Protecting New Moms From Mental Health Crises

After becoming pregnant 11 years ago, researcher Kara Zivin, PhD, had a near-fatal struggle with mental illness.

“I stared down my delivery date … as if looking straight into the barrel of a gun,” she said.

Zivin, a professor of psychiatry and obstetrics and gynecology at the University of Michigan Medical School in Ann Arbor, shared her story during an online briefing hosted last week by Health Affairs, where she and fellow panelists discussed strategies to help protect pregnant individuals in mental health crises, as well as their infants.

Before learning she was pregnant, Zivin kept her depression and anxiety at bay using a low-dose antidepressant. She was a busy researcher at the time trying to secure tenure, and had a long-standing fear of pregnancy, delivery, and new motherhood. While she knew of the risk of relapse, and of her own family history of perinatal mental illness, she wanted a medication-free pregnancy.

At the end of her first trimester — as her depression, anxiety, and insomnia grew worse — she reached out to a psychiatrist and mentor. “I had become convinced that if I could just delete myself, my husband, stepson, and son would go on without me,” she said.

With convincing, she restarted medication, but this time none of the pills or therapy helped. Still pregnant, and “in the fog of illness,” Zivin tried to end her own life with an overdose, she said.

Two days later she gave birth to her son, at 35 weeks and 5 days, who was taken to the neonatal intensive care unit while Zivin was moved to an inpatient psychiatric unit.

Six weeks after giving birth, she began electroconvulsive treatment (ECT), which worked almost immediately, she said. While ECT continues to be controversial, and she experienced some short-term memory loss, “it also represents one of the most effective treatments for treatment-resistant depression,” she wrote in an essay detailing her account for the October issue of Health Affairs.

Years after her experience, Zivin shifted her research focus to perinatal health and just last year shared her story publicly for the first time.

Mental Health of Mothers

One in five pregnant or postpartum people has been diagnosed with a mood or anxiety disorder, said panelist Jennifer Moore, PhD, RN, an assistant research professor at the University of Michigan in the Department of Obstetrics and Gynecology. Moore and Zivin, co-authored a paper in the latest Health Affairs on policies that aim to improve the prevention, diagnosis, and treatment of perinatal mental illness.

During the perinatal period, mothers are more at risk for depression and medication discontinuation, as well as addiction recurrence, overdose, and death, Moore explained. Perinatal mental illness also increases the risk of morbidity and mortality, as well as the potential for preeclampsia and cesarean birth.

A mother’s mental illness can also lead to adverse outcomes for the child, including preterm birth, low birthweight, fetal growth restriction, need for neonatal intensive care, poor cognition, and disruptions in infant attachment.

One of the challenges in addressing perinatal mental health is a lack of screening, said Moore. While mandatory screening has helped to identify patients with mental health concerns, pregnant people with mental health problems are less likely to use mental health services. Stigma and shame also contribute to the problem, and well-coordinated follow-up care by clinicians is limited, she noted.

Strategies to Help Moms in Crisis

To help address, prevent, and treat perinatal mental health problems, Moore outlined several policy solutions:

Extend Medicaid benefits for at least 12 months postpartum: An extension of “comprehensive perinatal care would ensure access to services, including prevention and treatment for postpartum depression and chronic conditions that are essential for the well-being of people and their infants,” she said.

Support co-location of care: Most mothers receive postpartum care at a different site from their infants. “Same-day, same-location appointments for the postpartum individual and infant reduces barriers to accessing care,” said Moore.

Cover evidence-based community-centered models of care: Doulas and other community-based maternity care professionals can flag signs of maternal depression during home visits and often provide “culturally congruent support,” she said.

Continue expanded telehealth services: The COVID-19 pandemic triggered new, more-flexible telehealth policies allowing a safer, more convenient way to engage in healthcare — including behavioral healthcare — but it’s unclear which of these policies will remain after the pandemic ends.

Enhance data, research, and accountability: Better data would help researchers to understand challenges related to perinatal mental health conditions, to better target interventions, and to hold the healthcare sector accountable for improvements, Moore said.

Implement policies that support families: Untreated maternal depression can lead to absenteeism, lower productivity, job loss, and difficulty returning to work. “Lack of paid family leave during this period negatively affects families’ economic security, but more importantly their physical and mental health,” Moore said.

For her part, Zivin, speaking as a survivor and a researcher, acknowledged her “extreme fortune and privilege” in having access to both healthcare and paid family leave and stressed her support for the paper’s recommendations.

Mother and Baby Units

In a separate essay in the latest Health Affairs, Zivin offered “complementary suggestions” around helping mothers in crisis, including support for perinatal psychiatry mother-and-baby units. (The issue includes an in-depth look at this more “humane” approach to care, which has become the “gold standard” in England and several other countries.)

Instead of separating infants from mothers with mental health problems — a practice that Zivin argued does a disservice to both mothers and infants with respect to bonding and development — these facilities allow joint inpatient admissions. “That [idea] never occurred to me and never was brought up as an option for me when I was struggling … earlier in my pregnancy,” she said.

Zivin also stressed the need for more education so clinicians and families understand that perinatal mental illness is not just postpartum depression, but can also include anxiety, insomnia, post-traumatic stress disorder, bipolar disorder, and psychosis. That lack of understanding and awareness can leave families feeling “isolated, ill-informed, confused, and unsupported,” she said.

She also called for better data collection to try to capture a more accurate picture of the public health burden of perinatal mental illness. Maternal mortality review committees and researchers tell part of the story, but because the data are not gathered in a systematic way, she suspects that the true cost of these problems have been underestimated. (Untreated perinatal mental health conditions experienced during pregnancy or the first 5 years of a child’s life “carry a societal burden of $14 billion per year in the U.S.,” Moore noted.)

Additionally, Zivin urged support for policies and environments that “make it safe for individuals to disclose suicidal feelings.” She never shared her own thoughts of suicide because she feared being hospitalized. Others have encountered “worse fates,” including being imprisoned and losing custody due to their own suicidal behaviors during or following pregnancy, she said.

“We must treat mental disorders, including suicidality and substance use, as medical conditions requiring care and support, rather than reasons for punishment,” said Zivin.