Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety.

In Reply: We appreciate Dr. Bhat’s interest and commentary on our recent Consensus Bundle on maternal mental health1 and agree with the critical importance of ensuring a health systems response to any depression screening protocol. Dr. Bhat describes one such model, collaborative care, as one mechanism to further a systems-based response to maternal mental health conditions. The intent of the Maternal Mental Health Bundle is to be nonproscriptive. Recognizing that resources and capacity to implement all Bundle elements will vary among health care providers, the Bundle provides a framework to guide integration of maternal mental health assessments and interventions across practice settings. Further, the Bundle commentary recognizes that a variety of therapy modalities and approaches to care may be effective for addressing perinatal mood and anxiety disorders.1 We agree that collaborative care is an excellent system of mental health care delivery, with compelling data from two randomized trials in the perinatal setting to support its practice.2,3 However, there remain pragmatic barriers to broad implementation of collaborative care. First, a central tenet of collaborative care is care management to enable maintenance of a patient registry to track adherence and response.4 Although Medicare has developed new behavioral health integration billing codes (G0502, G0503, G0504) to reimburse for these care management services, Medicaid and commercial insurances have yet to follow suit. Thus, although collaborative care has been demonstrated to be cost-effective,5 initial cost-neutral implementation of a true collaborative care model remains a challenge in the perinatal population without an independent funding source such as one provided through a clinical trial. In addition, gaps in mental health coverage continue to limit access to psychiatric consultation or the brief psychological therapies that may be recommended by a collaborative care program. Finally, there are regional differences in preferences for interventions that must be considered in staffing plans. Recommendations to tailor the collaborative care model toward regional perinatal patient treatment preferences are needed to assist individual sites with implementation. Owing to these current pragmatic limitations, and in keeping with the nonproscriptive nature of the Consensus Bundle, the workgroup could not recommend application of collaborative care across all perinatal settings. However, we certainly agree with Dr. Bhat that collaborative care holds strong promise as an example of an evidence-based health system approach to optimizing maternal mental health. We invite you to visit the Council on Patient Safety in Women’s Health Care website at http://safehealthcareforeverywoman. org/ to view Safety Action Series related to maternal mental health, including a recent webinar highlighting Collaborative Care Models for Perinatal Health.