Beyond Birth: Understanding Perinatal Depression With UMass Memorial Health

00;00;01;00 - 00;00;36;09
Tom Haederle
Carrying a child and giving birth is generally depicted as one of the happiest times in a person's life. And for many birthing people, it is. But not all. For one in five Americans who give birth and through no fault of their own, the experience of bringing a baby into the world can significantly impact their mental health. Welcome to Advancing Health, a podcast from the American Hospital Association.

00;00;36;16 - 00;01;10;17
Tom Haederle
I'm Tom Haederle with AHA Communications. Perinatal mental health conditions, including depression, anxiety and OCD, affect 800,000 new parents each year. That's roughly the population of San Francisco. Why are so many people experiencing perinatal depression? And most importantly, what can health care organizations do about it? In this next episode of the Beyond Birth series, the AHA’s Julia Resnick, director of Strategic Initiatives, explores these questions with an expert from UMass Memorial Medical Center in Massachusetts.

00;01;10;20 - 00;01;34;02
Julia Resnick
Maternal health in the United States is at a pivotal moment. Alongside an increasing maternal mortality rate, as many as 60,000 U.S. women are affected by severe maternal morbidity each year. And these unexpected outcomes can have serious, short or long term health impacts. So what will it take to improve maternal health outcomes? Identifying and addressing perinatal mental health is a crucial piece.

00;01;34;05 - 00;02;00;27
Julia Resnick
Maternal mental health conditions such as depression, anxiety, OCD and PTSD are the most common complications of pregnancy, affecting one in five women. That is 800,000 women each year in the United States alone. People at increased risk of maternal health conditions are those who have a personal or family history of mental illness, lack social support or experienced a traumatic birth or previous trauma in their lives.

00;02;01;00 - 00;02;29;10
Julia Resnick
There are also inequities in who is impacted by maternal mental health conditions. Up to 50% of women living in poverty will suffer from a maternal mental health disorder. Compared to white women, black women are twice as likely to experience maternal mental health conditions, but half as likely to receive treatment. And though these statistics focus on birthing people, we also have to recognize that fathers, spouses and partners can also experience mood changes during the perinatal period.

00;02;29;13 - 00;02;59;22
Julia Resnick
Up to 10% of new fathers will experience postpartum depression or anxiety. But there is good news. Most maternal mental health conditions are temporary and treatable with a combination of social support, therapy, medication and self-care. Welcome to Beyond Birth, a podcast series on how health care organizations can support the social and emotional needs of pregnant people and new parents. I'm Julia Resnick, director of Strategic initiatives at the American Hospital Association.

00;02;59;25 - 00;03;30;12
Julia Resnick
Today's episode will explore maternal mental health conditions, both looking at the root causes, as well as how providers can access the tools they need to identify and support their patients experiencing maternal mental health conditions. I recently spoke with Dr. Tiffany Moore Simas. She is the chair of Obstetrics and Gynecology at UMass Memorial Medical Center in Worcester, Massachusetts. UMass Memorial is the largest nonprofit academic medical center in central Massachusetts and is the fourth largest in the state.

00;03;30;14 - 00;03;45;16
Julia Resnick
They have a level three maternity center, a level three NICU and perform approximately 4500 deliveries a year. Dr. Moore Simas is an advocate for perinatal mental health. And as you'll hear, an expert on this crucial issue.

00;03;45;19 - 00;04;11;14
Julia Resnick
Before we talked about UMass Memorial's work, I wanted to tap Dr. Moore Simas’s expertise about perinatal mental health and what providers need to know about it. So before we really dive into UMass's work around maternal mental health. I'd love to just talk more generally about maternal mental health issues and what providers need to know. So can you talk about why pregnant people are particularly at risk for developing mental health conditions?

00;04;11;16 - 00;04;40;25
Tiffany Moore Simas M.D.
Yeah, it's sort of the perfect storm in many ways. If you think about mental health conditions, there are sort of inherent genetic predispositions, family, you know, family history. None of that goes away, of course, in pregnancy. But what happens in pregnancy is these hormonal changes, physiologic changes. And then if you think about many mental health conditions are exacerbated by, you know, by stress, pregnancy can be a particularly stressful time.

00;04;40;25 - 00;05;03;03
Tiffany Moore Simas M.D.
So you sort of combine biologic risk factors, environmental risk factors and psychosocial risk factors. Pregnancy brings all of those things together. One, sleep deprivation and changes in one sense of self as a new parent. What often happens is alterations in one's relationships and support systems that all comes together to increase risk.

00;05;03;05 - 00;05;07;20
Julia Resnick
And how prevalent is perinatal depression, both nationally and in your community?

00;05;07;22 - 00;05;36;13
Tiffany Moore Simas M.D.
So if you look at perinatal mental health conditions, like all mental health conditions, they affect about one in five perinatal individuals, perinatal being pregnancy in the full year postpartum. Perinatal depression as a single mental health condition. We sort of quote rates of about one in seven, but those are averages, right? As I just said, there are a lot of risk factors associated with mental health conditions, and some people have more risk factors than others and many people have many risk factors.

00;05;36;16 - 00;05;52;19
Tiffany Moore Simas M.D.
So there are some people for which the rates of perinatal depression are as high as one in three or, you know, example, women veterans, adolescents who have pregnancy, persons who are disadvantaged by socioeconomic status and racism. So really it's very, very common.

00;05;52;21 - 00;05;56;28
Julia Resnick
How can providers identify and address perinatal depression among their patients?

00;05;57;01 - 00;06;30;08
Tiffany Moore Simas M.D.
The key to that is the first part the identification. We should be screening pregnant and postpartum individuals for mental health conditions and most commonly depression anxiety. Using validated screening tools, you can't tell if somebody is depressed or anxious. You can't tell by looking at them. You really need to be using these validated instruments. Beyond that, what's a screening instrument is indicated as being positive or, you know, concern or high risk for condition need to do assessment, diagnosis, get connected with treatment. And getting connected with treatment

00;06;30;08 - 00;06;35;01
Tiffany Moore Simas M.D.
also isn't enough. We really need treatment to symptom remission.

00;06;35;04 - 00;06;44;13
Julia Resnick
So thinking about, you know, maternal mental health in the future, what are the challenges and opportunities as we're as we're looking at this space?

00;06;44;15 - 00;07;13;25
Tiffany Moore Simas M.D.
Oh, so many. So the vast majority of people with mental health conditions still go undetected and untreated. And so really providing universal screening at designated time points is at least a good first step. And then, as I said, you know, once, once a condition is identified, really helping everyone who has an identified mental health condition to get down that complete pathway through treatment to symptom remission.

00;07;13;27 - 00;07;29;17
Julia Resnick
So now turning to the work that you do, I know that faculty at UMass Chan Medical School and UMass Memorial Health were critical in developing the first in the nation perinatal psychiatry access program. Can you tell us about that program and what it is and what was the impetus for launching it?

00;07;29;19 - 00;07;56;17
Tiffany Moore Simas M.D.
Yeah, so the program is called MCPap for Moms. The MCPAP stands for the Massachusetts Child Psychiatry Access Program for Moms. There was never going to be enough perinatal psychiatrist or psychiatrist that we're comfortable, you know, treating pregnant postpartum individuals that we really needed to increase the capacity of any clinician that was caring for pregnant, postpartum, lactating individuals, persons who were pre-conception and thinking about conceiving.

00;07;56;19 - 00;08;48;13
Tiffany Moore Simas M.D.
So, MCPap for moms is the first perinatal psychiatry access program in the country. And this access program model, which started in Massachusetts, and now there are 22 state based ones in the country and two national ones are this model of helping clinicians that are not psychiatrists help their patients with a mental health condition. And so we help the clinicians by providing training and toolkits, by providing consultation with a perinatal psychiatrist, by providing, you know, linkages and connections to other behavioral health supports like therapists in the state, and by providing technical assistance to like obstetric practices, for example, and helping them, you know, develop workflows in their offices to to identify, detect, treat and get

00;08;48;13 - 00;09;19;21
Tiffany Moore Simas M.D.
patients through to symptom remission. And so this model is I liken it to sort of, you know, give a man a fish versus teach a man to fish. If, you know, the perinatal psychiatrist just treated that one patient, then they're treating that one patient and their capacity would get filled up very, very quickly. Versus if you teach me, the OBGYN, every time I pick up the phone and call the access program to treat a patient, then you've not just helped me treat that patient, you've educated me and then maybe I'm treating the next one and the next one.

00;09;19;21 - 00;09;25;17
Tiffany Moore Simas M.D.
So it's really building the capacity and thus the workforce to be able to address mental health conditions.

00;09;25;19 - 00;09;31;26
Julia Resnick
That's really fantastic. So can you talk about how providers and care team members can access the hotline?

00;09;31;29 - 00;09;53;11
Tiffany Moore Simas M.D.
Yeah, so it is we call it more of a warm line than a hotline. Hotline often means 24 seven emergency. With a warm line, it's really kind of Monday through Friday, 8 to 5 when, you know, OBGYN offices, for example, tend to be open. And it's not just OB-GYNs that can call. It's any clinician caring for a pregnant postpartum lactating want to conceive you know patient.

00;09;53;11 - 00;10;13;23
Tiffany Moore Simas M.D.
So if there's a reproductive concern during this, you know, mental health condition that needs to be treated or addressed, anybody can call. So you just literally pick up the phone and then you would be met with a resource and referral specialist. And that resource and referral specialist would get, you know, information about what you're calling for. You know, what's the general question that you have?

00;10;13;25 - 00;10;36;02
Tiffany Moore Simas M.D.
And then they would, depending on your need, if my need is, I would like to get some information about therapists in a certain area for this particular patient that's with me. Then I may just talk to the resource and referral specialist. If I have a patient that I really feel like I need to talk to the perinatal psychiatrist about their care, then the perinatal psychiatrist gets paged and the goal is for them to call me back within the next 30 minutes.

00;10;36;05 - 00;10;55;07
Tiffany Moore Simas M.D.
If when I talk to that perinatal psychiatrist, I feel like, okay, you know, we've talked about this patient. They're going to guide me in the care that she needs, and I'm good with that. And that's great. If at the end of that conversation, I say, you know, I'm really still pretty uncomfortable. I don't feel comfortable, you know, providing the care that you're recommending

00;10;55;07 - 00;11;20;08
Tiffany Moore Simas M.D.
then at least in our state, there is the option for that patient to be connected with that perinatal psychiatrist for one on one consultation. And the goal at the end of that consultation is that psychiatrist has done a complete evaluation and not just based on what I told the perinatal psychiatrist, but their actual evaluation of that patient. They can provide a concrete consultative treatment plan and then I can carry that through.

00;11;20;16 - 00;11;27;16
Julia Resnick
That's great. And at what point during pregnancy can you can you call this this warm line? Is it any point?

00;11;27;19 - 00;11;48;19
Tiffany Moore Simas M.D.
Any point. And it's not just pregnancy, it's any time in pregnancy, any time in postpartum, which is that year after childbirth. If they're lactating beyond that year childbirth, they're still eligible or if they're planning to conceive, have a mental health condition and, you know, some consultation around like would it be appropriate to continue this medication regimen or what have you.

00;11;48;24 - 00;11;51;06
Tiffany Moore Simas M.D.
And most of the time, it often is.

00;11;51;08 - 00;11;57;05
Julia Resnick
How do you train providers to ask these sort of sensitive questions to patients regarding their mental health?

00;11;57;07 - 00;12;17;28
Tiffany Moore Simas M.D.
That's a great question. I think, you know, there's a lot of stigma that comes with mental health and how you present the questions and engage in the conversation can be very important and and can dictate whether or not the patient chooses to engage with you in that conversation. So firstly, using some of these validated tools can be helpful and they're often self-administered.

00;12;18;00 - 00;12;55;29
Tiffany Moore Simas M.D.
And also our access programs and most in the access programs across across the country offer trainings. And so we can engage with providers on how to have these conversations. And we've created a lot of toolkits. And within those toolkits, not only do we provide, you know, sort of clinical guidance and recommendations, but we also provide actual verbiage on how you might pose a question around suicidal thoughts or thoughts of self-harm, which can be very hard for people to sort of initiate and vocalize. Most of the guidance and verbiage that we have provided

00;12;55;29 - 00;13;12;24
Tiffany Moore Simas M.D.
we have, you know, vetted with focus groups of persons that have lived experience with perinatal mental health conditions. And remember what things people said to them that turned them off or that felt really judgmental or what have you. And so we've incorporated a lot of that language into our suggested approach.

00;13;12;27 - 00;13;23;16
Julia Resnick
That's really wonderful. I'm also curious about how you're promoting this resource to providers that are working with pregnant people so that they know where they have resources that they can access.

00;13;23;19 - 00;13;55;09
Tiffany Moore Simas M.D.
Be very purposeful efforts into knowing every OB-GYN in the state and try to engage them in a very direct way, whether it was literally going to their offices, going to grand rounds, going to conferences and had an enrollment form like we knew everybody we talked to. And our goal was to get to everybody. We partnered with the Massachusetts chapter of ACOG and through, you know, email, communications, newsletters, conferences, any sort of obstetric related professional society we worked through.

00;13;55;12 - 00;14;10;09
Tiffany Moore Simas M.D.
And now, for example, there is a section about perinatal psychiatry access programs in the ACOG clinical practice guidelines that just came out in June regarding detection and treatment of perinatal mental health conditions.

00;14;10;11 - 00;14;24;11
Julia Resnick
So I know earlier you talked about how there are some populations that are at higher risk for experiencing perinatal mental health disorders. So how are you all taking health equity in to consideration when you're developing this program?

00;14;24;13 - 00;14;52;24
Tiffany Moore Simas M.D.
More recently, over these past years, we've really focused on equity inequities or disparities in persons who are socioeconomically disadvantaged or marginalized by racism have higher rates of these conditions, yet lower rates of detection and treatment. And if we look very concretely at our data, we know that in Massachusetts there's about 72,000 deliveries a year. We know that one in six or seven will have depression anxiety.

00;14;52;24 - 00;15;17;07
Tiffany Moore Simas M.D.
So that's about 12,000. And MCPap for Moms serves about 3,000 patients a year. Almost 25% of the population of patients in the state we could serve. And then if you look at the breakdown of that, for example, the payer mix of those for whom we've provided services. It correlates very closely with the payer mix of the perinatal individuals in the state.

00;15;17;09 - 00;15;26;00
Tiffany Moore Simas M.D.
We recently added to some of the demographics we collect very specifically collecting information about race, ethnicity and other social determinents of health.

00;15;26;02 - 00;15;37;01
Julia Resnick
And I'm sure that things are ever evolving. But I'm also just really interested in the impact of this and how, you know, you're making how do you know you're making progress and what data and metrics are you tracking?

00;15;37;04 - 00;16;00;16
Tiffany Moore Simas M.D.
Yeah, also that's a great question. And similarly, this has been an evolution. Our early metrics were basically like, were people willing to sign up for our trainings? Were we able to get them to engage in the program? How many people called us who were actually utilizing the program? We published a couple of papers early on as it related to that kind of the utilization and the acceptability of clinicians in using these services.

00;16;00;23 - 00;16;21;06
Tiffany Moore Simas M.D.
We recently just finished a five year CDC-funded grant, very specifically looking at, you know, does this make a difference? And so we did a systematic review. It was led by my partner, Nancy Byet. I was the lead author on it back in the 2015 timeframe in the Green Journal, which is the obstetrics and gynecology journal for us.

00;16;21;08 - 00;16;47;27
Tiffany Moore Simas M.D.
And we looked at in that in that systematic review, what is the likelihood of treatment, initiation and treatment sustainment? If you look at that, the likelihood of treatment initiation is less than 25%. So when we look at the study that we did and looked at the MCPap for Mom's program, 43 to 52% of people in the program initiated treatment and 20-25% sustained treatment.

00;16;48;04 - 00;17;17;01
Tiffany Moore Simas M.D.
In a systematic review, less than 25% initiated treatment. And with the MCPAP for Mom's model, 43 to 52%. So a doubling initiated treatment and the systematic review 0 to 1% sustained treatment. So we're seeing marked improvements, which is wonderful. And you asked a question earlier about opportunities, but they're still half people who aren't initiating treatment, who are getting treatment, initiation and, you know, 0 to 1% sustainment up to 20, 25%.

00;17;17;01 - 00;17;34;00
Tiffany Moore Simas M.D.
That's a great marked increase. And still right that 75 to 80% that don't have sustained treatment. And we don't know that they're getting to symptom remission. So we have evidence that this model is working and we have evidence that we have more to do.

00;17;34;02 - 00;17;58;24
Julia Resnick
Addressing maternal mental health in America as an ongoing process. Clinicians need the knowledge to detect patients symptoms and connect them with treatment and support. Every case looks different and providers may feel like they're stumbling in the dark. That's why Dr. Moore, Simas and her colleagues at UMass Memorial are dedicated to shining a light on perinatal depression and taking their work beyond the walls of their hospital and community

00;17;58;27 - 00;18;17;29
Julia Resnick
with Lifeline for Moms. She talked to me about how this project grew out of MCPAP for moms and how they are taking this movement nationally. So when you look back over the past ten years, what has been working well and are there any stories about this program that can really bring it to life for our listeners?

00;18;18;01 - 00;18;42;10
Tiffany Moore Simas M.D.
You know, when I started doing this work as an OBGYN and going out to my fellow OB-GYNs, I would hear things like, I'm an OBGYN not a psychiatrist. In the past ten years, that narrative has changed markedly, especially considering that perinatal mental health conditions are the overall leading cause and the overall preventable leading cause of maternal mortality.

00;18;42;10 - 00;19;05;29
Tiffany Moore Simas M.D.
So it is, you know, not acceptable to say, as women's health care providers, as providers of pregnancy and postpartum care, that mental health is not ours to deal with. It's all of ours to deal with. I think the last ten years is also seen a lot of support through professional societies and governmental organizations in agreement on we should be screening. In agreement on

0;19;06;05 - 00;19;33;20
Tiffany Moore Simas M.D.
we need to screen in contexts that take it beyond screening to actual treatment and a lot of new resources around that. And then for these programs, right, ten years ago, we were the first. Now there's 22 states with programs and there's two national programs. So we're seeing more attention to this. We're seeing more ownership of this by prenatal care providers in general, and we're seeing more resources and more of these programs.

00;19;33;23 - 00;19;40;26
Julia Resnick
That is really great. And last but not least, what's next for UMass Memorial in this space? What are your plans for the future?

00;19;40;29 - 00;20;07;25
Tiffany Moore Simas M.D.
That's a great question. I'll go back to you know, there's evidence that this program works and yet there's still more to do, right? There's still plenty of perinatal individuals who are suffering in silence, who have been screened and maybe are not getting the ready access to care that they need and or have not really achieved symptom remission. And there remain disparities and inequities across that spectrum.

00;20;07;25 - 00;20;21;19
Tiffany Moore Simas M.D.
And so until we can say 100% of people been screened, 100% of people have been identified, 100% of people have access to treatment and or have achieved symptom remission, we will have more work to do.

00;20;21;21 - 00;20;49;08
Julia Resnick
While our health care system is certainly making progress at identifying, addressing and de-stigmatizing perinatal mental health conditions, we still have a long way to go to reach the goal of 100% identified and treated. The AHA is grateful to have physicians like Dr. Moore Simons championing the cause. If you're interested in learning more about Lifeline for Moms, you can find their website at umassmed.edu/lifeline4moms, with the number four.

00;20;49;10 - 00;21;18;23
Julia Resnick
That's umassmed.edu/lifeline4formoms. Providers can access the hotline at 508-856-8455. AHA’s growing library of resources on improving maternal mental health can be found at www.aha.org/betterhealthformothersandbabies. Thank you for tuning in to this episode of Beyond Birth Advancing Health Podcast.