AUTHOR COURTESY COPY
BRIEF REPORTS
State Mandates Regarding Postpartum Depression
Paul J. Rowan, Ph.D., M.P.H., Stephen A. Duckett, M.P.H., John E. Wang, B.S.
Objective: Postpartum depression continues to be undertreated. This project identified state policies that have been
enacted regarding peripartum mental health and assessed
how effective they might be.
Methods: A systematic search strategy was used to detect
state-level legislative initiatives. Legislative tracking resources
were used to determine which were enacted. Policies were
sorted into categories. Related evidence was reviewed to
gauge the impact of each category.
Results: Thirteen states have enacted one or more statelevel peripartum mental health policies. Categories include
Estimates of the prevalence of peripartum depression range
from 5% (1) to 14% (2) and higher. Suspected negative outcomes are many, including premature delivery and lower
levels of newborn attentiveness and emotional expression
(2). Undertreatment has been widely recognized (3). Obstetric providers have been encouraged to detect depression
and to promote access to appropriate care (2).
To address undertreatment, some states have enacted
policies addressing peripartum mental health. Policies might
target patient barriers, which include lack of coverage,
lack of proximity of an acceptable provider, difficulty obtaining time off from work, stigma, and wariness of psychopharmacologic treatment (1,3). Also, a successful policy
might address provider barriers, such as reluctance or
inability to properly assess mood problems and to provide
acceptable interventions to patients in need (3). Finally,
effective policies might address structural aspects of the
health care system, including fragmented delivery systems and extension of health insurance access to the
uninsured.
This investigation was conducted to identify and summarize policy approaches that have been taken by states, to
review evidence of policy effectiveness, and, in the absence
of effectiveness evaluation, to evaluate the degree to which
any policy might translate into improved mental health. A
focus on states is appropriate because states generally hold
jurisdiction over health care and are recognized sources of
policy innovation.
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patient education mandates, depression screening mandates,
mandated task force, and public awareness campaigns. Those
mandating screening include Illinois, Massachusetts, New
Jersey, and West Virginia. Related outcomes evidence suggests a very limited impact.
Conclusions: Several states have enacted policies addressing
peripartum mental health, but these are probably not influencing
clinical outcomes. Home visits with a mental health component
are effective for postpartum depression; state policies could
support home visits.
Psychiatric Services 2015; 66:324–328; doi: 10.1176/appi.ps.201300505
METHODS
The criterion for inclusion as a state peripartum mental health
policy was as follows: a state-level legislative code law that is
intended to improve detection or treatment of peripartum
mental illness. A Web search strategy that used verified, optimal search terms was developed to detect policies. It seemed
likely that any state legislative proposal would be noted on at
least one Web page, whether by the bill’s sponsor, an advocacy
organization, a health care organization, or a news organization.
Relevant search results were investigated to resolution: either
identification of a state-level legislative code or dismissal as
a false positive.
Because a few state policies were already known, likely
search terms were tried to determine the fewest search term
categories (that is, legislation category and depression category)
and the fewest search terms for each category (that is, “mental”
and “depressive” for the depression category) that would reliably produce Web search results that included the known
policies. Three essential concepts had to be covered by the
search terms: depression, the peripartum, and legislation. Although many terms were tried, Web pages addressing the
known state policies were identified by Web searches of the
name of the state and two terms for each of the three categories:
“depression” and “depressive,” “peripartum” and “postpartum,”
and “legislation” and “legislative.”
Each term of each pair was crossed with each term of the
other two pairs, yielding eight sets of keyword searches for
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ROWAN ET AL.
each state (for example, “depressive,” “postpartum,” and
“legislation”). In this search development stage, the known
state policies emerged within the first 20 Web search
results. Therefore, the first 40 results were reviewed for
thoroughness. The search was carried out from April 2013
through August 2013. States with pending legislation (such
as the failed 2013 New York initiative S.7234) were monitored
across this time span, and states with policies were again
reviewed in July 2014 to determine whether any subsequent
policies had been enacted.
For each identified bill, the state’s legislative tracking resources were used to determine whether it had been enacted.
The approaches of enacted policies were analyzed, according
to framework analysis methods (4), to identify categories of
policies.
RESULTS
Thirteen states have enacted policies to address peripartum
mental health (Table 1). Analysis yielded four categories:
education mandates, by which a woman or family member
must receive education regarding peripartum depression;
screening mandates, by which health care providers must
screen for depression in the peripartum; postpartum depression awareness campaigns to be delivered to the populace
generally; and task force mandates, by which a state-level task
force or study group is mandated to investigate and report on
aspects of peripartum mental health.
States mandating screening include Illinois, Massachusetts, New Jersey, and West Virginia. The three task forces
had varied mandates. The 2005 Texas study evaluated the
benefit of including postpartum depression as a qualifying
condition for Medicaid. West Virginia’s 2006 study evaluated factors, such as maternal health, that contribute to low
birth weight and infant death. Oregon’s 2009 task force
noted state-level “actions to be taken” regarding “maternal
mental health disorders.”
Three of these 13 states later strengthened or expanded
a previously enacted policy. Virginia added midwives to
those under its education mandate. Minnesota added WIC
providers (Special Supplemental Nutrition Program for Women,
Infants, and Children) under its education mandate. New Jersey
changed the wording of its education and screening mandate
from “should” to “shall,” reducing clinical discretion.
Along with these 13 states, two others—Vermont and
Illinois—enacted peripartum health care policies that address peripartum psychosocial needs but not peripartum
depression specifically. In 1996, Vermont established a task
force to address public concern over the increasing practice
of hospital discharge within 24 hours after delivery. This
led to the state’s 1997 mandate for an evaluation of readiness for postdelivery discharge that includes assessment of
“psychosocial” and “emotional” concerns. In Illinois, a 2003
policy mandated a set of reimbursable antepartum care
practices, including mental health counseling, to address low
birth weight.
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Outcomes evidence for each of the four categories was
reviewed to estimate the degree to which any policy might
be effective. Only one of these policies has been evaluated.
For the others, related outcomes data were reviewed to estimate effectiveness.
The impact of New Jersey’s 2006 education and screening
mandate was evaluated by using data from the state’s Medicaid program (5). The portion of women initiating care,
indicated by an antidepressant prescription or by the documentation of at least one counseling session, was the same
before (6.3%) and after (6.2%) the 2006 policy change. Although this suggests that the mandate had no effect, it is
worth noting that the 2006 policy was only a modest change
from the 2000 policy.
Several studies that were not policy evaluations indicated
the degree to which peripartum depression screening efforts
might lead to engagement in mental health treatment for
depression detected by screening. Two of these studies were
clinical trials intended to treat depression. In the first, only
six of approximately 50 women were willing to enroll (6).
In the other, 40% chose to not participate in the study’s
structured clinical interview or declined any further study
participation (3).
Two observational studies have assessed the portion of
women with positive screens who connect with mental
health care. In one of these, despite follow-up monitoring, no
women made the link, even though nearly all had employersponsored health care coverage (1). Another study reported
outcomes from a depression screening program with lowincome women as part of an enhanced Healthy Start program (7). Only two-thirds accepted a mental health referral,
and only 60% of those made at least one mental health visit.
Based on this evidence, a state-level depression screening
mandate alone is unlikely to address peripartum depression.
Education mandates might increase awareness and so
increase detection. Two studies, one a randomized trial (8)
and one a historical-control trial (9), have tested whether
systematically delivered depression education led to greater
care seeking by those with elevated depression symptoms.
Neither study detected a significant effect.
Ideally, public awareness campaigns would be similar to
education mandates: recognition would lead a woman to seek
care from a provider. A spouse, friend, coworker, or health care
professional who received the campaign messages could encourage the woman to seek care. No outcomes evaluations have
been conducted of any of the state-level awareness campaigns.
A community awareness intervention to ameliorate postpartum
depression was carried out and evaluated in Australia (10).
Sixteen matched communities were randomly assigned to
receive the intervention or to serve as a comparison control.
Despite the wide array of efforts, depression scores among
postpartum women were similar between intervention and
comparison communities. A review of depression public
awareness campaigns, generally, concluded that the few that
had been conducted showed that attitudes can be changed
for a modest span of time, and these studies were not able to
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STATE MANDATES REGARDING POSTPARTUM DEPRESSION
TABLE 1. State mandates regarding peripartum mood disorders, by year enacted
State
Date
Type of mandate
Vermont
May 22, 1996
Task force
Vermont
May 2, 1997
Psychosocial evaluation
New York
December 15, 1998
Education
New Jersey
December 15, 2000
Education and screening
Virginia
March 18, 2003
Education
Illinois
August 18, 2003
Counseling reimbursement
Texas
September 1, 2003
Education
Virginia
March 22, 2005
Education
Minnesota
May 4, 2005
Education
Washington
Public awareness campaign
Texas
July 24, 2005;
Repealed:
June 30, 2012
September 1, 2005
West Virginia
February 24, 2006
Task force
New Jersey
October 10, 2006
Education and screening
Maine
June 6, 2007
Education
Illinois
January 1, 2008
Education and screening
West Virginia
May 28, 2009
Education and screening
Oregon
June 26, 2009
Task force
Oregon
March 4, 2010
Public awareness campaign
California
April 27, 2010
Public awareness campaign
Task force
Statute and title
Vermont Act No. 180 (1996 Vt., Adj
Sess.), Sec 40(a)(2), “An Act to
Coordinate the Oversight and
Regulation of Health Care and Health
Systems”
Vermont Insurance Division, Bulletin 114
(Revised), “Maternity Stay Guideline”
New York Public Health Law, Article 28
(Hospitals), 2803j, “Information for
Maternity Patients”
New Jersey Statutes, Title 26, 2-175 to
178, “An Act Concerning Postpartum
Depression”
Virginia Code Chapter 647, Section
32.1-134.01, “Relating to Perinatal
Information in Hospitals Providing
Maternity Care”
305 Illinois Compiled Statues 5/5-5.23,
“Prenatal and Perinatal Care, Illinois
Public Aid Code”
Texas Health and Safety Code, Title 2,
Chapter 161, Subchapter R, Sections
451–452, “Parenting and Postpartum
Counseling Information”
Virginia Code Chapter 647, Section
32.1-134.01, “Relating to Information
to Be Made Available to Maternity
Patients”
Minnesota Statute 145.906, “Postpartum
Depression Education and
Information”
Revised Code of Washington, Chapter
347, 2005 Session Laws, “An Act
Relating to Postpartum Depression”
Senate Bill 826, “Relating to a Study
Examining the Feasibility of Providing
Health Services for Women With
Postpartum Depression”
West Virginia Senate Resolution 27,
“Promoting Perinatal Wellness Study”
New Jersey Statutes, Title 26, 2-176, “An
Act Concerning Postpartum
Depression and Amending PL2000, c.
167”
Legislative Document 792, “An Act
Concerning Postpartum Mental
Health Education”
Illinois Public Act 95-0469, “Perinatal
Mental Health Disorders and
Treatment Act”
Chapter 16, Article 4E, “Uniform
Maternal Screening Act”
Chapter 624, Oregon Laws 2009,
“Relating to Perinatal Mental Health
Disorders; and Declaring an
Emergency”
Chapter 12 Oregon Laws 2010 Special
Session, “Relating to Perinatal Mental
Health Disorders; and Declaring an
Emergency”
Assembly Concurrent Resolution 105,
“Perinatal Depression Awareness
Month”
continued
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TABLE 1, continued
State
Date
Type of mandate
Massachusetts
August 19, 2010
Education and screening
Michigan
May 4, 2011
Public awareness campaign
Oregon
June 2, 2011
Education
California
July 28, 2011
Education, task force
Minnesota
July 1, 2012
Education
detect improved clinical outcomes (11). Therefore, it seems
unlikely that public awareness campaigns will achieve desired effects.
Might task forces be effective? Two of the three identified
task force mandates led to further actions. West Virginia’s
2006 mandated task force was followed by a 2009 state policy
calling for education, screening, and provider reporting of
screening activity. Oregon’s 2009 mandated task force was
followed in 2010 by a state mandate for a public awareness
campaign and in 2011 by an education mandate. Thus task
forces are an effective state-level policy avenue for boosting
the likelihood of future state-level actions.
Statute and title
Chapter 313, 2010 Session Law, “An Act
Relative to Postpartum Depression”
Senate Resolution 47, “A Resolution to
Declare May 2011 as Postpartum
Depression Awareness Month”
2011 Oregon Laws, Title 36, Chapter
431, Sections 862, 864, and 866,
“Maternal Mental Health Patient and
Provider Education Program”
California Assembly Concurrent
Resolution 53, “Relative to Perinatal
Depression Prevention”
Minnesota Health Statutes Chapter 145,
Section 906, “Postpartum Depression
Education and Information”
A published review of promising interventions for postpartum depression noted several strategies with efficacy data,
including mental health counseling, the collaborative care
model of depression, and peer support (12). Of the various
strategies reviewed, the one that might be promoted by a state
policy is home visit–based mental health care; states could
mandate insurance coverage for a set number of counseling
sessions. Postpartum home-visiting nurses have been shown
to be effective interventionists for postpartum depression (13)
and also are “accepted” and “accessible,” (14,15) overcoming
patient and provider barriers.
CONCLUSIONS
DISCUSSION
At least 13 states have enacted policies to address the challenge of peripartum behavioral health needs. These have
taken four forms: requiring education regarding peripartum
mood disorders, requiring depression screening, state-level
task forces, and public awareness campaigns. None of these
avenues seems especially effective for addressing barriers
to care at the patient, provider, or structural level. The
effectiveness of task forces suggests that sustained multistakeholder committees might be an avenue for fostering
new initiatives.
What state-level policies might work? Depression education and screening are obvious components of an effective
system. Any effective policy will need to address a set of
various patient barriers, which may include lack of coverage,
the distance to an acceptable provider, difficulty obtaining
time off from work, stigma, and possible wariness of psychopharmacological treatments (1,3). Also, a successful policy
will need to overcome provider barriers, such as provider
hesitancy to properly assess mood problems and to provide
acceptable interventions to patients in need (3). Finally, effective policies will need to address structural aspects of the
health care system, such as lack of insurance and fragmented
delivery systems in which mental health care is separated
physically and financially from medical care.
Psychiatric Services 66:3, March 2015
It seems that although several states have taken action, there
is no evidence that these efforts are ameliorating peripartum
depression. A successful policy will need to address a host
of barriers at the patient and provider level, as well as at the
structural level. Home visit programs could address peripartum mental health needs. Despite abundant good will,
there is no evidence that state polices are addressing this
great need.
AUTHOR AND ARTICLE INFORMATION
Dr. Rowan is with the Department of Management, Policy, and Community Health, University of Texas School of Public Health, Houston
(e-mail: paul.j.rowan@uth.tmc.edu). Mr. Duckett is with Navigant Consulting, Inc., Washington, D.C. Mr. Wang is with the College of Natural
Sciences, University of Texas at Austin.
The authors acknowledge the support of the School of Public Health,
University of Texas Health Science Center at Houston.
The authors report no financial relationships with commercial interests.
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