A pregnant woman walks into an obstetrician’s office. She’s handed a tablet and begins filling out a mental health questionnaire. She doesn’t realize it, but it’s choosing questions based on her answer to the last one. She’s done after two minutes and waits for the doctor to see her.
A social worker gets an alert that one of the office’s patients just finished an assessment indicating some symptoms of depression. It’s a prompt to enroll the woman into an app that will go through some therapy concepts with her.
Tools like CAT-MH, which is being used at some Veterans Affairs facilities and university hospitals, have the potential to help doctors better diagnose and manage depression, anxiety, and other conditions in their pregnant patients.
More generally thought of as a problem for women after they give birth, depression is more prevalent during pregnancy: 28.8 women per every 1,000 births had a diagnosis of depression at delivery in 2015, according to a 2019 study. Mental health conditions contributed to 75% of maternal deaths by suicide, homicide, or overdoses in 2015, according to a 2018 report.
But while these telehealth tools show promise in filling health-care gaps at modest cost, doctors who want to use them are facing an uphill battle to get insurers to pay for them—in particular Medicaid, which covers about half of all U.S. births. Questions have also been raised about the quality of their data, whether patients’ privacy is being adequately safeguarded, and whether doctors will follow through when risks are flagged by the tools.
Assessing and Treating
Traditionally, doctors have used a test called the Patient Health Questionnaire (PHQ-9) to screen and diagnose depression. It asks patients nine questions about how often they feel bothered by certain problems and a tenth question about how difficult those problems make the rest of their life.
However, medical professionals and other systems are beginning to use computerized adaptive testing tools. The CAT-MH tool chooses from 1,500 questions to determine if a patient has depression, anxiety, mania, or thoughts of suicide, and it bases what questions it chooses on previous answers, said Robert D. Gibbons, a health statistics professor at the University of Chicago and one of the creators of CAT-MH.
The test will ask patients questions until the uncertainty of diagnosis falls below a certain threshold.
The CAT-MH tool is more efficient and precise than the PHQ-9, Gibbons said. The assessment can be used repeatedly because it doesn’t keep asking the same questions. This allows doctors to monitor for early onset symptoms of perinatal depression, he added.
The test is being used at Veterans Affairs facilities, the University of California at Los Angeles with students, University of Illinois at Chicago facilities, and the Evanston, Ill.-based NorthShore University HealthSystem, among other systems. The Department of Veterans Affairs is also working to help develop new tools to diagnose PTSD and validate the test for predicting future suicidal behavior, Gibbons said.
However, providers say they don’t screen for mental health illnesses because of a perceived, and often real, lack of resources for the women if something is flagged, said Pauline Maki, director of the Women’s Mental Health Research Program at the University of Illinois at Chicago. It helps if they have somewhere to direct those patients in a concrete, actionable way.
That’s where a tool like Sunnyside for Moms comes in. It’s one of several application-based tools that provide cognitive behavioral therapy to women who are exhibiting signs of depression but haven’t reached the point of having major depressive disorder. Cognitive behavioral therapy is a type of therapy where people identify troubling situations, become aware of their thoughts and beliefs about the problem, identify negative or inaccurate thinking, and reshape that thinking.
The women are signed up with the app with the help of a social worker or other coach who checks in throughout the pregnancy to ensure the patient is sticking with the program. Women can also enter their own material, and the tool has been customized to include local resources in Chicago, where it is being tested.
Jennifer Duffecy, co-developer of Sunnyside and a psychiatry professor at the University of Illinois at Chicago, said the program takes less time than traditional therapy so is more cost-effective. It also helps women to see what mental health treatment looks like in practice and can make it less anxiety-provoking to seek it, she said.
Sunnyside was initially seen as a tool to bridge the gap until women could get in to see a mental health provider, but the clinical trials are showing that it’s very effective on its own, Duffecy said.
Women in the trials with depressive symptoms had a significantly lower rate of depression postpartum—4%—than the general population—15%-20%. They also saw a decrease in symptoms of anxiety from 18% when entering the trial to 5% postpartum. Sunnyside’s developers plan to evaluate it as a treatment for major depressive disorder, Duffecy said.
Privacy, Fragmented Care
Other tools—like MomMoodBooster, moodgym, Beating the Blues US, and SilverCloud Health—also provide internet-based therapy interventions.
These tools provide windows into how people with these illnesses live outside of the clinic, said John Torous, director of the digital psychiatry division at Boston-based Beth Israel Deaconess Medical Center.
Still, the evidence for how well these tools diagnose or treat conditions is in the very early stages, and not all of it is based on good data, Torous said.
Tools like these also present some some serious privacy risks, Torous said. Patients don’t always know if the tools abide by the Health Insurance Portability and Accountability Act or whether the developers can sell or share the data.
Doctors are also trying to coordinate care more, and that care can be fragmented if patients are using a variety of apps, Torous said.
When looking at higher-quality data on the success of types of programs, the tools can be helpful, but they’re “probably not clinically powerful enough to substitute care,” Torous said.
The biggest issue for any of these tools is who pays for them.
Because more than half of maternal care is covered by Medicaid, reimbursement changes from state to state. Most states let their managed care organizations decide how to reimburse for maternal care, although a few do give providers a fixed payment for an episode of care, said Jocelyn A. Guyer, managing director at Manatt, Phelps & Phillips LLP focused on the Affordable Care Act and Medicaid.
Maternity care tends to be one of the higher-cost items in Medicaid, so more states are dictating to managed care companies how they will be paid, Guyer said. States like California will give providers an extra payment for delivery of a baby, and North Carolina is paying an extra $50 to doctors who screen pregnant women for depression and socioeconomic risk factors.
Medicaid allows telehealth coverage, and CMS guidance in 2016 made clear that Medicaid pediatricians can check on a mother’s health, even if she doesn’t have coverage, because of the direct impact on the child’s health. But state licensing regulations and other policies covering appropriate visit settings can complicate eligibility, Guyer said.
Also, tools like Sunnyside don’t fit the typical definition of telehealth where a patient is directly engaging with a medical professional, Maki said.
Apart from the reimbursement complications, some CMS and National Quality Forum guidelines require doctors to use the PHQ-9 test to receive credit for screening their patients, Gibbons said.
Even when states reimburse for perinatal mental health screening, the payment doesn’t come close to covering the costs, said Richard Silver, chairman of obstetrics and gynecology at Northshore University Health System. His department has decided to make the investment in it because mental health is the most common complication that women face, but not every system can do that.
And when prenatal care is reimbursed in a fixed payment, there’s no financial incentive for providers to screen patients for mental health conditions, Maki said.
Pregnancy Is the Time
These tools are unlikely to go into wider use until there is a substantive reimbursement associated with mental health services, said Silver, who is also the associate dean for medical education at the University of Chicago Pritzker School of Medicine.
Still, Maki and Duffecy argue the new approach is needed.
Women are more able to learn therapeutic tools while they’re pregnant than when they have a newborn and are getting little sleep, Maki said.
Because women seek out health care regularly while they’re pregnant, that time is a “window of opportunity to provide something to women that they need, but may not seek out,” Duffecy said. Women are also becoming more aware of postpartum depression and want a way to prevent it, Duffecy said.
“We have the moment when women are open and willing to reach out, and we need to take it,” she said.