The following editorial is from Susan Dowd Stone, LCSW, board member of both Postpartum Progress Inc. and Healthy Mothers Healthy Babies. It's in response to a just-published study that concluded that New Jersey's mandatory postpartum depression screening did not get more vulnerable women into treatment.
Update: After you read this, you can receive the response Susan received from the study's authors here.
The February 2011 volume of the journal Health Affairs, has published a study entitled “New Jersey’s Efforts to Improve Postpartum Depression Care Did Not Change Treatment Patterns for Women on Medicaid”. The title of the article, authored by Kozhimannil, Adams, Soumerai, Busch and Huskamp, is curiously conclusive in its declaration of outcome for this population of Medicaid women, given subject exclusions which weaken its findings and a perspective which lacks understanding of NJ’s Maternal Child Health consortia system, the clinical course of PMAD’s and demographics of those served.
Also absent from the study’s reference is relevant current legislative and clinical context which could have refined and enhanced the study’s structure, subject selection, policy recommendations and conclusions. Given the involvement of public health policy makers/advisors associated with several major U.S. educational institutions, the study’s narrow context is surprising.
For starters, the population of Medicaid recipients chosen to participate in the study was taken from an initial group of 103,414 women – all of whom gave birth between July 1 and 2004 and October 31, 2007 – to a final group of just over 30,000, ultimately representing less than a third of those receiving Medicaid while pregnant/giving birth.
No other groups in the state of New Jersey who may have benefitted from its initiatives were included. The women who made it to the final study group had to have had deliveries covered by Medicaid and the mothers had to have had continuous enrollment in Medicaid for at least six months before and one year post delivery. Therefore, the study notes that “many women were excluded from the study based on the continuous Medicaid coverage requirement”.
The study also excluded women who were suffering from bipolar disorder (an illness which may have its first presentation or exacerbation of symptoms in the postpartum), and schizophrenia. It further excluded another 1193 women who were receiving medication during pregnancy in order to “distinguish new cases from ongoing illnesses”. No sufficient explanation is offered as to why this exclusion was necessary given the NJ initiative’s goal of inclusiveness of all pregnant and postpartum women regardless of when their illness develops.
Women already suffering from perinatal illnesses or other mental disorders are among those at highest risk for the development of additional or exacerbation of pregnancy related mood disorders. Indeed, while the study acknowledges that many cases of depression begin during pregnancy it excluded those high risk women and then failed to include results from service delivery to this same population of very vulnerable pregnant and new mothers.
How did the study developers decide which women already suffering from mental illness were to be excluded? Such eligibility was measured on the basis of prescriptions filled and covered by Medicaid; no clinical data on symptom development or presentation was considered! For example, if a woman was taking prescription medication for anxiety during pregnancy, an associated risk factor for PPD, she was excluded from the study. In this writer’s opinion, the significance of these exclusions is not given appropriate weight in the conclusion phase of this study.
In addition, Medicaid recipients include those who may have immigrant status who are often reluctant to enroll or who do so for brief periods of time. Therefore, many may drop out of such programs or decline to enroll in the first place. None of the NJ’s Maternal Child Health Consortias exclude access to services for women who do not have Medicaid insurance. Therefore, these high risk women who are served by these programs are not represented at all.
The study’s comment that perhaps women not on Medicaid or those in more affluent areas may have been the more significant beneficiaries of this program cannot be substantiated by any data presented in this study. In addition it fails to understand or acknowledge the outreach made to NJ’s most vulnerable populations by Consortia such as The Hudson Perinatal Consortia, or the Atlantic City Cooperative; both of which are community-based programs reaching out to those at highest risk.
As public health policy makers understand, when one is targeting a public health crisis, initial goals include raising public awareness, educating the professionals who will be charged with the targeted population’s care and inclusion of all stakeholders. The study references the aggressive training program initiated in NJ which included healthcare professionals from several disciplines.
But the study did not cite the training offered to social workers, nurse practitioners and psychologists, the professions who will most often be charged with performing the mandated assessments. It failed to reference the availability of a list of those trained which is maintained by the consortia, is available to all healthcare facilities and which offers associated healthcare professionals a well-trained reference base for referrals.
It is agreed that state or agency funding of payment for such assessment could be an additional inducement, but such reimbursement does already exist within some consortia. There is no proof offered in this study that lack of state funding for assessment negatively impacted the availability, access to help or willingness of associated mental health professionals to offer services.
This author further agrees that it is more likely that medical providers, who would prefer not to be in the business of mental health, would be more encouraged to identify and assess women for perinatal mood disorders if a referral base is associated with such compliance is readily available.
Finally, the study’s suggestion that mandated screening be partnered with policy to ensure compliance is well intended and supported by this writer. However, a recent historical perspective and review of this policy would have yielded evidence of the strong controversy which continues to surround this issue.
Mandated screening is not included in the federal legislation because it failed to find sufficient support for passage. Indeed, the federal PPD legislation included in the Patient Protection and Affordable Healthcare Act asks for a study to further determine the effectiveness of screening and seeks to fund many other programs (included concrete services) supportive to women suffering from postpartum depression. It does not mandate screening.
This author continues to support and encourage states to develop new PPD awareness and treatment policies, programs and mandates and appreciates the well-intentioned efforts of the study’s authors to also encourage such exploration. As each state’s population presents unique features which require adjustment to maximize responsiveness and effectiveness, the study’s suggestion of developing focus groups, use, access, means and needs studies is well appreciated. But it is hoped future studies will take more care to allow current clinical, legislative, economic and program relevance to inform study structure, subject selection and policy recommendations.
A better understanding of NJ’s outstanding Maternal Child Health Consortia systems – and the dedicated administrators and staff who oversee these life-saving programs; all of which vary in response to the needs of rich, diverse demographics – would also have provided better context for this study.
NJ’s groundbreaking initiatives led by Richard and Mary Jo Codey and championed nationally by U.S. Senator Robert Menendez, continue to galvanize a country long deaf to the suffering and needs of maternal mental health.
If state policy makers feel they cannot pass or implement legislation responsive to this crisis without the expensive and controversial mandates suggested by this study, they may feel discouraged from initiating policy changes on a more modest level.
Given the current economic climate, and urgency of early detection and treatment, this could doom many women and families from having access to even basic services resulting from educational and outreach programs that are indeed proven to save lives.
Susan Dowd Stone, LCSW
