Diagnosis and Treatment of Mental Health Conditions During and After Pregnancy is On the Rise, But Disparities Still Exist
Posted on by Dr. Monica M. Bertagnolli
Pregnancy and childbirth are often thought of as joyful times. Yet, we know that mental health conditions including perinatal depression, anxiety, and post-traumatic stress disorder (PTSD) are common complications during and after pregnancy, and this is contributing to a maternal health crisis in this country.
Now, a trio of NIH-supported studies reported in the journal Health Affairs show that diagnosis and treatment of mental health conditions such as anxiety, depression, and PTSD during pregnancy and in the first year after giving birth rose significantly in Americans with private health insurance from 2008 to 2020.1,2,3 While these are encouraging signs of increasing mental health awareness and service use, these studies also showed that this increase hasn’t happened equally across all demographic groups and states, making it clear there’s more work to do to ensure that people from all walks of life have access to the care they need, regardless of their race, ethnicity, geographic location, financial status, or other factors.
The findings come from a research team including Kara Zivin and Stephanie Hall and their colleagues at the University of Michigan, Ann Arbor. They recognized a worrying crisis in maternal mental illness in the U.S., with serious health risks and many potential long-term negative impacts for new parents and their infants. While earlier studies had looked at the prevalence of mental health conditions in the perinatal period, Zivin and Hall wanted to explore nationwide trends in the diagnosis of PTSD and what they refer to as perinatal mood and anxiety disorders (PMAD) among people giving birth between ages 15 and 44.
In the first study, using a database of administrative medical claims representing insured people across the U.S., the researchers examined PMAD diagnoses (including depressive and anxiety disorders) among those with private health insurance and found that the diagnosis rate had increased by more than 93% over the 12-year period under study. The rates also showed a sharp uptick after 2015, after the Affordable Care Act (ACA) went into effect in 2014. By 2020, 28% of those who were pregnant or in their postpartum period received a diagnosis of PMAD.
The researchers found that rate of suicidality (that is, suicidal ideation or diagnoses of self-harm) among people during pregnancy and just after childbirth more than doubled over the same period, although that rate dipped among those who had received a PMAD diagnosis. The rate at which individuals who were pregnant or in their postpartum period received any form of talk therapy covered by their private insurance increased by 16% from 2008 to 2020.
The second report focused specifically on PTSD diagnoses among privately insured people over the same period. The data show a near quadrupling of PTSD diagnoses in the months surrounding childbirth, with diagnoses in nearly 2% of privately insured people by 2020. Most of the increase in PTSD diagnoses occurred in people who had already been diagnosed with PMAD.
In the third study, the researchers wanted to learn if there were increases in antidepressant prescriptions for those diagnosed with PMAD, especially after new guidelines from several professional organizations were issued in 2015 and 2016. The findings show a decrease of 3% per year from 2008 to 2016, followed by a 32% increase in 2017, with prescription rates continuing to climb each year through 2020. By 2020, slightly less than half of those diagnosed with PMAD received a prescription for an antidepressant, suggesting that the clinical recommendations made a difference in clinical practice. However, there are signs of racial disparities, with White people with PMAD diagnoses receiving antidepressants more often than people in other racial groups.
In fact, all three studies show differences between people in different age, race, ethnicity, and geographic groups. For example, White people were more likely to be diagnosed with PTSD during the perinatal period, followed by Black people. By comparison, people of unknown race, as well as people who identified as Hispanic and Asian, were diagnosed less often. At the same time, the largest increase in PMAD diagnoses among races and ethnicities was among Black people, increasing from 14% of deliveries in 2008 to 22% in 2020.
Looking at age groups, the initial prevalence of PMAD diagnoses was highest among people aged 40 to 44, yet the youngest people (aged 15 to 24) experienced the largest increase in diagnoses. The youngest age group also had the largest increases in antidepressant prescriptions, and those aged 15 to 26 were more likely to be diagnosed with PTSD than those in older age groups. The first study also showed wide variation between states in the rate of PMAD diagnoses before and after implementation of the ACA.
The findings suggest there have been improvements in doctors’ recognition and treatment of PMAD and PTSD in the months surrounding childbirth. Increases in health insurance coverage and laws requiring equal treatment of mental health conditions may also be playing a role, along with greater social awareness and acceptance of mental health conditions generally. The researchers noted, however, that the findings don’t represent people with government-funded health insurance or those who lack health insurance completely.
It will be important to learn in future studies more about those who may still not be receiving the mental health care they need. The researchers report plans to look deeper into changes that have taken place at the state level and the impact of the pandemic and the rise of telehealth since 2020. Other recent NIH-supported research suggests that relatively straightforward interventions to reduce postpartum anxiety and depression can be remarkably effective. The key step will be not only identifying interventions that work, but also figuring out how to deliver effective treatments to the people who need them.
References:
[1] Zivin K, et al. Perinatal Mood and Anxiety Disorders Rose Among Privately Insured People, 2008-20. Health Affairs. DOI: 10.1377/hlthaff.2023.01437 (2024).
[2] Hall SV, et al. Perinatal Posttraumatic Stress Disorder Diagnoses Among Commercially Insured People Increased, 2008-20. Health Affairs. DOI: 10.1377/hlthaff.2023.01447 (2024).
[3] Hall SV, et al. Antidepressant Prescriptions Increased for Privately Insured People With Perinatal Mood And Anxiety Disorder, 2008-20. Health Affairs. DOI: 10.1377/hlthaff.2023.01448 (2024).
NIH Support: National Institute of Mental Health, National Institute on Minority Health and Health Disparities
