At the end of last month President Obama signed into law  comprehensive health-care reform. Thanks to the analysis of the government relations people at the APA, I can distill some of the meaning to patients who require mental health care and to the professionals who provide it for them

Coverage For All Includes Mental Health

Virtually all Americans will have comprehensive health insurance coverage that includes coverage for treatment of mental illness including substance use disorders.The provision that  individuals may not be excluded due to pre-existing conditions or dropped because of their health status will also pertain to theses condition. Mental Health and Substance Use Disorders benefits must be offered at “parity” with other medical and surgical benefits for all insurance plans sold within the health insurance exchanges that are created under the new law. There will be no annual limit or life time limits. Private insurance costs will be subsidized for those with lower incomes.

Special Support for Delivery of Services, Education and Research  for Depression

The new legislation directs the Administrator of the Substance Abuse and Mental Health Services to award grants to centers of excellence in the treatment of depressive disorders starting in 2011. This provision is in recognition of the need to develop better methods of care for this condition. This is in addition to the funding which will continue to come from the NIH & NIMH for research.

There is also  a mandate that supports screening for women suffering from post partum depression and psychosis as well as education for mothers and their families about these conditions. There will be funding for research into the  causes, diagnosis and treatment of post partum depression and psychosis. This latter support is really the culmination of the efforts of so many people including the families of women who have died from post partum depression and led to the proposed Melanie Stokes legislation.

The overall direction of increased funding for depression, in my opinion,  confirms the recognition of depression being a systemic condition which goes beyond it simply being an important mental disorder. This is one of the many advantages and benefits of another provision which authorizes $50 million in grants for coordinated and integrated services through the co-location of primary and specialty care in community based mental and behavioral health settings. The interaction of mind and body is well established and the delivery of health care is always going to be better when there is facilitated communication and access between primary and mental health services.

Medicaid and Other State Program by Other Names

In many places the success or failure of this legislation will determine how the poorest and least advantaged are able to receive mental health benefits. Much of the action here will be on the state level and until the economy turns around this will be perhaps the most difficult part to achieve.

Medicaid eligibility will be increased 133% of poverty with 100% of federal funding to all states for newly eligible Medicaid recipients for three years. Starting in 2014, former foster children will be covered by Medicaid. Also, benzodiazepines and smoking cessation drugs will be removed from  the Medicaid exclusion drug list.

There will be the Medicaid Emergency Psychiatric Demonstration Project which requires the establishment of  a Medicaid project in up to eight states requiring  reimbursement of  certain institutions for mental diseases for services provided to Medicaid beneficiaries between the ages of 21 and to stabilize an emergency psychiatric condition under the hospital anti–dumping law known as EMTALA.

Another demonstration project would be established in up to eight states to study the use of bundled payments for hospital and physicians services under Medicaid.

A third program provides options for health homes for enrollees with chronic conditions such as serious mental illness. They would be composed of a team of health professionals providing comprehensive medical services including care coordination.

There also would be increased funding for Community Mental Health Centers which traditionally provide low cost care for recipients on Medicaid ( as well as others ).

If these programs prove to be effective, they will encourage the development of similar programs in other states.

Medicare- The Most Complicated of ALL

The Medicare Part D Coverage Gap (doughnut hote) is scheduled to be closed which of course will make it easier for seniors to get all medications which they need including psychotropic drugs.

There is 5% increase for psychotherapy services scheduled to go into effect for 2010. This is an extension of the increases scheduled for part of 2008 -09 which expired in 2010. HOWEVER, Congress has not acted to prevent the 21% reduction in the Medicare Sustainable Growth Rate which is suppose to go into effect now. They have postponed this vote twice . The establishment of an equitable Medicare fee schedule for mental health services is essential for the success of the new healthcare legislation. This is especially true if psychiatrists are able to continue to participate in the Medicare program in large numbers. Psychiatric consultation and the delivery of most effective psychotherapy is a time intensive service. While it may be possible to deliver psychopharmacology in a high quality manner in brief follow-up visits, that is usually not the case with psychotherapy. If psychiatrists have to opt out of the Medicare program in order to treat senior citizen at anywhere near their usual fee for psychotherapy they will not be able to provide psychopharmacology treatment which creates a dilemma for the patients, providers and our health care system. I have discussed this issue in a previous blog.

There are also two provisions in the new legislation pertaining to Medicare which may cause further complication in the delivery of Medicare. There would be a Payment Advisory Board which may be able to recommend reductions in Medicare payment if spending exceeds certain limits. While cost cutting could be necessary, directing it at our senior citizens, when the payment fees are borderline at best, could further limit mental health care. A second provision requires all physicians participating in Medicare to report on performance measures with failure to report bringing about a 1.5% penalty.  I think this is  a good idea once it is fairly set up but premature enforcing of this provision could discourage participation in the Medicare program.

Work Force

There appears to be some wording the legislation which allows repayment of loans to doctors who are providers of mental health services to children or will be working in under-served areas.  There also will be funding for the National Health Services Corps and for mental health education as well as training grants for  social work, graduate psychology  and child psychiatry. We need to make efforts to encourage the best students to go into professions which provide mental health services.

We need to examine the new program  and try to make it work. If it needs fixing we should advocate for changes.

Several years ago I was called to the hospital to see a 33 year old women who was in the intensive care unit. As I entered the unit with my colleague, a psychiatrist who was training in the psychiatry subspecialty which we now call Psychosomatic Medicine, we noted that there was a police guard at the patient’s door. I reviewed the medical chart which stated that the patient had attempted to kill her self by cutting her wrists and ingesting lye. It also reported the horrifying information that she had drowned her three children ages 3 weeks, 2 years and 4 years old .

The Devil Made Her Do It

As I write this now years later, it is easy to recall the sick feeling I had when I read those words. When we turned our attention to the patient, it was clear immediately that she was completely out of touch with reality. She was hearing voices which she said was that of the devil and he was telling her that he was going to torture her and make her do terrible things. She was very fearful and said she needed to die so she could go to heaven and be with her children. She also readily told us how she had saved her children from the devil and sent them to heaven.

There was some information in the hospital chart which had been obtained from her husband and her minister who told the admitting doctors that she had been a good mother and had attended church regularly. She did not have any psychiatric history although she did have the blues (some mild depressive feelings) after the birth of each of her previous children, from which she reportedly had recovered without any treatment after a few weeks. Her husband had seen that she was again feeling sad after the latest birth of a healthy infant but figured she would get over it as she had in the past. Her sister had recently moved in to the house to help out with the children as the mother hadn’t been sleeping, was complaining of bad dream and was increasingly withdrawn. The sister was out shopping when the patient killed her children and attempted suicide

Will Treatment Make Her Worse?

My junior colleague suggested to me that we could most likely easily resolve her psychosis and her terrified state by giving her antipsychotic medication. I turned to him and said that is when her troubles will really start. “If you think she is distressed now, can you, imagine how she will feel when she realizes what she has really done?” This was, in fact, what happened. We, of course, had no choice but to give her antipsychotic medication over the next several days and also started her on antidepressants. At first she began to think that all her frightening thoughts and hallucination were a bad dream. She appeared to block out what she had done to her children. However, as her psychosis completely cleared she fully understood what she had done. She then became profoundly depressed, spent the day curled up in her bed and had to receive intravenous fluids and nutrition. She still needed medical treatment for her lye ingestion but was expected to recover from it. I saw her almost daily for the next three weeks while she was in the medical hospital. She gradually began to talk with me but there was little change in her self recriminations and her profound grief although she appeared to understand that her actions were a result of a postpartum depression and psychosis. She showed some interest in learning that other women have had a similar condition and this gradually became the one topic about which she was at all comfortable in talking with me.

What Do We Know About Depression After Childbirth?

(The following is a summary of complicated clinical states for discussion in this article and should not be used for make an diagnosis which should be done a qualified physician or mental health professional)

Baby Blues

Baby blues is quite common and is reported in about half of women after childbirth.

It is characterized by mood symptoms but lacks the severity, persistence or pervasive quality of post postpartum depression. The sad feelings that are characteristic can be quite labile. A woman can start to cry for no apparent reason or a seemingly minor one. A more serious diagnosis should be considered when there is difficulty sleeping, a persistent depressed mood, diminished interest in things previously cared about or loss of self-esteem.

Postpartum Depression

The general prevalence of clinical depression in women after delivery is about 13%. Women with a past history depression of depression are at a 30% risk and those who have suffered from a previous episode of postpartum depression have a 50 % risk.

Women with postpartum depression often present with prominent anxiety and obsessive thoughts and behavior characteristically worrying about their baby’s safety or feeding habits and often questioning their own adequacy. In addition there are the usual signs and symptoms of a major depression which include sleep difficulty, loss of appetite, weight loss, persistent depressive mood, diminished interest in things previously cared about, loss of self esteem and even self destructive or suicidal thoughts.

Postpartum Psychosis

Postpartum depression rarely progresses to psychosis which occurs in about 1 to 2 cases per 1000 pregnancies

In such a situation the mother will show evidence of being out of touch with reality. This could be illustrated by having hallucinations, paranoid ideas or other delusions, which are fixed false beliefs. She could be suicidal or have ideas about killing her infant such as in the case history presented in this article or in the widely publicized case of Andrea Yates who reportedly drowned her five children in the similar belief of that she was saving them from eternal damnation. Infanticide is quite rare even in cases of psychosis but obviously can happen.

Just as post partum depression is more likely to occur in women with a history of depression, while I don’t have statistics to support this, I do assume that post partum psychosis will be more likely to occur in women with a history of a major mental illness. However it is important to note the psychosis can be manifested for the first time following childbirth and that it may never occur again.

What Causes These Conditions?

There are many factors that are believed to influence the development of postpartum depression. It is believed that the changing hormonal levels are a factor as might be a genetic predisposition. Co-morbidity with other major mental conditions as well with situations of substance abuse, domestic violence, childhood abuse and other psychological factors can play a role . I look forward to discussing this topic and the latest research in a future blog.

Treatment Approach For These Conditions

Patients with postpartum depression usually respond well to treatment. While initially often frightened by their symptoms, they are usually determined to improve their functioning as mothers and work well with their mental health professionals. Also, often key in the treatment of these women was the use of visiting nursing services and other social agencies in assisting with care of their infants and other children especially in the first few months after delivery. Obviously the support of other family members makes a big difference.

When medication is recommended, patients who understand their need for it are usually compliant and have a good response. Some patients report feeling calmer and less depressed sometimes even before the onset of the expected therapeutic effects of antidepressant medication. There are strategies for prescribing these medications for women who need them even if they are breast-feeding. In those rare cases of psychosis, antipsychotic medication can be effective in bringing about a relatively rapid improvement of those symptoms. At times, a usually brief psychiatric hospitalization is needed

Follow-up with Patient Described Above

The patient described in the beginning of this article was transferred to a special forensic psychiatric hospital unit and I lost contact with her. I feel confident that she was not convicted of murder and would most probably be determined to be under the influence of a mental disorder at the time of her actions.

I have treated many patients with postpartum blues, post postpartum depression and even a few with postpartum psychosis but I have never seen another patient who progressed to infanticide. However I have thought a great deal about this patient.

Can She Go On With Her Life?

When a mother has progressed to a point in a psychotic state where she has murdered her child or children, it may be hard to to imagine that she would recover in any way from that situation. It is easy to say to such a women, that it was not her fault; it was the disease that made her do it. While true, do we believe that she would ever accept this idea and not eternally blame herself? Can she ever go on with her life?

While I have not had the opportunity to follow up with women who have killed their infants, I have had experience in working with people who faced situations that might have seemed to be insurmountable. These have included drivers of vehicles involved in accidents where others have been killed, soldiers who have seen comrades die where they survived, and burn victims who suffered extreme scarring that distorted their appearance in a major irreparable manner, parents who lost a child sometimes in a horrific manner and other equally difficult situations. In each of these cases, while they were deeply psychologically altered, many such persons found a way with psychotherapy and other forms of assistance to resume their lives in a meaningful manner. With some people, it was a religious or spiritual factor that made the difference. In others, it was the presence of other children and loved ones who needed them.

There May Be A Way

There often was still another element that in many cases was an essential ingredient to allow these victims of a tragic situation, to find a way to go on. They found a way to be helpful to others who might have to go through a similar tragedy.

Mothers Against Drunk Drivers (MAD) was founded and developed by parents who had lost their beloved children to drivers who were intoxicated – many of whom may have not no idea that they were too drunk too drive. How many lives were saved by the efforts of this movement and what solace did it provide to these parents to know they saved other children? The work of veteran groups in supporting other veterans and their families is well known. As a consultant to a burn unit for many years , I saw the great value of the members of the Phoenix Society who were burn survivors themselves, in helping struggling patients who were recently burned. There are other examples of such organizations and the work of people in these organizations and individuals volunteering on their own.

Recall, that I mentioned that the postpartum patient I described above had an interest in knowing that other women in the postpartum state had developed depression and psychotic ideas. That understanding might ultimately give her the ability to forgive herself and conceivably even help others to appreciate that this is something that can happen to any women. I hope that she found a way use the experience of this tragedy to do something to make her life worthwhile for herself and others.

Should There Be A Law?

It just so happens that the post partum depression and suicide several years ago of another women, Melanie Stokes, has inspired her family, friends and others to work together and advocate for federal legislation concerning post partum depression. Initially this proposed law was not passed by Congress but it has been reintroduced this year in the 2009 Congress. It was passed by the House of Representative (HR 20) and is due for a vote in the US Senate in the near future.

The Melanie Stokes Mothers Act

This bill known as the Melanie Stokes Mothers Act is not without controversy. The wording of bill is of course subject to change as it is debated. Its stated purpose is to provide education and services with respect to the diagnosis and management of postpartum conditions. The Secretary of Health and Human Services may allow such projects to include providing education to new mothers and as appropriate, their families, about postpartum conditions to promote earlier diagnosis and treatment. The advocates of this bill correctly point out in my opinion that this could save many lives and reduce the hardships and complications of post partum depression. The opponents of it are concerned that grantees would be required to screen all new mothers that they serve. They feel this could bypass informed consent (although any research I ever know of always gives the participant the right to opt out) . They are also claiming that this would lead to an overuse of antidepressant medication and suspect that the pharmaceutical industry is behind this movement. Some of the opponents have claimed that medication used to treat this condition harms women and their unborn children.

Education of Healthcare Workers About Postpartum Depression

As far as I can see this bill does not order specific mandatory testing of women for post partum depression and certainly doesn’t mandate medication. Health care workers who interact with women after childbirth should be educated about the signs and symptoms of post partum depression. Physicians should include an evaluation of the mother’s emotional condition as part of their post partum examination. I am all for these doctors and other healthcare workers to be trained on the latest information on these conditions as part of their Continuous Medical Education (CME).

Depression Chosen As Theme of OB Presidential Year

On May 6, 2009, Gerald F. Joseph Jr. MD of Louisiana became the 60th president of the American College of Obstetricians and Gynecologists (ACOG). Dr. Joseph announced that postpartum depression is the theme of his presidential initiative. He emphasizes the need to develop evidence-based guidelines for ACOG members in the areas of screening, identification, counseling, treatment, referral to specialists and development of community-based resources for women suffering from PPD.

If screening questions have been researched to be valid predictors of these conditions, this information should be readily available to them. Putting specific words or questions in their mouth is not in the tradition of good medical practice. All of this appears to be supported by this proposed legislation.

Role of Antidepressant Medication

As far as the use of antidepressants in women with post partum depression or other types of depression, there is no doubt in my mind that these medications have saved untold numbers of lives and reduced much suffering. The value of them easily outweighs the side effects and occasional adverse reactions, which of course must be fully understood by the treating doctors and their patients.

I welcome your comments on the subject of this blog.

* Personal identifying information and some details have been disguised to protect confidentiality