infrastructure in place for case management programs and some don’t. But there is consensus among insurers and health advocates that such programs save money in the long run.

“The sooner that you can get good treatment for a mom, the less expensive that condition will be to manage over the course of the woman’s life and over the course of that child’s life,” Root Askew said.

Doctors still have their objections. Under the bill, they could be disciplined for not screening. And screening takes time. Sometimes a doctor asks a mom how she’s sleeping, and she’s in tears for the next 30 minutes.

The health care system, and the incentives, aren’t set up for this, said Dr. Sirott.

“Currently, I get six dollars for screening a patient,” she said. “By the time I put it on a piece of paper and print it, it’s not worth it.”

And it’s not clear it’s worth it to the patients either. Four other states – Illinois, Massachusetts, New Jersey, and West Virginia – have tried mandated screening, and it made no difference in patient outcomes, according to a study published in Psychiatric Services in 2015.

Even with California’s extra requirements on insurance companies to facilitate care, women could still face high co-pays or limits on therapy sessions. Or, they’re so overwhelmed caring for a newborn, they never leave the house.

What does seem to work, according to the study, is when nurses or mental health providers visit new moms at home.

“Despite abundant good will, there is no evidence that state policies are addressing this great need,” the study authors wrote.

But supporters of the proposed bill say doctors need to start somewhere. Screening is the first step in recognizing the full scope of the problem, said Mountain View psychiatrist Nirmaljit Dhami, adding that women should be screened on an ongoing basis throughout pregnancy and for a year after birth, not just once or twice as the bill requires.

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“I often tell doctors that if you don't know that somebody is suicidal it doesn't mean that their suicidality will go away,” she said. “If you don't ask, the risk is the same.”

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