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Mari Edlin is a frequent contributor to Managed Healthcare Executive. She is based in Sonoma, California.
Physicians must evaluate the use of antidepressant medications based on new guidelines from two gynecological organizations
The Incidence Of Depression runs high, and the utilization growth of antidepressants is a testament to this common condition. Unfortunately, pregnant women who also need to manage depression present a chronic-care challenge for doctors and health plans.
Between 14% and 23% of expectant moms experience depressive symptoms, according to the American Psychiatric Association (APA) and the American College of Obstetrics and Gynecologists (ACOG). Treatment with antidepressants for pregnant women is a bit tricky, prompting discussion about whether to prescribe and whether women already taking the drugs should continue their regimen despite being pregnant.
"The Management of Depression During Pregnancy: A Report from the American Psychiatric Association and The American College of Obstetricians and Gynecologists," published in Obstetrics & Gynecology (September 2009) and General Hospital Psychiatry (September/October 2009), weighs the risk and benefits of different treatment options for depression. The new guidelines should serve as a call to obstetricians to look for signs of depression in their patients.
The study also makes recommendations for pregnant women not on medication for depression, saying risks and benefits of treatment choices should be evaluated and discussed, including factors such as stage of gestation, symptoms, history of depression and other conditions and circumstances (smoking, difficulty gaining weight, etc.).
Nishendu Vasavada, MD, clinical associate professor, Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, says it is not unusual for women to be on antidepressants when they get pregnant but cautions against their use in the first trimester.
"It is generally safer to take antidepressants after the first trimester," he says, recommending the lowest possible dose and the use of Class C drugs. "Women should talk with their providers and find out as much as they can about medication choices to make the best decisions."
"The therapist is able to assess a member's condition and related issues, oversee medication regimens and communicate with the obstetrician," he says. "We can determine if a member should remain on an antidepressant once she is pregnant and when it is safe to stop taking the drug. We generally don't prescribe drugs for depression during a woman's first trimester, but provide other support."
CBHNP partnered with its sister company, AmeriHealth Mercy Health Plan, a Medicaid managed care plan in Pennsylvania, in implementing the Perinatal Depression Pilot Program in November 2008. Nurse case managers at AmeriHealth Mercy screen women for depression by phone using a validated set of questions designed for a pregnant population. Those at high-risk (15% on average) are referred to CBHNP behavioral health specialists for evaluation and appropriate interventions.
"While the member is on the phone, a nurse case manager arranges an appointment with a mental health provider to ensure these women receive timely attention. The nurse not only coordinates care but follows the member's progress, recommends appropriate resources and conducts follow-ups," says Lawrence Kay, MD, senior medical officer for the health plan. "Access for these women is the most critical issue."
As of September, 125 women have been screened, nine referred to a behavioral health provider and two to an outpatient clinic.