The February, 2011 issue of Health Affairs has published a study entitled “New Jersey’s Efforts to Improve Postpartum Depression Care Did Not Change Treatment Patterns for Women on Medicaid”. The title of the article, authored by Kozhimannil, Adams, Soumerai, Busch and Huskamp, is curiously conclusive in its declaration of outcome for this population of Medicaid women, given subject exclusions which considerably weaken its limited findings and an overall perspective which I feel lacks understanding of New Jersey's Maternal Child Health consortia system and demographics of those served.
Also absent from the study’s context are current legislative and clinical references which would have provided more context for the study’s structure, subject selection, policy recommendations and conclusions. Given the involvement of public health policy makers/advisors associated with several major U.S. institutions, this narrow context is surprising.
For starters, the population of Medicaid recipients chosen to participate in the study was taken from an initial group of 103,414 women, all of whom gave birth between July 1, 2004 and October 31, 2007 to a final group of just over 30,000, less than a third of those receiving Medicaid while pregnant/giving birth. No other groups in the state of New Jersey who may have benefited from its initiatives were included.
The women who made it to the final study group had to have had deliveries covered by Medicaid and the mothers had to have had continuous enrollment in Medicaid for at least six months before and one year post delivery. Therefore, the study noted that “many women were excluded from the study based on the continuous Medicaid coverage requirement."
The study also excluded women who were suffering from bipolar disorder (an illness which may have its first presentation or exacerbation of symptoms in the postpartum), and schizophrenia. It further excluded another 1,193 women who were receiving medication during pregnancy in order to “distinguish new cases from ongoing illnesses." It is never explained why this exclusion was necessary to evaluate the effectiveness of screening programs designed to reach out and support new mothers regardless of when their illness developed.
Women already suffering from perinatal illnesses or other mental disorders are among those at highest risk for the development of additional or exacerbation of pregnancy related mood disorders. Indeed, the study acknowledges that many cases of depression begin during pregnancy yet it faults a delivery system which may have been treating the same population it chose to exclude from assessment of effectiveness.
How did the study developers decide which women already suffering from mental illness were to be excluded? Such eligibility was measured on the basis of prescriptions filled and covered by Medicaid; no clinical data on symptom development or presentation was considered. For example, if a woman was taking prescription medication for anxiety during pregnancy--a risk factor for PPD--she was excluded from the study. In this writer’s opinion, the significance of these exclusions is not given appropriate weight.
In addition, Medicaid recipients include those who may have immigrant status who are often reluctant to enroll or who do so for brief periods of time. Therefore, many may drop out of such programs or decline to enroll in the first place. None of the New Jersey Maternal Child Health Consortias exclude access to services for women who do not have Medicaid insurance. Therefore, these high risk women who are served by these programs are not represented at all.
The study’s comment that perhaps women not on Medicaid or those in more affluent areas may have been the better beneficiaries of this program cannot be substantiated by any data presented in this study and fails to acknowledge the outreach made to New Jersey's most vulnerable populations by the Hudson Perinatal Consortia, or the Atlantic City Cooperative, both of which are community based programs reaching out to those at highest risk.
As public health policy makers understand, when one is targeting a public health crisis, initial goals include raising public awareness, educating the professionals who will be charged with the targeted population’s care and inclusion of all stakeholders. The study references the aggressive training program initiated in New Jersey which included health care professionals from several disciplines.
But the study did not cite the training offered to social workers and psychologists--the professions that will most often be charged with performing the mandated assessments. It failed to reference the availability of a list of those trained which is maintained by the consortia, is available to all health care facilities and which offers associated health care professionals a well-trained reference base for referrals.
It is agreed that state or agency funding of payment for such assessment could be an additional inducement, but such reimbursement does already exist within some consortia. There is no proof offered in this study that lack of state funding for assessment negatively impacted the availability, access to help or willingness of associated mental health professionals to offer services.
This author further agrees that it is more likely that medical providers, who would prefer not to be in the business of mental health, would be more encouraged to identify and assess women for perinatal mood disorders if a referral base is associated with such compliance is readily available.
Finally, the study’s suggestion that mandated screening be partnered with policy to ensure compliance is well intended and supported by this writer. However, a recent historical perspective and review of this policy would have yielded evidence of the strong controversy which continues to surround this issue.
Mandated screening is not included in the federal legislation because it failed to find sufficient support for passage. Indeed, the federal PPD legislation included in the Patient Protection and Affordable Healthcare Act asked for a study to further determine the effectiveness of screening and seeks to fund many other programs (included concrete services) supportive to women suffering from postpartum depression. It does not mandate screening.
This author continues to support and encourage states to develop new PPD awareness and treatment policies, programs and mandates and appreciates the well-intentioned efforts of the study’s authors to also encourage such exploration. As each state’s population presents unique features which require adjustment to maximize responsiveness and effectiveness, the study’s suggestion of developing focus groups, use, access, means and needs studies is well appreciated.
But it is hoped future studies will take more care to allow current clinical, legislative, economic and program relevance to inform study structure, subject selection and policy recommendations. A better understanding of New Jersey's Consortia systems--whose programs vary in targeted response to the needs of demographics--would also have provided better context for this study. New Jersey's groundbreaking initiatives led by Richard and Mary Jo Codey continue to galvanize a country, long deaf to the suffering and needs of maternal mental health.