Improving access to perinatal mental health services: the value of on-site resources

Abstract

Perinatal mood disorders have both short- and long-term negative consequences for mothers and their babies. National organizations recommend universal screening for postpartum depression. Little is known, however, about screening and referral among women living in underserved areas with limited access to care. The objective of this report was to evaluate the utilization of mental health services in an urban, inner-city hospital following the implementation of colocated counseling services across 10 county-sponsored clinics that serve a medically underserved population. We further explored antecedents of a positive postpartum depression screen, factors associated with successful referral, and the rate of perinatal mood disorder diagnoses following universal screening. We hypothesized that integrated mental health services would improve referral rates following positive postpartum depression screening compared with historically separated services. This was a retrospective cohort study of women undergoing universal postpartum depression screening with deliveries from January 2017 to December 2019 who were compared with a historic cohort from the same population from June 2008 to March 2010. The Edinburgh Postnatal Depression Scale was used to evaluate women at their postpartum visit, and a mental health service referral was offered to women with a score of ≥13. The primary outcome was a comparison of completed referrals between cohorts with and without colocated mental health services following a positive postpartum depression screen. Statistical analysis included chi-square tests with a P value of <.05 being considered significant and adjusted multivariate analyses for perinatal outcomes associated with a positive postpartum screen. Between January 2017 to December 2019, 25,425 women completed a postpartum depression screen with 978 (4%) of those recording a positive screen. After implementation of colocated mental health counselors, completed perinatal mental health referrals significantly increased when compared with the historic cohort without colocated services (57%; 560 of 978 vs 22%; 238 of 1106; P<.001). Adverse neonatal outcomes, such as stillbirth (adjusted risk ratio, 9.5; 95% confidence interval, 6.35-14.26) and neonatal demise (adjusted risk ratio, 14.3; 95% confidence interval, 6.67-30.46), were most strongly associated with a positive depression screen. There were 122 (21%) women with a positive screen who were diagnosed with a depressive disorder in the peripartum period. There were no specific features associated with those who did or did not complete referral. One-fifth of women were referred for psychiatric evaluation following an initial evaluation, and the referral rate was associated with higher scores on the depression screen (P<.001). Utilization of mental health services following a positive depression screen more than doubled following the implementation of colocated services.