Collaborative Care for Perinatal Depression: A Value-Based Approach BY C H R I S TO P H E R R E I S T, M D
Perinatal depression (PPD) is a common but underdiagnosed complication of childbirth that affects up to 23% of women. It is associated with pregnancy complications, impaired maternal-infant bonding, and a host of other negative consequences for both mother and child. The suicide death rate has been estimated to be between 2.0 and 3.7 deaths per 100,000 live births,1 making suicide a leading cause of maternal mortality in the first 12 months postpartum. PPD often goes unrecognized because changes in sleep, appetite, and libido may be attributed to normal pregnancy and postpartum changes. In addition to healthcare providers not recognizing such symptoms, women may be reluctant to report changes in their mood. In one small study, less than 20% of women with postpartum depression had reported their symptoms to a healthcare provider. Less than 5% of women with PPD experience spontaneous remission of their symptoms, suggesting that nearly 95% of women with PPD require treatment.
ECONOMIC IMPACT OF PPD As awareness of the widespread prevalence of PPD has increased, so, too, have efforts to examine the financial costs of this disorder. Researchers using a cost-of-illness model to estimate the five-year costs related to perinatal mood and anxiety disorders found the total sum of all costs amounted to $31,800 per mother-child pair and $14 billion for the U.S. as a whole.2 This model allowed for the consideration of a range of costs, from those associated with suboptimal breastfeeding to the societal costs of maternal suicide. While this study focused on long-term economic burden, a recent report examined the more immediate impact on households in the first year of the child’s life. A study by Epperson3 showed that mothers with PPD had significantly higher annual direct total all-cause medical and pharmaceutical spending than matched controls without PPD ($19,611 versus $15,410), driven primarily by more outpatient visits.
26 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS
Spring 2022
When examined more broadly, however, PPD had an impact on the entire household, not just the affected mother. This translates into significant all-cause family medical and pharmaceutical spending during the first year following childbirth ($36,049 versus $29,448) and an average of 16 more outpatient visits than unaffected households.
IMPLEMENTING ROUTINE SCREENING
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Implementation of Collaborative Care lags far behind the substantial body of empirical evidence that supports its use.”
In the search for valuebased care, addressing these maternal mental health needs represents an opportunity to alleviate not only the humanistic burden on a household, but also the substantial household economic burden that goes beyond costs incurred by the mother.
Screening for PPD in primary care settings—the first step to address this public health problem—is currently very sporadic. A study by Sidebottom4 found that prenatal and postnatal screening occurred in less than two-thirds of mothers. There was considerable variation associated with race and income level. In 2016, the U.S. Preventive Services Task Force changed its recommendation for routine depression screening to endorse depression screening in the general adult population, including in pregnant and postpartum women. The American College of Obstetricians and Gynecologists also recommends that obstetric care providers screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.5 A full assessment of mood
