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Detection and treatment rates for perinatal depression in a state Medicaid population

  • Michelle L. Geier (a1), Nancy Hills (a2), Marco Gonzales (a3), Karoline Tum (a4) and Patrick R. Finley (a5)...

The purpose of this investigation was to assess detection and treatment rates for perinatal depression among women enrolled in the California State Medicaid (Medi-Cal) program in comparison to female beneficiaries of reproductive age who did not give birth during the same study period.


Investigators conducted a retrospective longitudinal cohort analysis of women between the ages of 18 and 39 years old who were continuously enrolled in the Medi-Cal fee-for-service program between January 2006 and December 2009. The perinatal cohort consisted of women with evidence of a live birth occurring between October 2007 and March 2009. The control cohort consisted of women in the same age group and health plan without evidence of pregnancy during this time frame. The primary outcome of this investigation was diagnosis of depression during 3 contiguous 9-month time frames: immediately prior to presumed conception, during pregnancy, and throughout the postpartum period. Secondary outcomes included within-group and cohort comparisons of treatment patterns (antidepressant or psychotherapy). A multivariable analysis of demographic factors predicting depression diagnosis or treatment was conducted as well.


A total of 6030 women was identified in the perinatal cohort, and 56,709 women were included in the control group. The perinatal cohort was significantly less likely than nonpregnant controls to receive a diagnosis of depression both during pregnancy (prevalence=1.6% vs 3.5%; OR=0.45; 95% CI=0.35–0.55) and postpartum (2.2% vs 3.6%; OR=0.59; 95% CI=0.50–0.71). Similar differences were noted in antidepressant prescribing patterns apparent during these 2 time frames. A subgroup analysis of women who received a depression diagnosis revealed that only 48% of the perinatal cohort was provided any treatment during pregnancy (vs 72% of the control group; p<0.0001) or postpartum (57% vs 73%; p<0.0001). Specific demographic factors predicting a lower prevalence of depression detection or treatment included Hispanic descent, age <25 years, or primary residence in an rural setting.


Depression was often overlooked and undertreated among women who are pregnant or postpartum in comparison to services delivered to similar nonpregnant controls. Significant disparities in the healthcare received by certain subpopulations of perinatal women suggest that research into barriers to care and subsequent interventions are warranted.

Corresponding author
*Address for correspondence: Patrick R. Finley, PharmD BCPP, Department of Clinical Pharmacy, University of California at San Francisco, 3333 California Street, Box 0613, San Francisco, CA 94143-0613, USA. (Email:
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1. Kessler, RC, Berglund, P, Demler, O, et al. The epidemiology of major depressive disorder—results from the national comorbidity survey replication. JAMA. 2003; 289(23): 30953105.
2. Murray, CJL, Lopez, AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Geneva, Switzerland: World Health Organization; 1996.
3. Gavin, NI, Gaynes, BN, Lohr, KN, Meltzer-Brody, S, Gartlehner, G, Swinson, T. Perinatal depression—a systematic review of prevalence and incidence. Obstet Gynecol. 2005; 106(5 Pt 1): 10711083.
4. Banti, S, Mauri, M, Oppo, A, et al. From the third month of pregnancy to 1 year postpartum: prevalence, incidence, recurrence, and new onset of depression. Results from the perinatal depression-research and screening unit study. Compr Psychiatry. 2011; 52(4): 343351.
5. Le Strat, Y, Dubertret, C, Le Foll, B. Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States. J Affect Disord. 2011; 135(1–3): 128138.
6. Silva, R, Jansen, K, Souza, L, et al. Sociodemographic risk factors of perinatal depression: a cohort study in the public health care system. Rev Bras Psiquiatr. 2012; 34(2): 143148.
7. Zuckerman, B, Amaro, H, Bauchner, H, et al. Depressive symptoms during pregnancy: relationship to poor health behaviors. Am J Obstet Gynecol. 1989; 160(5 Pt 1): 11071111.
8. Chung, TK, Lau, TK, Yip, AS, Chiu, HF, Lee, DT. Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosom Med. 2001; 63(5): 830834.
9. Orr, ST, James, SA, Blackmore Prince, C. Maternal prenatal depressive symptoms and spontaneous preterm births among African-American women in Baltimore, Maryland. Am J Epidemiol. 2002; 156(9): 797802.
10. Field, T, Hernandez-Reif, M, Diego, M, et al. Still-face and separation effects on depressed mother-infant interactions. Infant Mental Health Journal. 2007; 28(3): 314323.
11. Whisman, MA, Uebelacker, LA, Weinstock, LM. Psychopathology and marital satisfaction: the importance of evaluating both partners. J Consult Clin Psychol. 2004; 72(5): 830838.
12. Kurstjens, S, Wolke, D. Effects of maternal depression on cognitive development of children over the first seven years of life. J Child Psychol Psychiatry. 2001; 42(5): 623636.
13. Murray, L, Woolgar, M, Cooper, P, Hipwell, A. Cognitive vulnerability to depression in 5-year-old children of depressed mothers. J Child Psychol Psychiatry. 2001; 42(7): 891899.
14. Zahn-Waxler, C, Iannotti, RJ, Cummings, EM, Denham, S. Antecedents of problem behaviors in children of depressed mothers. Dev Psychopathol. 1990; 2(3): 271291.
15. Yonkers, KA, Wisner, KL, Stewart, DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009; 31(5): 403413.
16. Revicki, DA, Siddique, MS, Frank, L, et al. Cost-effectiveness of evidence-based pharmacotherapy or cognitive behavior therapy compared with community referral for major depression in predominantly low-income minority women. Arch Gen Psychiatry. 2005; 62(8): 868875.
17. Freeman, MP. Antenatal depression: navigating the treatment dilemmas. Am J Psychiatry. 2007; 164(8): 11621165.
18. Ko, JY, Farr, SL, Dietz, PM, Robbins, CL. Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005–2009. J Womens Health (Larchmt). 2012; 21(8): 830836.
19. Ng, RC, Hirata, CK, Yeung, W, Haller, E, Finley, PR. Pharmacological treatments for the management of postpartum depression: a systematic review. Pharmacotherapy. 2010; 30(9): 928941.
20. Domar, AD, Moragianni, VA, Ryley, DA, Urato, AC. The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Hum Reprod. 2013; 28(1): 160171.
21. National Research Council and Institute of Medicine. Depression in Parents, Parenting and Children: Opportunities to Improve Identification, Treatment, and Prevention. Washington, DC: The National Academies Press; 2009.
22. Marcus, SM, Flynn, HA, Blow, FC, et al. Depressive symptoms among pregnant women screened in obstetric settings. J Womens Health (Larchmt). 2003; 12(4): 373380.
23. Bennett, IM, Marcus, SC, Palmer, SC, Coyne, JC. Pregnancy related discontinuation of antidepressants and depression care visits among Medicaid recipients. Psychiatr Serv. 2010; 61(4): 386391.
24. Witt, WP, Keller, A, Gottlieb, C, et al. Access to adequate outpatient depression care for mothers in the USA: a nationally representative population-based study. J Behav Health Serv Res. 2011; 38(2): 191204.
25. Flynn, HA, Blow, FC, Marcus, SM. Rates and predictors of depression treatment among pregnant women in hospital-affiliated obstetrics practices. Gen Hosp Psychiatry. 2006; 28(4): 289295.
26. Goodman, JH, Tyer-Viola, L. Detection, treatment, and referral of perinatal depression and anxiety by obstetrical providers. J Womens Health (Larchmt). 2010; 19(3): 477490.
27. Spettell, CM, Wall, TC, Allison, J, et al. Identifying physician-recognized depression from administrative data: consequences for quality measurement. Health Serv Res. 2003; 38(4): 10811102.
28. Walkup, JT, Boyer, CA, Kellermann, SL. Reliability of Medicaid claims files for use in psychiatric diagnoses and service delivery. Adm Policy Ment Health. 2000; 27(3): 129139.
29. Gjerdingen, D, Katon, W, Rich, DE. Stepped care treatment of postpartum depression: a primary care-based management model. Womens Health Issues. 2008; 18(1): 4452.
30. Bonari, L, Koren, G, Einarson, TR, Jasper, JD, Taddio, A, Einarson, A. Use of antidepressants by pregnant women: evaluation of perception of risk, efficacy of evidence based counseling and determinants of decision making. Arch Womens Ment Health. 2005; 8(4): 214220.
31. Leddy, M, Haaga, D, Gray, J, Schulkin, J. Postpartum mental health screening and diagnosis by obstetrician-gynecologists. J Psychosom Obstet Gynaecol. 2011; 32(1): 2734.
32. Dietrich, AJ, Williams, JW Jr, Ciotti, MC, et al. Depression care attitudes and practices of newer obstetrician-gynecologists: a national survey. Am J Obstet Gynecol. 2003; 189(1): 267273.
33. LaRocco-Cockburn, A, Melville, J, Bell, M, Katon, W. Depression screening attitudes and practices among obstetrician-gynecologists. Obstet Gynecol. 2003; 101(5 Pt 1): 892898.
34. Thomas, N, Sleath, BL, Jackson, E, West, S, Gaynes, B. Survey of characteristics and treatment preferences for physicians treating postpartum depression in the general medical setting. Community Ment Health J. 2008; 44(1): 4756.
35. Coleman, VH, Carter, MM, Morgan, MA, Schulkin, J. Obstetrician-gynecologists’ screening patterns for anxiety during pregnancy. Depress Anxiety. 2008; 25(2): 114123.
36. Palladino, CL, Fedock, GL, Forman, JH, Davis, MM, Henshaw, E, Flynn, HA. OB Cares—the obstetric clinics and resources study: providers’ perceptions of addressing perinatal depression—a qualitative study. Gen Hosp Psychiatry. 2011; 33(3): 267278.
37. Centers for Disease Control and Prevention (CDC). Adequacy of prenatal-care utilization—California, 1989–1994. MMWR Morb Mortal Wkly Rep. 1996; 45(30): 653656.
38. Johnson, KA. Public finance policy strategies to increase access to preconception care. Matern Child Health J. 2006; 10(5 Suppl): 8591.
39. Dietz, PM, Williams, SB, Callaghan, WM, Bachman, DJ, Whitlock, EP, Hornbook, MC. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry. 2007; 164(10): 15151520.
40. Gonzalez, HM, Vega, WA, Williams, DR, Tarraf, W, West, BT, Neighbors, HW. Depression care in the United States—too little too few. Arch Gen Psychiatry. 2010; 67(1): 3746.
41. Kozhimannil, KB, Trinacty, CM, Busch, AB, Huskamp, HA, Adams, AS. Racial and ethnic disparities in postpartum depression care among low income women. Psychiatr Serv. 2011; 62(6): 619625.
42. Borowsky, SJ, Rubenstein, LV, Meredith, LS, et al. Who is at risk of nondetection of mental health problems in primary care? J Gen Intern Med. 2000; 15(6): 381388.
43. Kimerling, R, Baumrind, N. Access to specialty mental health services among women in California. Psychiatr Serv. 2005; 56(6): 729734.
44. H.R. 3590 (111th): Patient Protection and Affordable Care Act. [accessed February 5, 2013].
45. Screening for Depression in Adults, Topic Page. December 2009. U.S. Preventive Services Task Force. [accessed February 5, 2013].
46. World Health Organization. Integrated management of pregnancy and childbirth: WHO recommended interventions for improving maternal and newborn health. WHO/MPSO7.05 (2nd ed.) Geneva, Switzerland; 2009. [accessed February 5, 2013].
47. American College of Obstetricians and Gynecologists: Committee opinion no. 453. Screening for depression during and after pregnancy. Obstet Gynecol. 2010; 115(2 Pt 1): 394395.
48. LaRocco-Cockburn, A, Reed, SD, Melville, J, et al. Improving depression treatment for women: integrating a collaborative care depression intervention into OB-GYN care. Contemp Clin Trials. 2013; 36(2): 362370.
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