This post is part of “Mental Health: The Missing Piece in Maternal Health,” a blog series co-hosted by the MHTF, the Mental Health Innovation Network at the London School of Hygiene and Tropical Medicine and Dr. Jane Fisher of Monash University.
Have you ever been in a position to really help someone, only to have them refuse your help? Has this happened to you with one of your pregnant patients?
Whether she shows signs of anxiety or depression during her prenatal care visit, your patient may be reluctant to ask for or accept help. She might not even realize she would benefit from additional support.
A recent study of 1,000 mothers in the UK found that the stigma attached to mental illness stopped pregnant women from seeking treatment and support for their depression. The UK BabyCentre survey found that 44 percent did not seek help because they did not want to be labelled as mentally ill.
While this statistic is alarming, there is some good news. In January, national experts on the U.S. Preventive Services Task Force issued new guidelines recommending all women be screened for depression during pregnancy and after giving birth. These recommendations reflect new studies that contradict the common belief that women only develop depression after the baby is born.
In fact, mental health challenges can impact all stages of pregnancy and post-pregnancy. According to the Centers for Disease Control and Prevention, mental health conditions including depression and anxiety are common among pregnant, postpartum, and nonpregnant women of reproductive age. Screening is a fundamental first step. Women with behavioral health conditions who become pregnant face immediate challenges to managing their health and ensuring proper prenatal care.
Lisa, a 24-year-old who suffers from several mental health conditions along with diabetes, exemplifies the complexities intrinsic to maternal and mental health. . When Lisa became pregnant and began to see an OBGyn in a high-risk clinic, providers screened Lisa for depression. They learned she had a history of depression, bipolar and schizoaffective disorder. She missed many prenatal appointments. Lisa was paired with a community health worker (who we call “Advocates”) because of her chronic mental health conditions and her struggle to follow through with her prenatal care. Because a case manager had advised her to stop taking them due to pregnancy, Lisa was not on any psychiatric medication at that time. Without medication, Lisa’s depression increased. Her biggest obstacle to care became her deep distrust of doctors and the health care system despite providers’ attempts to establish a collaborative and trusting relationship with her.
The clinic social workers struggled to connect with Lisa. Her behavior, including making inflammatory comments while at the clinic, alienated her from clinic staff and worsened the situation.
It is a complex decision whether to prescribe psychotropic medications to manage a pregnant woman’s mental health challenges. The American College of Obstetrics and Gynecology issues recommendations based on the evidence that exists and the consensus of expert opinion. The recommendations consider the impact of the medications on the fetus as well as the implications on the mother’s:
- Compliance with prenatal care,
- (In)adequate nutrition
- Exposure to alcohol or tobacco use
- Mother-infant bonding
- Disruption in the family environment
There are no definitive answers. Often, pregnant women with mental health conditions stop their medications, either on their own or based on the advice of health care providers who may or may not be reviewing recommended guidelines.
In Lisa’s case, the decision to stop taking medications was devastating. Sharon, her Advocate, worked diligently to build a trusting relationship with her so that Lisa could take care of herself more effectively. Sharon supported Lisa’s goals and advocated for her needs. Sharon was also clear that she wanted to help Lisa engage with her prenatal care and attend appointments. Sharon visited Lisa in her home and discussed the types of support available. Together, they developed a plan for managing her pregnancy and mental health conditions and staying in regular contact. With Lisa’s consent, Sharon shared Lisa’s trust concerns with the clinic staff and worked with them and the Medicaid and behavioral health insurance case managers to address them.
Eventually Sharon was able to help Lisa understand better dietary choices to manage her diabetes and connect her with a psychiatrist who prescribed medications post-partum. Lisa re-engaged in prenatal care and attended appointments prior to the birth of her child. Lisa attended her post-partum appointment and has continued with her therapy and medications.
It is critical for health care providers to know the mental health status of their patients. Knowing these diagnoses helps them answer important questions: How can providers adequately support pregnant women with mental health conditions? How can providers respond when pregnant patients’ symptoms make it challenging for them to seek treatment and remain engaged in their prenatal care? How can providers ensure pregnant women receive qualified guidance on psychiatric medications during and after pregnancy? Community health workers can address these needs by providing non-clinical support and bridging the gap between pregnant women with mental health conditions and their care providers.