In September 2022, The United States Preventive Services Task Force (USPSTF) invited public comment on the draft recommendations for screening for suicide risk, and anxiety in adults. The Policy Center, formerly 2020 Mom submitted the following letter co-signed by 10 other organizations. It commends the USPSTF for its recommendation to screen adults, including the perinatal population, for anxiety, and suggested those who disclose suicidal ideation on a depression screener, be screened for suicide risk. Read more below.

Dear U.S. Preventive Services Task Force,

Thank you for providing the opportunity for public comment on the USPSTF draft recommendations for “Screening for Depression and Suicide Risk in Adults” and “Screening for Anxiety in Adults.” We are writing as a collective group of non-profit organizations working to solve challenges in diagnosing and treating those with Maternal Mental Health disorders (MMHDs) in the U.S.

Maternal Mental Health Disorders (MMHDs) are the most common complications of pregnancy leading to a wide range of adverse health outcomes for the mother and baby.1 Affecting up to one in five women, MMHDs include a range of disorders including but not limited to depression and anxiety.1 Rates of MMHDs, including Anxiety, have risen during and post the COVID-19 pandemic due to physical and social isolation and increased financial burdens. Anxiety in perinatal women previously affected 29% of the population and rose to 72% during the pandemic.2 Additionally, due to structural racism, Black women are disproportionately affected by MMHDs (facing rates double that of white women) and are less likely to have access to mental health care.3 The Centers for Diseases Control and Prevention issued its latest report in September 2022 and found that 80% of pregnancy-related deaths that occur during and up to one year after pregnancy can be avoided.4 Suicide is a leading cause of maternal death in the first year following childbirth.5

Following is our feedback on the draft USPSTF recommendations:

Screening for Depression and Suicide Risk in Adults
Recommendation: “The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in the adult population, including pregnant and postpartum persons as well as older adults.”

Comment:
We applaud the extensive research conducted by the USPSTF to understand the benefits and risks of screening for suicide in the general population. We, however believe that the USPSTF shouldn’t have considered suicide screening for all patients, but rather screening for the risk of suicide when a person reports thoughts of suicidal ideation through the completion of a depression screener. This “if this, then that” approach is both feasible in primary care and obstetric care settings and is critical to saving lives. We want to ensure the USPSTF is aware of the following research on maternal suicide:

  1. Maternal suicide deaths are more common than maternal deaths caused by postpartum hemorrhage or hypertensive disorders6
  2. Suicide accounts for up to 20% of maternal deaths that occur in the postpartum period7
  3. Maternal suicide is most frequently completed between 6 to 12 months postpartum8
  4. Depression during pregnancy greatly increases thoughts about suicide while pregnant9
  5. Research shows that screening has reduced symptoms of depression and decreased the risk of suicide10

Because of the high rates of maternal suicide, we encourage the USPSTF to recommend screening for suicide risk when a person reports suicidal ideation in a depression screener.

Screening for Anxiety in Adults
Recommendation: “The USPSTF recommends screening for anxiety in adults, including pregnant and postpartum persons.”

Comment:
We applaud the addition of screening for anxiety. It is vital to screen for anxiety in pregnant people because anxiety is more common than depression and can be a precursor to depression, supporting early diagnosis and treatment of depression.11

We acknowledge that finalized USPSTF A/B recommendations mean that services must be covered by insurance at no cost-share for the patient, however, we would like to highlight the importance of increasing the workforce capacity in Obstetric and PCP settings so screening for depression and anxiety will actually occur. Capacity-building strategies must include adjustment of capitation rates or reimbursement on a Fee-For-Service (FFS) basis for screening and support with follow-up care, for those who are both privately and publicly insured. Additionally, Behavioral Health Integration (BHI) efforts must be scaled if these recommendations are to be adopted by providers. Novel workforce solutions like embedding certified peer support specialists into Obstetric and PCP settings, with support provided by payers about how to bill for these services, should be addressed with urgency.

We appreciate your consideration of these recommendations, and we are grateful for this opportunity to share feedback. Please don’t hesitate to contact Sarah Johanek with questions or clarifications, at [email protected].

Sincerely,

2020 Mom
American Psychological Association
Children Now
Georgetown University Center for Children and Families
Lifeline for Families Center and Lifeline for Moms Program at the UMass Chan Medical School
Mom Congress
MomsRising
National Birth Equity Collaborative
Postpartum Support International
Shades Of Blue Project
Women’s Behavioral Health at Women & Infants Hospital of Rhode Island

References

1. Howard, L. M., & Khalifeh, H. (2020). Perinatal mental health: a review of progress and challenges. World psychiatry: official journal of the World Psychiatric Association (WPA), 19(3), 313–327. https://doi.org/10.1002/wps.20769

2. Davenport, M. H., Meyer, S., Meah, V. L., Strynadka, M. C., & Khurana, R. (2019). Moms Are Not OK: COVID-19 and Maternal Mental Health. Frontiers in Global Women’s Health. https://doi.org/10.3389/fgwh.2020.00001

3. Hernandez, Natalie (2022) “Addressing Maternal Mental Health among Black Perinatal Women in Atlanta, Georgia: a CBPR approach,” Journal of the Georgia Public Health Association: Vol. 8: No. 3, Article 14. DOI: 10.20429/jgpha.2022.080314. Available at: https://digitalcommons.georgiasouthern.edu/jgpha/vol8/iss3/14

4. Four in 5 Pregnancy-Related Deaths in the U.S. Are Preventable, Centers for Disease Control and Prevention, 19 Sept. 2022, https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html.

5. Orsolini, L., Valchera, A., Vecchiotti, R., Tomasetti, C., Iasevoli, F., Fornaro, M., De Berardis, D., Perna, G., Pompili, M., & Bellantuono, C. (2016). Suicide during Perinatal Period: Epidemiology, Risk Factors, and Clinical Correlates. Frontiers in psychiatry, 7, 138. https://doi.org/10.3389/fpsyt.2016.00138

6. Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. J. (2011). Homicide and suicide during the perinatal period: Findings from the National Violent Death Reporting System. Obstetrics and Gynecology, 118(5), 1056–1063. Retrieved from https://doi.org/10.1097/AOG.0b013e31823294da

7. Lindahl, V., Pearson, J. L., & Colpe, L. (2005). Prevalence of suicidality during pregnancy and the postpartum. Archives of Women’s Mental Health, 8(2), 77–87.

8. Goldman-Mellor, S., & Margerison, C. E. (2019). Maternal drug-related death and suicide are leading causes of post-partum death in California. American Journal of Obstetrics and Gynecology. doi:10.1016/j.ajog.2019.05.045

9. Campbell, J., Matoff-Stepp, S., Velez, M. L., Cox, H. H., & Laughon, K. (2021). Pregnancy-Associated Deaths from Homicide, Suicide, and Drug Overdose: Review of Research and the Intersection with Intimate Partner Violence. Journal of women’s health (2002), 30(2), 236–244. https://doi.org/10.1089/jwh.2020.8875

10. Miller, Benjamin, and M. Justin Coffey. “Understanding Suicide Risk and Prevention.” 2021, https://doi.org/10.1377/hpb20201228.198475.

11. Kalin, Ned H. “The Critical Relationship between Anxiety and Depression.” American Journal of Psychiatry, vol. 177, no. 5, 2020, pp. 365–367., https://doi.org/10.1176/appi.ajp.2020.20030305.