Most moms on Medicaid who screen positive for depression don’t get follow-up care

The usually upbeat and energetic mother surprised me by screening positive for postpartum depression at her 2-month-old daughter’s well-child visit. After reviewing the screener, the mom, who I’ll call Dana, tearfully revealed a common refrain I hear from so many mothers: she was feeling overwhelmed. Overwhelmed by her responsibilities as a new mother, by caring for her aging parents, by the feeling that her partner was not supportive, and by juggling the demands of work and home. We discussed how her feelings might be related to postpartum depression. I put her in touch with our onsite social worker and provided her with a list of community mental health resources.

But that might not be enough. Recent research conducted by myself and colleagues at PolicyLab at Children’s Hospital of Philadelphia, suggests that despite identifying Dana’s depression and pointing her to helpful services, the odds that she will receive the mental health care she needs are quite low.

Postpartum depression is common, affecting between 10 and 15 percent of all women, with higher rates seen in mothers with low incomes and less education. In addition to the direct effects of depression on the mother, untreated postpartum depression can negatively impact infants’ cognitive and socio-emotional development. Mothers with postpartum depression are also less likely to breastfeed and heed infant safety practices like using car seats. In other words, helping moms stay healthy helps the whole family. That’s why the American Academy of Pediatrics (AAP) recommends routine screening for postpartum depression at infant well-child visits and just last month expanded that commitment to include repeat screening over multiple visits during infancy.

We found that in the six months after screening positive for postpartum depression, only about one in 10 mothers referred for mental health care had even one mental health visit. 

As a primary care pediatrician, I’ve noticed that many of the mothers who screened positive for depression at their visits struggle to receive follow-up mental health services. As a researcher, I wanted to know if my anecdotal experiences were matched by data. My colleagues and I conducted a study utilizing a unique dataset that linked infants’ medical records with mothers’ Medicaid claims to answer the question of whether mothers who screen positive for postpartum depression at infant well-child visits ultimately receive mental health services.

We found that in the six months after screening positive for postpartum depression, only about one in 10 mothers referred for mental health care had even one mental health visit. Additionally, mothers without a recent history of depression were even less likely to receive mental health services. That suggests it’s especially challenging for mothers who did not already have a connection to mental health care to find services after they give birth.

Screening is an essential first step for identifying postpartum depression, but as our research makes clear, it is not sufficient for ensuring mothers receive the care they need. While this study did not explore why mothers aren’t accessing mental health care, from what I have seen in my clinical practice, there are many barriers to care during this challenging time. For instance, a new mother like Dana must figure out transportation to the mental health facility and arrange child care for her infant during the appointment time. And the depression itself may cause her to feel less motivated to seek care, while the perceived stigma of postpartum depression may make her fearful of admitting she needs help. After deciding to take the step to get care, she may have difficulty finding a provider with expertise in postpartum depression, face long wait times for appointment availability or even experience a lapse in her insurance coverage. Given all of these barriers, not to mention the routine demands of caring for an infant, it is no wonder that so few low-income moms are receiving mental health care in the postpartum period. 

My colleagues and I are using this research as an opportunity to reframe our thinking about the best ways to support mothers in seeking and following through with treatment. In addition to a commitment to screening, we also need innovations in how we make referrals and deliver treatment. For example, research has shown that using community health workers to educate families about postpartum depression and how to navigate the health system helped mothers get mental health care. Alternatively, placing adult mental health providers within pediatrics or providing care in the home can help address transportation and child care challenges.

For many new moms, seeing me during their babies’ well-child visits are their only meaningful interaction with the health care system. By exploring new, innovative ways to provide support in pediatric settings, we can do more to help moms like Dana get the care they need to help themselves and their children thrive.

Stacey Kallem is an instructor at PolicyLab and teaches pediatrics at the Children’s Hospital of Philadelphia (CHOP) and the Perelman School of Medicine at the University of Pennsylvania.