Gold Award: Building the Capacity of Frontline Providers to Treat Mental and Substance Use Disorders Among Pregnant and Postpartum Women

For many years, several broad-based coalitions of professional and consumer stakeholders had encouraged policy makers in Massachusetts to address the problem of untreated perinatal depression. By 2013, a sense of urgency about the extent of the problem had begun to develop. “It was clear that frontline health care providers by and large did not have the resources and supports needed to address mental and substance use disorders among perinatal women,” said Dr. Byatt, “and the majority of women went untreated.”

In July 2013, Massachusetts provided funding to develop and implement a program to respond to this critical public health issue. The program is modeled after MCPAP, a successful population-based program for delivering psychiatric consultation to pediatric settings. Like the MCPAP program, MCPAP for Moms builds mental health treatment capacity among frontline medical providers by leveraging the expertise of professionals located offsite.

A team of professionals is located at geographically distinct locations throughout the state: Baystate Medical Center in western Massachusetts; UMass Memorial Medical Center in central Massachusetts; and Brigham and Women's Hospital in eastern Massachusetts. The program employs one full-time-equivalent (FTE) perinatal psychiatrist and divides the position among five psychiatrists located at one of the three program locations. Resource and referral specialists (2.3 FTEs) are also based at each location.

The program is funded by the Massachusetts Department of Mental Health, partially through surcharges paid for by commercial insurers. MCPAP for Moms is payer blind and accessible to providers and patients irrespective of insurance. The Massachusetts Behavioral Health Partnership (MBHP), a Beacon Health Options company, administers the program, which is led by Dr. Byatt and Executive Director Marcy Ravech, M.S.W. The MCPAP for Moms leadership team also includes Associate Medical Director Leena Mittal, M.D., Lead Obstetric Liaison Tiffany Moore Simas, M.D., M.P.H., and Lead Resource and Referral Specialist Elizabeth Spinosa, L.M.H.C. John Straus, M.D., founding director for the original MCPAP, also provides ongoing oversight of the program. Each institution is reimbursed for direct and indirect expenses through annual contracts with MBHP. The program serves all pregnant and postpartum women in the state for up to one year after delivery. Because care is integrated into usual care rather than provided directly by mental health providers, costs are kept low, with the total cost of the program totaling $750,000 for fiscal year 2017–2018.

Much of MCPAP for Moms work is conducted on the telephone. Obstetricians and other frontline providers access MCPAP for Moms by dialing 855-MOM-MCPAP, a statewide toll-free phone number. Calls are first answered by a resource and referral specialist, who gathers basic information to assess the nature and urgency of the need. This information is shared securely with the psychiatrist on call. The psychiatrist then calls the provider to initiate the consultation, usually within 30 minutes.

Consultations are intended to serve as individualized, case-based education for providers. During the conversation, the MCPAP for Moms psychiatrist assesses the knowledge, skills, and comfort level of the provider, inquires about the current treatment plan, and discusses evidence-based approaches for treatment. Obstetric providers, the primary target provider population for MCPAP for Moms, are encouraged to screen for depression and anxiety by using standardized tools at the initial obstetric visit, at 24–28 weeks’ gestation, and at the postpartum visit. Responses to these screens often prompt calls to the MCPAP for Moms program.

About 61% of calls to the consultation team involve a question about a specific medication or requests for information about community resources. More than one-third of calls involve questions about the risks and benefits of medication use in pregnancy. A significant number of calls involve disorders other than depression, including anxiety, bipolar, and substance use disorders.

When telephone consultations are not sufficient to answer providers' clinical questions, MCPAP for Moms’ psychiatrists can provide a one-time, face-to-face consultation with the patient at any one of the three MCPAP for Moms’ locations. Outpatient consultations are scheduled as soon as possible, generally within two weeks from initial contact. Face-to-face consultations last approximately one hour and are followed within 48 hours by a letter containing recommendations for the provider and referred patient. The MCPAP for Moms psychiatrist does not initiate treatment. If medication treatment is indicated, this is discussed with the patient and clear recommendations are given to help the provider manage the patient’s treatment. Recommendations for and referrals to support groups or individual therapists are also common and facilitated by the MCPAP for Moms team.

Resource and referral specialists are responsible for identifying mental health services and facilitating referrals. They match patient needs to the available resources by using a database of community mental health supports and providers with expertise in perinatal mental health. The database was developed and is maintained by the INTERFACE Referral Service, a program of William James College. All referrals provided to the patient are communicated to the calling provider.

If clinically indicated during the telephone or face-to-face consultation, the resource and referral specialist can call patients directly to help them identify and schedule community mental health services. For example, if during the telephone or face-to-face consultation it becomes clear that the patient needs a psychiatrist, the consulting psychiatrist can ask the resource and referral specialist for assistance in helping the patient establish care with a psychiatric provider in the community with whom they can have a longitudinal relationship. Results of care coordination are reported back to the referring provider. For all cases in which the resource and referral specialist is in contact with a patient, there is a follow-up call approximately one month after care is scheduled, to check on progress and determine whether more supports are indicated.

Resource and referral specialists maintain close relationships with community mental health agencies and keep up with changes in wait times and availability of clinicians. If the wait time for an outpatient psychiatrist is deemed unacceptably long, depending on the clinical situation, the MCPAP for Moms’ psychiatrist can see the patient for follow-up consultation and continue to make recommendations to the referring provider until an outpatient appointment with a psychiatrist can be secured.

The perinatal period is an ideal time to screen for, assess, and treat mental and substance use disorders among perinatal women. But screening alone does not improve treatment rates or patient outcomes, said Dr. Byatt. It must be coupled with strategies that build patient, provider, and practice-level capacity to address mental and substance use disorders.

From the beginning, MCPAP for Moms worked vigorously to engage obstetric practices, conducting presentations at regional medical conferences, grand rounds, and practice-level training sessions and leveraging other personal and professional networks. MCPAP for Moms leadership developed relationships with individual stakeholders and professional societies to facilitate broad engagement. The MCPAP for Moms leadership team worked with two Ob/Gyn providers whose role is to help develop and maintain relationships with professional societies, individual providers, and leaders at birthing hospitals and practices throughout the state. Several professional societies included introductions to and information about MCPAP for Moms in their newsletters, e-mails, and other communications to their membership. MCPAP for Moms team psychiatrists proactively called individual practices, described the program, and offered to visit the practice to conduct training.

Those efforts have paid off. Enrollment in MCPAP for Moms among obstetric practices grew nearly every month between July 2014 and May 2017. Since its launch in June of 2014, MCPAP for Moms has enrolled 124 Ob/Gyn practices that together perform 77% of all deliveries in the state of Massachusetts and has provided services to 2,824 women. Of the nearly 2,111 telephone consultations performed by MCPAP for Mom providers, obstetricians and midwives account for nearly 63%, followed by psychiatrists (15%), family physicians (8%), and pediatricians (4%).

Enrollment in MCPAP for Moms for obstetric practices is free. To enroll in the program, practices must complete a one-hour training session conducted by a MCPAP for Moms consulting psychiatrist. The training provides an orientation to the program and tools for detecting, assessing, and managing perinatal depression and other conditions that can emerge during the perinatal period, such as perinatal anxiety, PTSD, obsessive-compulsive disorder, postpartum psychosis, and substance use disorders. A tool kit is also provided during the training. A separate tool kit is available for pediatricians, who may be the only medical provider many mothers see during the child’s first year of life. The tool kits are available at www.mcpapformoms.org. Booster training sessions are conducted upon request.

The MCPAP for Moms tool kit is a unique resource for identifying perinatal mental and substance use disorders, deciding whether treatment is necessary, and guiding evidence-based treatment. Each tool kit contains screening and treatment algorithms to help providers evaluate the severity of symptoms, assess which treatments may be indicated, discuss treatment options, and initiate and follow-up on treatment. The tool kit recommends that providers use the Edinburgh Postnatal Depression Scale (EPDS), a validated ten-item questionnaire for identifying women experiencing depression during pregnancy and the postpartum period. In addition to screening efforts in the obstetric environment, the MCPAP for Moms team also encourages and recommends that pediatric providers screen women for depression at one-, two-, four-, and six-month well-child visits.

Patients who score 10 or higher on the EPDS are further assessed by the provider. Clinicians are encouraged to ask open-ended questions, such as “How are you feeling about being pregnant or being a mother?” What things are you most happy about?” and “Are you able to enjoy your baby?” They should also find out if the patient has a personal or family history of depression, if she can care for herself and the baby, and if she is experiencing comorbid anxiety or any suicidal ideation.

The “Assessment of Depression Severity and Treatment Options” lists treatment options for patients based on the severity of symptoms. Women who score 9 or above on the EPDS and report mild feelings of sadness or edginess are advised to consider medication, adopt self-care measures, and seek community and social support. Women who score 14 or above and who report more serious symptoms, such as pervasive sadness or gloominess, are strongly advised to consider medication. Women who answer yes on the self-harm question of the EPDS may be at risk of self-harm or suicide and should be further assessed and have an established treatment plan, said Dr. Byatt. For these women, it is important to ask how often they have thought of harming themselves in the past two weeks, whether they have planned how to harm themselves, whether they have any intention of harming themselves, and whether they have ever attempted to harm themselves in the past.

The “Antidepressant Treatment Algorithm” provides step-by-step directions on how to introduce an antidepressant or adjust the dose of an existing medication. If a patient has used an antidepressant for four to eight weeks with little effect, the provider may suggest increasing the dose or substituting a different medication if the patient is already using a maximum therapeutic dose. The guidelines recommend using one of four SSRIs as first-line treatment, with specific instructions on the initial dose and increments for increasing the dose if necessary, including directions for use with lactating mothers. Providers are advised to reevaluate depression treatment in two to four weeks by using the resources in the tool kit. The MCPAP for Moms team is available at any time during regular work hours to provide immediate consultation regarding clinical questions that arise during screening, assessment, or treatment.

Providers are instructed to a contact resource and referral specialist at MCPAP for Moms to arrange follow-up care if needed. If a woman is already in treatment, the provider should ensure that an upcoming appointment is scheduled. At all times and with all patients, regardless of symptoms, clinicians are urged to discuss support and treatment options, including psychoeducation and community and psychosocial supports.

MCPAP for Moms has quickly earned a reputation as a national model for perinatal mental health care. The leadership has been contacted by 16 other states asking for advice on how they too can have a MCPAP for Moms–type program in their states. MCPAP for Moms is the basis for the federal Bringing Postpartum Depression Out of the Shadows Act (H.R. 3235), which was consolidated into the 21st Century Cures Act. The 21st Century Cures Act was signed into law in December 2016 and will appropriate $5 million per year for five fiscal years for other states to establish MCPAP for Moms–type programs. MCPAP for Moms has also received the national American Congress of Obstetricians and Gynecologists 2016 Council of District Chairs Service Recognition Award. These recognitions demonstrate the potential for MCPAP for Moms to help improve how we address perinatal mental health on a national scale.

“Having a baby is extraordinarily challenging,” said Dr. Byatt, “and every woman deserves support.” For some that may mean receiving psychoeducation and information about support groups. Other women may need treatment, which can include psychotherapy and medication treatment. For more severe illness, women may require more intensive intervention, including partial or inpatient hospitalization. Whatever the need, frontline providers in Massachusetts, with support from MCPAPs for Moms, are increasingly ready to help.