How one famous hospital turned around its low rate of screening new moms for postpartum depression
This article originally appeared on Center for Health Journalism.
Cedars-Sinai in Los Angeles worked hard to bring up its low rate of screening postpartum women for depression. If signed, one of the new bills would require obstetric teams to do the same.
The hospital’s screening success is largely due to the dogged persistence of clinical psychologist Eynav Accortt, who also testified in support of the statewide screening bill.
“We are working to normalize mental health as part of postpartum health,” Accortt said. “It doesn’t just affect the mothers. It affects the entire family. It affects the spouse. It affects older children. It affects extended family.”
Left untreated, depression during pregnancy can put women at risk for preterm births and low birth weight babies. Postpartum depression can hinder mother-baby attachment, and negatively impact the physical and emotional development of the baby in childhood and beyond.
The hospital’s efforts are part of a broader effort among health care systems to recognize depression in new mothers earlier and get them the help they need. In California, Kaiser Permanente and Dignity Health are also taking steps to improve mental health care for pregnant and new mothers.
Bumping up the rates
When Accortt started at Cedars-Sinai in 2015, fewer than 10 percent of new mothers were screened for depressive symptoms, she said. This was despite a 2014 hospital-wide policy that mandated depression screening for every patient that came through its doors.
At the time, pregnant women were supposed to be screened in the labor and delivery ward.
“It just seemed like due to the emergency nature of our admissions — women are in active labor, they could be bleeding — they really just needed their physical health taken care of immediately,” Accortt said. “And there wasn’t really time or it wasn’t really the right time to ask these questions about depression.”
With help from the hospital’s OB-GYN and nursing leaders, Accortt brought together four departments (OB-GYN, nursing, psychiatry and social work) to plot ways to increase the number of women screened for depressive symptoms in the days immediately following birth.
In Los Angeles, 13.6 percent of mothers experience depressive symptoms after having their babies, according to new data released by the California Department of Public Health and Kids Data. Nationwide, about 11 percent of women experience symptoms of postpartum depression, according to the Centers for Disease Control and Prevention. But in some states, the figure approaches 20 percent.
A huge jump in screenings
At Cedars-Sinai, Accortt found there was no standard process for referring new mothers to specialists, and nurses weren’t formally trained to test for signs of depression. She helped implement their new screening, education and referral program. She also moved screenings from labor and delivery to the less harried setting of the postpartum unit.
Eynav Accortt, a clinical psychologist at Cedars-Sinai.
The results were dramatic. By October 2017, Accortt and her team had boosted the screening rate for these new mothers from 10 percent to 66 percent over the course of six months. Then, after a training for nurse leaders, they raised the rate to 99 percent by December 2017 and have maintained it since their last count in June.
Educating hospital staff proved crucial. Accortt gave presentations throughout the hospital, sought buy-in from the hospital’s administration, and brought in the Los Angeles-based organization Maternal Mental Health NOW to help with trainings. That organization also provided resources and materials that nurses could give to mothers in need of specialty care.
“We know from decades of research that screening alone is ineffective,” said Accortt. “If you don’t provide educational materials, if you don’t provide specific referral information that is vetted, screening is useless.”
The screening bill on Gov. Jerry Brown’s desk would not only require doctors to screen new mothers for depression, but would also require health insurance companies to help mothers find a therapist, and connect doctors to psychiatric specialists.
Screening alone doesn't always work
Despite the impressive jump in screening rates, Accortt and her team have not been able to actually identify many women with depressive symptoms. The rates for those who screened positive for depressive symptoms at Cedars-Sinai were just 0.4 percent of the new mothers they tested, far lower than the national prevalence of postpartum depression — 11 percent.
“We realize this, and we’re not going to blow smoke,” Accortt said. “We’re going to say, this is an issue and we need to solve it.”
This could partly be a training issue. Many of the nurses tasked with administering the standard questionnaire were not comfortable asking questions about depression and suicidal thoughts, Accortt said.
Nurses also need training in how to field questions from the mother herself. To that end, Accortt and her team just created a video that features a social worker role-playing with a new mother.
“Really nuanced training is needed,” she said. “We realized that we need to model how to do every little step. How to prepare the room. For example, the nursing staff needs to have the vocabulary and be prepared to kindly and respectfully ask these others to leave the room because you can imagine that if a mother-in-law was in the room, that may, it may not, but it may sway a mother’s responses to questions about depression.”
Racial disparities persist
Of the 7,900 women who gave birth at Cedars-Sinai between April 2017 and June 2018, 633 of them were black. Only two of these women were assessed as high risk for depression, even though 78 of them already had mental health diagnoses in their medical records, according to Accortt.
In Los Angeles County, black women are twice as likely to be depressed during pregnancy than white women. After birth, about 28 percent of black women reported a depressed mood compared to 22.5 percent of white women.
Meanwhile, there is growing awareness of how black women are treated during pregnancy and the births of their children, further brought to light by Serena Williams, Beyoncé, and the work of NPR and ProPublica on maternal mortality.
At Cedars-Sinai, Accortt’s next project is to improve how the hospital screens and treats black women who deliver there. With the help of several local agencies, she and her team will conduct implicit bias training for hospital staff and work on culturally appropriate referrals to treatment for women who screen as high risk for depression. They also plan to add an in-hospital support group for black mothers.
“We have to intervene,” Accortt said. “We need to reduce the stress. We need to reduce the impact that it has on a woman’s physical and mental health.”
The advocacy organization 2020 Mom is also working on the issue in California, developing a “words to use” resource for birth staff serving black mothers.
“We have heard there is much unintended bias and some would say outright disrespect,” said Joy Burkhard, 2020 Mom Executive Director. “We want to create not just a report documenting the problem, but a tool to prevent it.”
This piece was produced as part of the Rosalynn Carter Fellowships for Mental Health Journalism.
Q&A: Dr. Emily Dossett on the disturbing lack of mental health care for moms in the safety net
This article originally appeared on Center for Health Journalism.
Dr. Emily Dossett met a patient once who had schizophrenia, but went off her medication when she got pregnant. The pregnant patient then ended up in the hospital several times for psychotic episodes, and eventually landed in jail for assaulting a fellow patient. Dossett, a psychiatrist who works with women struggling with mental and emotional issues connected to pregnancy and postpartum, met her once she was in jail. The woman gave birth while incarcerated, and the Department of Child and Family Services took the baby because there was no family member to take custody. Dossett thinks the woman’s situation could have been a lot less traumatic had she gotten specialist psychiatric care a lot sooner. She says this woman’s story is all too common.
Dossett, an assistant professor in both the Psychiatry and Behavioral Sciences and OB-GYN departments at USC’s Keck School of Medicine, believes that connecting doctors — general physicians, OB-GYNs, pediatricians and general psychiatrists — to specialists who can treat pregnant women for behavioral health issues could help women who would otherwise fall through the cracks. She is spearheading a pilot program in Los Angeles County to do just that.
Email-based programs have already proven successful for getting other safety net patients specialty advice, treatment and referrals. In 2012, the Los Angeles County Department of Health Services (DHS) implemented the souped-up email system eConsult to connect primary care providers with specialists. Dossett is adding maternal mental health to the existing mix of specialties.
In California, low-income mothers are much more likely to experience prenatal depression than women with private insurance. Untreated behavioral issues can be damaging to both the mother and the child’s long-term physical and mental health.
Together with collaborator Christopher Benitez, a psychiatrist with the Department of Health Services, Dossett launched the pilot for Los Angeles County’s Department of Mental Health Services this past summer. I recently sat down with Dossett to learn more about how her project might help get women the behavioral health care they need.
The following interview has been edited for length and clarity.
Q: What problem are you trying to solve?
A: The missing piece for a lot of people in this field is what’s called “reproductive psychiatry” — psychiatrists who are trained to feel comfortable working with pregnant and postpartum women.
You can get all the way through medical school and four years of a psychiatric residency at most places and, unless you seek it out, you’re not going to get a single lecture on perinatal mental health. When you look at the statistics, the highest number of psychiatry patients are women of childbearing age. And we’re prescribing medications that are sometimes teratogenic, meaning they may cause some problem with the fetus’s development. It is crazy. I don’t know if it’s years of sexism or not understanding that this is a real issue. I know for some psychiatrists, it could be a liability; they’ll just take the women off their meds. Or they’ll just basically say, “Come back when the baby’s born.”
And a lot of it is women themselves who go off their meds. So it’s not like women are dying to stay on their meds, and doctors are thwarting them. A lot of women just go off because they hear that they’re bad for the baby.
I was really frustrated of seeing women get pregnant and then not have adequate care. I felt like my clinic was putting women back together who had dropped out of the system because they got pregnant.
Q: What are some of the issues for the fetus or child if the mother suffers from a perinatal mood disorder?
A: What we know from the literature is that relapse is very real and untreated anxiety and depression is really bad for the mother and the fetus. It actually has repercussions for the life of the child.
These are hard to separate out: being exposed to depression and anxiety in the womb, and then the issues around being raised by a parent who is struggling with anxiety and depression. So it’s a little bit nature and nurture, and it’s kind of a mashup.
There’s this idea of epigenetics. You have your genome that you get in your DNA and how that’s actually expressed is heavily influenced by what’s called the “intrauterine milieu” — what's going on in the womb.
And so if the mother, say, is struggling with untreated anxiety or depression, her own stress management and stress hormones are off kilter. Cortisol is one that has been studied a lot. Of course, Serotonin and norepinephrine and other neurotransmitters are also at play.
Those are real chemicals that really float around in your body. And they really can cross the placenta and affect the developing child. And what happens is that the child’s own stress management system can be expressed in such a way that’s it’s just always off kilter for the life of the offspring. So those kids are more likely to be anxious, they’re less resilient to stress and trauma, they’re more likely to have ongoing mental health issues themselves. Having said that, it’s certainly not a one-to-one correlation. There are a lot of other things that play into it.
So that’s actually why we think that untreated anxiety and depression leads to preterm delivery as well because cortisol is also the hormone that kicks off labor, so if it’s dysregulated, then it can lead to this signalling that it’s time to give birth a little too early.
And then there are studies that have followed children out to age 18 that look at antenatal depression [occurring before birth]. I think those are really hard to do. Because if the mothers — we always talk about mothers, fathers of course are involved, but mothers tend to be the primary caregivers — if the mother lacks affect, if the mother isn’t responsive to the emotional needs, if the mother is neglectful, if the mother’s not motivated to sign the child up for Head Start because she’s depressed, then that’s going to, of course, affect the child.
Q: How does eConsult work, and how does your pilot factor into the bigger system?
A: Basically, it’s a fancy, HIPAA-compliant, email exchange.
When the practitioner logs on, they have to put in some patient information and ask their question, then submit it. And then I get an email in my inbox because I’m what’s called the “specialty reviewer.” I read it and I can either answer it, or if I have questions, I go back. I can also refer them to a specialist.
Q: So, they can’t really tap your expertise until the next appointment?
A: So, what advocates have wanted is a perinatal psychiatry phone line where the doctor can call someone who is trained, who can advise from the other end of the line. Massachusetts has a program like that called MCPAP for Moms [Massachusetts Child Psychiatry Access Program for Moms].
Of course that would be ideal. But if we can’t have the gold standard, let’s use what we have and try to at least see if using it works. If it does, great. If it doesn’t, then that actually adds fuel to the argument that we do need some kind of phone line.
Q: Why is maternal mental health such a challenging problem to tackle, especially in safety net systems?
You have the biological issues and the emotional and the psychological issues and then on top of that you have these systems issues, where in general — in both the public and private sectors — women with serious mental illness get bounced around like a hot potato between mental health care providers and prenatal care providers.
The women in the safety net systems are usually so ill that the self-advocacy piece becomes almost impossible. So, we’re trying to bridge that gap to try to capture these women where they are.
We don’t know if it will work. But, we hope it will.
Q: So right now, as a pregnant person, how would I find a reproductive psychiatrist?
A: You could call Postpartum Support International. You would ask your OB-GYN.
It’s all word of mouth at this point. It’s hard enough if you have a laptop and an internet connection.
Also, you may not even know a reproductive psychiatrist is what you need.
This piece was produced as part of the Rosalynn Carter Fellowships for Mental Health Journalism.
The Emptiness of the All-Male Panel
This article originally appeared in Undark Magazine.
Late fall, Sophia Roosth, the Frederick S. Danziger Associate Professor in the History of Science at Harvard, sat in the back row of a packed auditorium at the university’s law school, where a gathering of experts discussed the ethics of growing human embryos in a lab.
For more than three hours, the panelists delved into the scientific, legal, and ethical considerations surrounding the current guidelines for growing human embryos. They also discussed synthetic embryos — embryo-like entities that scientists are starting to grow with stem cells rather than using a sperm and an egg from human bodies.
It was a wide-ranging discussion notable both for its importance and for its surprisingly one-sided perspective: The panelists numbered nine, and all of them were men.
“My assumption was probably I wasn’t speaking on [the panels] because it would be limited to scientists who were actually engaged in that kind of research,” Roosth later told me. “I didn’t realize that they were actually going to be bringing in bioethicists and other social scientists who would be speaking to the same issues that I’m trained to talk about.”
She continued to try to rationalize the exclusion. Perhaps she wasn’t invited to join the panel because she did not have tenure, or because her book, “Synthetic: How Life Got Made,” hadn’t yet been published? Or maybe, she thought, it was because she is not really a legal expert.
LOW VACCINATION RATES AT BAY AREA SCHOOLS RAISE ALARM
This article originally appeared on the front page of the San Jose Mercury News.
With alarm over the Disneyland measles outbreak growing across California, almost 5,000 kindergartners enrolled in Bay Area schools are without proof they've been fully vaccinated, a major concern as the highly infectious disease continues to spread.
"They're not immunized, they're not protected," said Amy Pine, director of the Immunization Program for the Alameda County Public Health Department.
But the reasons why so many kindergartners — one of 13 in the Bay Area — don't have up-to-date vaccinations is as diverse as the students themselves: While many lower-income parents struggle to get their kids to the doctor or deliver the paperwork, some higher-income parents are refusing to get their children immunized over concerns the shots lead to autism and other illnesses.
MAJORITY AT SOME LA KINDERGARTENS ARE UNDER-VACCINATED
This article originally appeared on the front page of the Los Angeles Daily News.
Over 90 percent of kindergarteners at some Los Angeles Unified School District (LAUSD) schools are walking the halls without all of their state-required vaccinations. At some Oakland schools, the numbers top 80 percent.
These “conditional entrants” must have received at least one dose of each of the required vaccines to enter school, with the promise to get fully up to date in due time.
But neither the state nor school districts has a formal tracking system to ensure that these children become fully vaccinated.
what mental illness looks like
This article original appeared as a blog post on the Center for Health Reporting.
They sat for photographs and told me their stories. One lost a father when she was seven-years-old to a bullet from a bar’s bouncer. Another served five years in prison. Another met his girlfriend through his treatment and therapy.
Each person had been diagnosed with a mental illness, ranging from mild depression to schizophrenia. And they each found community and help within the walls of the Stanislaus chapter of the National Alliance on Mental Illness (NAMI).
And they almost didn’t happen.
A WEDDING CRASHER NAMED IRENE
This article originally appeared in the Styles section of The New York Times.
The lights flickered. The music stopped. The dancers stood still. We could hear the horizontal rain drumming the tent flaps.
For months before, from our Los Angeles apartment, Jake de Grazia and I had envisioned our three-day homegrown wedding on Jake’s family farm in Chadds Ford, Pa., about 25 miles west of Philadelphia.
In the end, nature disrupted our plans by sending the ultimate wedding crasher — Irene.
President’s letter: Support for Jill Abramson
The members of the Journalism and Women Symposium (JAWS) support you.
As you ascended the ranks of top newspapers, you impressed us with your investigative journalism chops. When you became the first woman to run one of the most influential news organizations in the world, you inspired us to reach for leadership positions in our careers. And when you spoke to us during our annual conference last fall, you re-invigorated us with your self-proclaimed optimism about the journalism field and the influence we can have as women in it. Now we want to support you.
At the JAWS conference, you brought us to our feet declaring yourself to be “the newest member of JAWS” and acknowledging us as your “peeps.” Well, your peeps are here for you if you need us. We are hundreds strong in newsrooms all across the country and we stand with you and will help if we can.