Up to 25% of all pregnant, postpartum and parenting women suffer some kind of depression, which is more prevalent in low-income mothers.A new federal ruling allows Medicaid agencies to cover maternal depression screening as part of a well-child visit and mandates that states cover medically necessary treatment for the child as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
The ruling, released May 11 by the Centers for Medicare & Medicaid Services (CMS), was hailed as a victory by AAP members and others who have advocated for awareness of the problem along with the need for payment.
Screening vs. treatment coverage
Under the ruling, state Medicaid agencies have discretion to determine the payment approaches for pediatric professionals who screen for maternal depression. Among the details:
- Screenings may be covered for both Medicaid-eligible and non-Medicaid-eligible mothers during the well-child visit because they are for the direct benefit of the child, according to CMS.
- Diagnostic and treatment services aimed solely at the mother are available only for Medicaid-eligible mothers.
- States may cover treatment for non-Medicaid-eligible mothers when both the child and mother are present; treatment focuses on the effects of the mother’s condition on the child; and services are for the direct benefit of the child.
- Activities to promote maternal depression screening among Medicaid providers and train them to incorporate screening and treatment into the EPSDT well-child visits are “generally eligible” for Medicaid administrative matching funds.
Critical need, support
Five percent to 25% of all pregnant, postpartum and parenting women suffer some kind of depression, which is significantly higher (40%-60%) and more severe in low-income mothers. The severity ranges from “maternity blues” or “baby blues” lasting a few days to two weeks to postpartum depression and postpartum psychosis.
Timely screening and the right treatment can reduce maternal depression, which is “a significant early risk to proper child development, the mother-infant bond and the family,” CMS Director Vikki Wachino noted in the CMS bulletin.
The impact of maternal depression can include negative effects on cognitive development, social-emotional development and behavior, and family functioning. Other concerns are adherence to preventive care, a risk of child abuse and a lack of breastfeeding.
An AAP Periodic Survey found that in 2013, less than half of pediatricians routinely screened or asked about maternal depression; however, the number had increased from 33% in 2004.
Meanwhile, some pediatricians have remained passionate about the issue.
AAP President Benard P. Dreyer, M.D., FAAP, visited CMS in February to highlight the issue. Other AAP leaders active on both federal and state levels include Marian F. Earls, M.D., FAAP, lead author of a 2010 clinical report (see resources) CMS cited in the ruling, and Michael W. Yogman, M.D., M.Sc., FAAP, chair of the AAP Committee on Psychosocial Aspects of Child and Family Health.
The CMS bulletin quoted the Academy’s stance that screening mothers for depression is a best practice for pediatricians and can be part of the well-child care schedule and the prenatal visit.“From the perspective of the infant, you’re really screening the infant’s environment,” Dr. Earls explained.
The bulletin further quotes Bright Futures guidelines in which recommendations for well-child visits include a call for checks of parental (maternal) well-being. Also cited in the report is the U.S. Preventive Services Task Force January 2016 recommendation (B grade) on the need for depression screening in the general adult population, including pregnant and postpartum women.
Even before CMS detailed how Medicaid can cover maternal depression screenings at well-child visits, eight states provided coverage: Colorado, Illinois, Massachusetts, Minnesota, New York, North Dakota, Ohio and Virginia.
Dr. Yogman was screening for postpartum depression in his Massachusetts-based practice long before it was paid for in his state. He always assumed he could identify when a parent was depressed, but quickly discovered that people disclose details on a screening form that they will not offer verbally. Over the years, Dr. Yogman has found use of the screening instrument critical. He has identified three to four extremely serious cases of depression, in which the women were potentially suicidal or homicidal and went on to receive treatment.“I can’t tell you how grateful they were. We were able to identify it, alleviate the stigma and refer them for successful treatment. …If I ever was a believer before that, I became a zealot about how important it was,” he said.
Referrals and treatment
Pediatricians should be aware of referral resources for those who screen positive.
One option is focusing on the mother-infant pair or dyad. This is a specialty of some early childhood mental health professionals who work on improving the relationship, according to Dr. Earls. The CMS bulletin describes promising results for intensive interventions on mother-child attachment.
Home visiting programs, as well, can encourage positive parenting that improves maternal-child health, and Dr. Yogman suggested employers back parent support programs.
“There’s so much stigma for postpartum depression,” Dr. Yogman said. “…(People think) ‘What’s wrong with me that I’m not enjoying this wonderful baby? And I’m depressed.’ So people hide it and don’t realize how common it is, how treatable it is and how important it is to ask for help.”