This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Over 23,000 Michigan women and their families per year are affected by perinatal mood and anxiety disorders (PMAD) —  historically known as postpartum depression. That's nearly 20% of mothers and 10% of fathers of infants. Many more cases go unreported or undiagnosed. But several innovative Michigan initiatives are working to better screen, diagnose, and increase treatment capacity for PMAD.

Although PMAD primarily impacts birth mothers, it can affect adoptive mothers, fathers, partners, caregivers, and other children in the family. In fact, PMAD is considered an adverse childhood event that can lead to attachment disorders that prevent children from achieving academic success, meaningful relationships, and emotional health throughout their lives.
Andrea Wittenborn.
"We really need to support the women who are experiencing this. But we have to think, too, about the whole context, the whole family," says Dr. Andrea Wittenborn, director of the Michigan State University Couple and Family Therapy doctoral program. "It's really important to recognize that the effects of postpartum depression are felt by the mother, but also felt by partners, newborns, other children in the house, and other important people in their lives. Partners can also experience some pretty challenging symptoms, some of which mirror those the mother experiences — experiences of helplessness, also a lot of increased stress and the emotional impact of seeing your partner suffer."

PMAD can manifest as a variety of symptoms including depression, anxiety, guilt, irritability, anger, difficulty sleeping, poor appetite, overwhelm, disconnection from the baby, and frightening, intrusive thoughts. And while the common misconception is that PMAD happens right after birth, it can emerge during pregnancy and up to two years after a baby is born.

"A lot of times, it's challenging for women because maybe they've experienced depression earlier in their life and there can be fears about how to treat it when they're pregnant," Wittenborn says.  "Sometimes women who may have been on antidepressants make decisions to go off and then experience a spike in their symptoms during pregnancy. Even if you've never experienced symptoms before, the transition to parenthood can create challenges and stress and can cause depression."

Wittenborn's project, Implementing and Sustaining Integrated Care for Perinatal Depression, provides training and technical assistance to screen and treat perinatal depression in in three health centers: McLaren Health Care in Flint and two Sparrow Health System clinics in Lansing and Mason. The project is being funded by the Michigan Health Endowment Fund.

"These sites primarily care for women who are eligible for Medicaid, and their patients are often diverse and underresourced," Wittenborn says. "We learned a lot from COVID data. Women of color, whether Black or Latina, are more likely to experience postpartum depression. People with lower incomes are also more likely to experience postpartum depression. So this project was meaningful because it helped those who were underresourced and most likely to experience symptoms."

Collaborative care model proven to help

The collaborative care model utilized in Wittenborn's project is an evidence-based model of integrated care tested in more than 80 randomized controlled trials. Wittenborn's project took a very effective practice, trained Michigan providers in how to use it, and made it widely available to Michigan families.

"There's even some data that shows that collaborative care results in an overall decrease in health care costs, so it really has a strong return on investment," Wittenborn says. "It's a team-based approach. It engages physicians, behavioral health specialists, and a consulting psychiatrist all together to care for patients with perinatal depression. It is a systems-based method for shifting the way that we think about health care."

The team working with Sparrow's clinics includes psychiatrist Dr. Leigh White, pharmacist Anne Otney, the patients' primary care providers, and counselor Emalie Karp, who works directly with the patients.
Emalie Karp, Sparrow Health System/MSU Family Medicine Residency behavioral medicine faculty member, and Amy Romain, program director of behavioral medicine, Sparrow Health System/MSU Family Medicine Residency.
Karp tells the story of a young mom with a new baby and three other children under the age of four. Her husband worked 12-hour overnight shifts and she had very little support from family and friends.

"Her depression was pretty bad," Karp says. "When I met her, she wasn't eating very much, was sleeping maybe three to four hours a night, and felt really hopeless. She had tried other medication in the past, and nothing seemed to be working. [Dr. Karen Blackman, the original psychiatrist working on the project,] was able to suggest other medication and coached the PCP on drug interactions."

Before implementing the collaborative care model at these sites, only 16% of at-risk women were being connected with behavioral health care workers.

"After we implemented it, 71% of at risk-patients are connected to behavioral health specialists," Wittenborn says. "It's quite a difference."

Training increases access to care

In Calhoun County, the Battle Creek Community Foundation (BCCF) is collaborating with Calhoun County's Population Health Alliance to offer Frontline Provider PMAD Training. The purpose of the training is to provide underserved pregnant and postpartum parents in Calhoun County with greater access to specialized mental health care screening. Other collaborators include Integrated Health Partners, Oaklawn Medical Group, Bronson Healthcare, and the Calhoun County Health Department Nurse-Family Partnership. The training is also funded by the Michigan Health Endowment Fund.
Sicily McLaughlin.
"The training itself is to educate non-behavioral health medical staff and other non-medical professionals in the area that work with parents to better recognize the signs and symptoms of perinatal mood and anxiety disorders," says Sicily McLaughlin, BCCF program manager. "We have a high number of medical and mental health care providers in the county compared to other counties, but they're not always accessible with the rates of folks in our area that are underinsured or uninsured."

The training instructs obstetricians, primary care providers, pediatricians, internists, nurses, health departments, and home visit staff on how to integrate PMAD screening into their care.

"We want to create a structure to make this new information part of routine care and standardize it across the providers that we have in the area," McLaughlin says. "We want to empower providers and non-providers who work with families to help these families experiencing postpartum depression and perinatal mood and anxiety disorders and reduce the stigma in the community around talking about them."

More programs helping Michigan parents

These programs represent just a few of the promising signs for improving support for PMAD in Michigan and nationwide. In Lenawee County, the University of Michigan School of Social Work's Implementing Depression Treatment for Mothers in Head Start initiative partnered with Adrian Public Schools Head Start Early Childhood Programs to identify unmet mental health needs among the 178 families served by the latter program. Through conducting depression screening, Head Start staff consistently found high rates of depression among the mothers of young children and pregnant women.

Wayne State University's High Touch High Tech initiative has provided iPads loaded with the Pregnancy Checkup app that screens pregnant people for mental health and substance use-related risks in prenatal clinics while in the waiting room. After their checkups, providers can opt to send patients text messages that address needs revealed in the screenings, including the existence of or risks for PMAD. The initiative has succeeded in increasing behavioral health service use among patients who were previously hesitant to seek help — and welcomed healthier babies to the world. Another project uses text messaging to specifically prevent PMAD. Parents who sign up receive informational messages tailored to their individual needs as well as links to helpful additional content.

And, on a national level, the FDA recently approved the first oral medication for postpartum depression.

The combination of screening, therapy, medication, and a supportive health care team helps people experiencing PMAD not only start on the road to recovery but also stay on it until they are truly better. These initiatives also address another reason new parents may avoid getting help for PMAD: stigma.

"I can think of many times that we have worked with young moms who were afraid that if they shared their mental health struggles with us, their kids would be taken from them, that they would be deemed not a good enough parent," says Amy Romain, program director of behavioral medicine, Sparrow/MSU Family Medicine Residency. "We are trying to normalize PMAD and educate people. It kind of goes hand in glove with the screening process."

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Amy Romain and Emalie Karp photos by Roxanne Frith. All other photos courtesy of the subjects.