How Folding Mental Health Services Into Maternal and Infant Care Can Help Low-Income Families

Integrating therapy, other services, or information into routine visits can make getting help easier and chip away at the stigma regarding postpartum depression.

Unlike the "baby blues," which are commonly associated with mild feelings of worry and fatigue after having a baby, postpartum depression is a mood disorder characterized by a broad range of symptoms including anxiety, extreme sadness, and exhaustion. Shutterstock

When Catherine Monk trained as a clinical psychologist in New York City, she began looking for ways to improve the well-being of pregnant people and their future children’s lives. Part of her vision included offsetting the stigma associated with postpartum depression. Monk realized that vision in the integration of behavioral health services into primary care.

Now as the director of the women’s program of psychiatry at Columbia University Medical Center, Dr. Monk and her colleagues have developed Practical Resources for Effective Postpartum Parenting (PREPP), an ongoing clinical trial at the medical center aimed at preventing postpartum depression by providing behavioral and prenatal support to low-income women.

“We still have a lot of mental health stigma in our country, and since our focus is on both the mother and baby, it removes the unfortunate shame that women feel about seeking treatment,” Monk said.

Unlike the “baby blues,” which are commonly associated with mild feelings of worry and fatigue after having a baby, postpartum depression is a mood disorder characterized by a broad range of symptoms including anxiety, extreme sadness, and exhaustion. According to the Centers for Disease Control and Prevention, one in eight women experience this form of maternal depression, which can severely hinder their ability to take of their infant or themselves.

Considering that only an estimated 15 percent of women with postpartum depression ever receive professional treatment, this means that about 850,000 women are at risk each year. Many are more likely to shrug off their symptoms and self-medicate with alcohol or drugs. Moreover, they may lack the state of mind to follow up with physicians or adhere to care regimes, and they may struggle with making healthy lifestyle decisions for their children and themselves. Furthermore, if left untreated, postpartum depression can impair a child’s cognitive and emotional development.

A growing body of research indicates that chronic maternal depression can expose children to poor parenting practices, neglect, and even abuse. A Pediatrics study showed that infants of women with persistent depressive symptoms are nearly three times more likely to be hospitalized in the first year of life, and that these same mothers had twice the likelihood of using corporal punishment with their infants. 

To offset those possible issues, PREPP centers on three major components in order to reduce stigma and provide services to women: mindfulness, parenting skills, and psychoeducation—which is a way of providing people with more information about mental health issues and in this case, giving women realistic expectations of the postpartum period.

“Because so much of how the mother is doing influences the baby and vice versa—we want to get the two of them onto the best pathway possible,” said Monk, who recently published a study that shows the link between prenatal exposure to maternal depression and infant risk for neuropsychiatric disorders such as anxiety and depression.

The program, which begins in pregnancy, aims to give women the tools they need during difficult moments of caring for a newborn. In five sessions, study psychologists or coaches teach participants self-reflection skills, techniques to help reduce infant crying, and ways to cope when their babies are distressed.

Empowering women with the tools they need to become confident mothers can also combat poverty, said Monk, because it allows them to concentrate on their studies and increase their odds of staying in school. She believes that early interventions that address mothers’ mental health can ultimately improve their autonomy and social mobility.

Initiatives like PREPP that focus on the psychosocial well-being of low-income mothers are especially vital in helping overcome barriers such as lack of access, financial strain, and the cultural stigma that often accompanies seeking help. And because the program is tied into routine obstetrics visits, it’s convenient for women on Medicaid, who are at high risk for postpartum depression. A study in the Journal of Women’s Health puts this rate ata staggering 40 percent for women living in poverty.

Yet routine screening can provide a way to destigmatize pregnancy-related depression. As Judy A. Greene, a reproductive psychiatrist at Bellevue Hospital Center in New York, explained, “By treating mental illness in pregnancy, you reduce the risk of postpartum depression and other psychiatric illness that can impact bonding and attachment.”

Similar to PREPP, which has psychiatrists on location, the women’s health clinic at Bellevue Hospital Center screens expectant mothers for depression and offers the option of receiving individual therapy as well as psychiatric treatments.

The clinic itself currently serves a diverse patient population that includes undocumented and uninsured women who are either on Medicaid or pay a sliding-scale fee, and it is partnered with a New York University fellowship that began in 2012. The fellowship entails a full-time, one year clinical psychiatrist who coordinates with OB-GYNs in order to reach moms.

The goal is for patients to have access to treatments they otherwise couldn’t afford, explains Greene, who is also the fellowship’s program director. She suggests that these kinds of prenatal models have shown to be increasingly effective in the OB-GYN setting.

“Logistically, it’s much easier,” she noted. “A lot of our patients have other children, and so if they’re here for an ultrasound for their prenatal care visit, and they can see their mental health professional on the same day—that just makes the likelihood that they’ll attend these appointments much higher.”

Despite limited funding, many clinics and hospitals around the country are eager to address the mental health concerns of this vulnerable demographic. At Sinai Hospital of Baltimore, patients are routinely offered a voluntary screening after delivery. But unlike PREPP and the program at Bellevue, which have psychiatrists streamlined into prenatal visits, patients are referred to Sinai’s on-site perinatal support counselor, Sara Daly, who works with patients by making connections in the community with therapists and psychiatrists specializing in maternal mental health disorders.

Daly says that for many low-income women, having this kind of encouragement is paramount to receiving the care they need. In 2016 alone, she provided support to more than 700 women who came to her by way of obstetrics referrals, screenings, and her weekly postpartum support group. She’s quick to explain that many new moms suffering from depression end up putting their own health at risk by not going in for their routine postpartum check-up.

“We already have a mental health system in our country that’s very difficult to access, and then when you add in someone who has a newborn and significant mental health distress—it’s really hard to continue to make phone calls to get the help you need,” she said.

Like Monk, Daly understands that while many medical providers care about this issue, it’s not always a straight line for low-income women to receive adequate treatment. “There’s just so many places a mom can get tripped up along the way and not get the care she needs for her own well-being and safety, [that] of her children, and the whole family system.”

In order to shed further light on these issues, Daly was part of a working group that last year wrote the legislation to create a task force to address maternal mental health disorders in Maryland. It’s an initiative that comes on the heels of other collaborative care projects like ThriveNYC and MCPAP for Moms, both of which integrate behavioral health services into primary care. The success of models like these comes down to looking at a broader perspective—one that takes into account the potential long-term impact on women and their entire families.

Ultimately, said Monk, “we’re talking about the psychological process of the mother and baby becoming as well-coordinated as possible in their relationship from the beginning,” and interventions like PREPP help normalize the conversation surrounding maternal mental illness.

“This is a positive direction …. When you bring behavioral health services into primary care, it takes away stigma and provides women with the tools to take care of their baby.”