Just last week, an influential government-appointed health panel, the Unites States Preventive Services Task Force, issued recommendations that women should be screened both during and after pregnancy—to detect signs of depression, which studies suggest affects at least one in eight women during or after pregnancy.
But detecting such depressions may be the easy part. The hard part is treating it, some experts say, and paying for that treatment.
“I hope this recommendation will galvanize a larger conversation around the issue,” said Dr. Samantha Meltzer-Brody, the director of the perinatal psychiatry program at the University of North Carolina at Chapel Hill. “But we need to look at the big picture—If every place is going to screen, they’re going to have to offer good services too.”
At the University of North Carolina, mental health providers are embedded in the psychiatry and pediatric wing—and they take Medicaid. According to Meltzer-Brody this should be the model everywhere: psychiatrics working with the pediatricians and ob-gyns. “You also need to have an adequate number of psychiatrists who take a wide range of insurance, like Medicaid,” she said. However, as she pointed out, New York, despite having so many psychiatrists, has a shortage of those who take insurance. “There are many mental health providers in New York, but most are privatized,” she said, “which means you can get care, but it’s very expensive.”
Olivia Bergeron, based in both Manhattan and Park Slope, is a social worker who has experience in working with mothers diagnosed with postpartum depression and mood disorders. “The screening costs are minimal and covered by insurance,” she said. “But the problem is about the treatment—how can women afford the services they need after diagnosis?”
Bergeron does not take insurance. “Many therapists and social workers don’t. It’s extremely time consuming and I don’t have a billing person,” she said, “I’d rather spend that time on a client.” She operates on a sliding fee scale depending on patients’ incomes, where one hour of therapy can range from $30 to $400.
Studies suggest that during or after pregnancy, at least one in eight women—and as many as one in five—develop symptoms of depression, anxiety, obsessive-compulsive disorder, or a combination.
New York City has been ahead of the wave on screening. In November last year, First Lady Chirlane McCray announced that New York would screen every pregnant woman and new mother for maternal depression. Mayor de Blasio said that screening for maternal depression “should be a part of routine care.”
In New York and everywhere, the new recommended screening can be done by any trained health provider, including obstetricians and pediatricians—the doctors who tend to see women most often during and after pregnancy. The most prevalent screening method is the 10-question Edinburgh Postnatal Depression Scale, which is covered by the Affordable Care Act, but the new recommendation makes coverage even clearer. The recommendations make coverage of screenings possible but are less clear about the services accessible after- in terms of both mental health providers and insurance.
Beth Halpern is a psychologist based in Brooklyn Heights who counsels mothers struggling with perinatal mood disorders, encompassing depression and anxiety-related issues. While she sees a pro-bono client every week and tries to accommodate more clients along a sliding-fee scale payment model, she agrees that it’s hard to get coverage for private therapy. “I don’t take insurance,” she said. “It’s very arduous—all the paperwork and caps on hours that dictate when and how often you can see your patient.” She isn’t a provider for any of the New York based health insurance plans as “it’s difficult for a solo practitioner—there’s no administrator or staff to go through all the insurance paperwork.”
She pointed out that a mother who qualifies for Medicaid can go to a clinic and see a good provider, but from her experience, “It’s not always ideal for the mother—it’s hard to mobilize and the waiting lists can be endless so the process of getting help can be time consuming in itself.” The amount and kind of mental health services a person can access is largely dependent on their insurance plan and, as Halpern pointed out, “usually there is a cap on your health insurance plan, which varies greatly and affects the time you can spend with a patient.”
Back in April of last year, the Centers for Medicare and Medicaid Services (CMS) announced a proposal to combine mental health and substance abuse disorder benefits for low-income individuals, by collaborating with private health insurance plans. The proposal draws on specific provisions of the Mental Health Parity and Addiction Equity Act of 2008 to Medicaid and Children’s Health Insurance (CHIP). In June 2015, the Behavioral Health Parity in conjunction with Medicaid required all Medicaid managed care organizations to provide mental health services in parity with medical/surgical benefits.
But as Halpern and Bergeron point out, compensation for mental health therapists has dwindled to the point where few will take insurance, many preferring out-of-pocket coverage.
Molly Peryer struggled with postpartum depression and anxiety during her last month of pregnancy when she was carrying her first child. “What is worse in our culture than the idea of a bad mom?” Peryer asked. “We’re terrified of being given that label.” Five months after the birth, she decided to get help. Now she and her partner, Chris Lindsay-Abaire, run Brooklyn PPD Support. In 2006, the two moms—who both struggled with postpartum depression—established a peer support group in Brooklyn as a place where pregnant and postpartum women can get help. “I started the group because I wanted to go to something like this and there wasn’t one,” she said.
In her monthly group meetings in Brooklyn, Peryer would find that many mothers would find the discussions extremely helpful. “These women need to be able to talk in a stigma-free environment. Often, I’ve seen mothers voice their feelings for the first time in the group. Many repress their thoughts in fear that talking about it would mean their child might get taken away,” she said. Halpern, too, believes that support groups like Brooklyn PPD Support are an integral part of the treatment process—“I wish there were more support groups in Brooklyn.” But while the group is a helpful support unit, it doesn’t meet all the treatment requirements.
Peryer has a list of local mental health practitioners that she refers her clients to. But, money is an added source of anxiety for many of these mothers. “There’s nothing worse than having a woman come to the group and me tell her all the things she needs to do to get better, only to have them look at me and say, ‘I can’t afford any of that’,” Peryer said. Peryer herself paid out of pocket for her treatment and it was an added cost. “Many women take time off from their jobs when they have a baby or they become stay at home moms,” she said, “So the additional expense of treatment often prevents them from seeking out help.”
The new recommendation is certainly forcing the issue of screenings, but a larger problem remains—the huge gap in the range of services afforded by the wealthy people and the lack of options for the less well off. As Meltzer-Brody pointed out, unless these screenings also push for more coherent and comprehensive insured mental health services within hospitals, the well-intentioned thought behind it may never be fully realized. “That’s still something we need to work on,” she said, “developing services that are affordable.”
Further, Bergeron hopes that this recommendation will be “critical in getting the word out to pediatricians and obstetricians to do more screenings.” Jada Shapiro, founder of Birth Day Presence in Brooklyn and an experienced doula, agrees. “The big issue is not just regular screenings, rather it’s the disconnect between the care providers. We need more pediatricians in the area to administer screenings for mothers.” While the pediatrician’s realm of expertise is the child, they are the ones who see the mother the most after pregnancy. “The mother and the baby are a unit, it’s that simple,” she said.
At Premier Pediatrics, a program about to launch in May, “The First Month,” is hoping to bridge this gap. Jon Sarnoff, a pediatrician who works in Manhattan and Brooklyn, hopes the program will engage the pediatric community to regulate depression screenings for mothers. According to Sarnoff, the program will have three major components—provision of lactation rooms and pumps (there’s been a link between nursing and feelings of empowerment), educational resources made available to both mothers and fathers, and carrying out screenings. “We will also work with a network of ob-gyns so that the mothers are in more regular contact with them after the screenings,” he said, “for example, have the ob-gyn call and check in, in case the mother doesn’t.”
But once again, it all comes down to money. Sarnoff said that the biggest challenge his group is facing is working around the cost structure—“How do we help out the mom who really needs therapy but doesn’t have the insurance coverage? That still remains unresolved.”