From the Journals

Maternal mental health: New consensus on optimal care



A new consensus bundle of recommendations calls on ob.gyns. to integrate mental health care into their care of pregnant and postpartum women.

The interdisciplinary Council on Patient Safety in Women’s Health Care issued a consensus document summarizing existing recommendations on maternal mental health and pairing them with appropriate screening and other resources. The bundle of recommendations was jointly issued by the American College of Obstetricians and Gynecologists, the National Association of Nurse Practitioners in Women’s Health, and other groups (Obstet Gynecol. 2017 Mar;129(3):422-430)*.

Perinatal depression affects one in seven women during pregnancy, while between 11% and 21% experience anxiety during pregnancy and in the postpartum period.

While no novel information is included in the bundle, the goal is to provide a streamlined document that pairs previous recommendations with resources and tools.

“Embedding a mental health professional with the women’s health care provider would seem to be the ideal, [but] in reality, this may not be available in every setting or geographic location,” Susan Kendig, JD, MSN, WHNP-BC, FAANP, policy director for the National Association of Nurse Practitioners in Women’s Health, and one of the authors of the document, said in an interview. “The purpose of the consensus bundle is to provide a framework for women’s health care providers to use in developing a system of care that includes standardized risk assessment for existing or emerging mental health issues, strategies for brief interventions, identification of community resources available to the woman, and/or resources to support the provider in addressing the woman’s needs and facilitating appropriate referrals, and addressing emergencies to prevent harm.”

The framework is grouped in four domains: readiness, recognition and prevention, response, and reporting and systems learning.

Readiness is focused largely on setting up clinical and administrative protocols, including mental health screening that is seamlessly integrated into the patient visit, established algorithms that are triggered according to screening results, and designated staff to both educate colleagues on the protocols and to drive their implementation.

The goal for physicians in all settings, according to the authors, is to balance cost, availability of tools, ease of use, and the validity of the tools against the need to capture often unrecognized signs and symptoms of mood and anxiety disorders, including changes in sleep patterns, appetite, or anxiety levels that often are attributed to the physiologic and neuroendocrinologic changes inherent in childbirth. More than 80% of women know something is “off” but do not bring up their symptoms to their clinician, according to the recommendation document.

“Coordination and team cohesiveness is not necessarily dependent on co-location,” Ms. Kendig said. “Virtual teams, where care is coordinated among providers at different locations, can also achieve positive outcomes.”

The follow-on to this – recognition and prevention – views every patient visit as an opportunity to draw a thorough picture of mental and physical health by taking a complete family and patient history, maintaining routine screening, and offering psychoeducation to patients and their families or others on whom they rely for emotional support.

When a woman does screen positive for perinatal mood or anxiety disorders, the next bundle offers a rough outline of a stage-based response for intervention and follow-up.

“Screening alone does not appear to improve pregnancy or maternal-child outcomes,” the authors wrote.

Several possible algorithms are included in the document, including for emergent mental health concerns such as suicidal or homicidal ideation.

The final domain relies on data capture, taking a systems approach to not only delivering care, but also improving it. This includes scheduling regular staff debriefings after severe maternal mental health crises, troubleshooting why some patients become lost to follow-up, and examining data to see patterns.

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