Teenage Girls are Suffering

By Juli Fraga, Psy.D. and Joy Burkhard, MBA

Did you know that America’s girls are getting sadder and have you thought about what that could mean for the field of Maternal Mental Health?

A recent study published in the medical journal, Pediatrics, shows a general increase in depression among teenagers. Of even greater concern, girls are more likely to suffer from major depressive disorder than their male peers and the number of girls struggling with depression  has risen sharply since 2011.

Why the Increase?
There are likely a number of factors at play (we’d love to hear your thoughts about potential causes in the comments field below). The researchers state that social media may be partly to blame: In an interview with NPR, Catherine Steiner-Adair, psychologist, and author of the study states, "young girls are continually impacted by media messages that convey that their physical appearance is more important than their intelligence.”

Teenage girls who struggle with depression are more likely to wrestle with low self-esteem, social isolation, and relationship difficulties. At a time when a teenage girl’s hormones surge, it’s easy for parents to misread the signs and symptoms of her depression as “teen angst” or normal moodiness. And unfortunately, many adolescent girls are not telling their parents about their sadness. Just like mothers suffering from MMH disorders, the majority of teens are never screened, diagnosed, or treated for their malaise.

Contrary to what parents and teachers may believe, the effects of this mental illness doesn’t vanish once these young women leave their teenage years behind.

A Young Woman’s Story
Ann, age 24, of Los Angeles has suffered from depression and anxiety since she was a teenager.  She says, “It’s a lonely condition because people rarely talk about it and for a long while, it affected my self-esteem, even as I reached my adult years.”

Ann says that if she had learned how to recognize the signs and symptoms of her mood concerns earlier in life, it would have made a world of difference.

“I spent a lot of time blaming myself. Other people told me that I was Type A and that I worried too much. Once I realized I had a mood concern, it made a world of difference because I could finally get the help that I needed.”

Ann also realizes that she's at risk for a relapse, which is why she makes her self-care a priority and uses some cognitive-behavioral therapy techniques to challenge her obsessive thoughts. Even though she uses these tools, Ann is aware that her mental health concerns may resurface if she has children in the future.

What this means for Maternal Mental Health
Girls who suffer from depression and anxiety are of course at a higher risk of developing a maternal mental health disorders, such as postpartum depression when they become mothers.

Early screening and detection of depression and anxiety among teen girls can also help to prevent maternal mental health disorders during new motherhood. Having a family and personal history of mental health concerns is a risk factor for postpartum depression and anxiety, but early diagnosis and treatment can catch these women in a safety net by providing them with the care that they need for years to come.

Girls who suffer from depression and anxiety are of course at a higher risk of developing a maternal mental health disorders, such as postpartum depression when they become mothers.

Our field should be ready for an Influx
We are bringing this up because we think the field needs to be prepared. This of course is not easy when we are dealing with a system that isn’t catching mothers now. But nonetheless we must be talking about this and using this to our advantage when making the case for access to services like telepsychiatry lines, hospital based outpatient and inpatient treatment programs and more.

Join us for important conversations like these at 2020 Mom’s Annual ‘Emerging Consideration’ forum in Los Angeles, February 2018.

What does the USPSTF Screening Recommendation Really Mean?

– POLICY –

by Joy Burkhard, MBA
Founder and Director 2020 Mom

It's an exciting development that the USPSTF no longer excludes pregnant women from its depression screening recommendations, and now notes the specific importance of screening pregnant and postpartum women due to negative consequences of untreated depression on fetus/infant development.

Patients are Already Provided Coverage
Insurers currently provide coverage to patients for depression screening in the full adult population.  However, most primary care doctors and OBGYNs continue (and will continue) NOT to screen because of lack of referral and case management support, which is a critical need for them in feeling comfortable when uncovering positive screens.

Provider Payment Still Depends on the Contract
Some are wondering whether this position means that insurers must pay providers for screening. It's an interesting question. The recommendation and ACA don't dictate how an insurer contracts or pays a provider. There are several types of insurance payment mechanisms. The two most well-known payment structures are Fee-for-service (a provider bills for every service s/he provides) and capitation (providers receive a flat payment per month for any/all services provided). Under a fee-for-service type arrangement, an insurer would reimburse for a depression screen. Under a capitation payment, providers are expected to provide all necessary services under their negotiated monthly payment, including depression screening. The USPSTF recommendation doesn't change these structures. Because of the focus on staying healthy, the Centers for Medicare/Medicaid Services (CMS) and others are promoting capitation type arrangements with primary care doctors, including pediatricians who may screen mothers for depression. Separate, and often in place for maternity, an OBGYN agrees to be paid a "global maternity rate" by the insurer for prenatal and postpartum services (through the postpartum visit). Under these types of arrangements, insurers generally expect providers to render all medically necessary screenings and services, which generally would include maternal depression screening and other types of screenings. Insurers are not obligated to pay providers for depression screening outside of this flat rate.
Note, however, that some payers/insurers have addressed this.  For example in Colorado, the state Medicaid program is reimbursing pediatricians and OBGYNs for conducting screening. Our sources tell us that there are challenges, including limitation on the number of times screening can occur (causing challenges as the pediatrician may not know if the OBGYN already screened) and low reimbursement levels, leaving many to not bother billing even if they do screen. Further, there is no measurement currently in place, so there is no evidence that payment is making a difference.  Furthermore, several years ago, Aetna, interested in improving depression screening and treatment rates, began reimbursing primary care providers for depression screening. They found it didn't increase depression screening rates (though those who were already screening were thrilled) pointing to the notion that clear referral and treatment pathways must be in place first, and additional payment really is secondary.

What should Insurers Do?
Insurers are in a unique position to provide this complex case management service (they do so now for many other conditions) but until there is also a way to locate psychiatrists as well as therapists who have training/experience in treating maternal mental health insurers will have difficulty making a dent.  Beyond the general difficulty in knowing who is qualified to treat these moms, there are also general psychiatry shortages, and most reproductive psychiatrists don't contract with insurers because they don't have to.
This is why the federal bill, HR 3235, Bringing Postpartum Depression out of the Shadows Act is critically important.  If passed states could apply for federal grants to implement innovative access solutions, like the Massachusetts telepsychiatry program, MCPAP for moms, which successfully addresses and integrates training of providers, referral pipelines for qualified therapy, and prescription consultation for OBGYNs and other MDs when necessary.  

Screening Rates Must be Measured
There is no measurement in place to capture how often OBGYNs (or others) are screening for depression.  "We don't manage what we don't measure" the adage goes.  It's critical that accreditation bodies and/or states require measurement of screening rates.  Insurers are in the best position to monitor these rates, through a program like the National Committee for Quality Assurance's (NCQA's) Healthcare Effectiveness Data and Information Set (HEDIS) measures, which involve monitoring medical records and/or claim submission data.   Cigna was the first insurer to adopt a HEDIS-like measure developed by external bodies, in 2013 but this measurement process needs to be implemented widely.  When health plans understand what gaps in care exist they invest resources to improve screening and health outcomes and work collaboratively with providers to support their needs.
 
Conclusion
Inclusion of pregnant and postpartum women in the USPSTF position is a critical step in validating the importance of this screen, but much more work is needed to ensure providers are actually able to screen.  2020 Mom is supporting this work through in several ways. Want to know more?  Drop us a line: 
info@2020mom.org