The Los Angeles County Maternal Mental Health Access (LAMMHA) program is a five-year program funded by The California Health Care Foundation (CHCF) to support community health centers in the identification and treatment of urgent but common perinatal mental disorders in primary care. Participating organizations are provided training and support to implement the evidence-based Collaborative Care Model (CoCM) for their perinatal population.
Context within LA County
Los Angeles County is home to nearly 10 million people living in 88 cities and unincorporated areas. Unfortunately, it also has the biggest gap between the supply and demand for perinatal mental health specialists. Within Los Angeles County, one in five women experience perinatal depression, yet the County is simply too big, with too many births a year, to provide individual perinatal mental health care to all the patients who may need it. PROMISE offers one solution. PROMISE is modeled on the well-researched, evidence-based Perinatal Psychiatry Access Program model, pioneered by McPAP for Moms in Massachusetts over a decade ago.
PROMISE
PROMISE’s goal is to increase the capacity of any provider working with a pregnant or postpartum patient to best address their mental health and substance use disorder needs. PROMISE accomplishes this in three different ways:
- Provider-to-provider, real-time phone line consultation with subject matter experts
- Provider training on all facets of perinatal mental health and SUD care
- A robust resource and referral system, anchored in the SANA SANA perinatal peer support line
Perinatal Psychopharmacology – PROMISE Case Study
A Women’s Health Nurse Practitioner (NP), concerned around a pregnant patient in her practice, called PROMISE, LA County’s newly-launched perinatal mental health and substance use disorder consultation phone line. The patient found out she was pregnant about two months ago and three weeks later, she called the NP with complaints of increasing tearfulness, worsening anxiety, strong feelings of guilt, and a noticeable lack of joy. At that time, the NP initiated sertraline (Zoloft) 25 mg daily. However, the patient did not show any improvement and in fact, felt worse, despite taking the medication regularly. The NP was not sure what to do.
The PROMISE consultant reviewed the case with the NP, including any previous mental health history, medications, or psychotherapy treatments, all of which were negative. She then discussed the standard dosing for sertraline, explaining that the target dose for depression is typically 100-150 mg a day, and can be up to 200 mg a day for anxiety. The NP was concerned about risk to the fetus with a higher dose. The PROMISE consultant reviewed the evidence that the minimum effective dose is recommended and that undertreated depression is an additional exposure to the fetus. The NP agreed to increase in 25-50 mg increments, as tolerated, until the patient found symptom relief. The patient also received resources for SANA SANA, a perinatal peer-support line run by Maternal Mental Health NOW, which she could call for support and further connection to psychotherapy.
Perinatal Psychopharmacology Consideration
Medication management of psychiatric conditions in pregnancy and postpartum is complicated by the need to not only treat the patient but also to ensure the safety of the developing fetus. Weighing the risks of untreated psychiatric disorders in pregnant women against the risks of psychotropic medications can be challenging. Ethical considerations preclude randomized, double-blind trials in this population, leaving little in the way of evidence-based guidelines. When balancing the risks and benefits of treating a psychiatric disorder, it is important to remember that all untreated psychiatric disorders have effects on functioning and quality of life, and behavioral effects such as obesity, smoking, alcohol and drug abuse, poor nutrition, suboptimal antenatal care, or intentional harm through suicide or neonaticide. Women with untreated psychosis or mood disorder may also have difficulty parenting, leading to adverse effects on child development.
In addition to considering the risks of untreated psychiatric disorder, other rules of thumb for prescribing psychotropics in the perinatal period include: avoid polypharmacy (regular use of five or more medications at the same time) when possible to reduce the number of exposures for the baby; optimize non-medication treatments such as psychotherapy; and avoid valproic acid (a commonly prescribed mood stabilizer for patients with bipolar disorder) as it is a known agent for malformation of an embryo (rate of malformations elevated in all dosage ranges and 25% at doses above 1450 mg/day) and is associated with significantly decreased IQ in children exposed in utero.
For patients of reproductive potential who are not pregnant, remember that about 50% of pregnancies are unplanned. It is important to educate patients about the risks of their medication(s) during pregnancy, and to make any medication changes before pregnancy if possible. Ideally, the patient should be psychiatrically stable for at least three months before trying to conceive.
Finally, providers should remember that they are not alone in trying to navigate this complex topic. Team-based models of care such as LAMMHA CoCM support providers in delivering high quality evidence-based care and make psychiatric consultation available. PROMISE is a great way to obtain expert input into prescribing decisions. Some patients may need referral to specialty mental health; directories of perinatal psychiatric providers are listed in the resources.
Additional Resources
- PROMISE Flyer
- PROMISE FAQ
- PROMISE Website: PROMISE Provider-to-Provider Consultation Phone Line
- SANA SANA Website: SANA SANA Perinatal Peer Support Services
- For additional resources, please see LAMMHA resource page.
References
Payne JL . Psychiatric medication use in pregnancy and breastfeeding. Obstet Gynecol Clin N Am 2021; 48:131-149.
Britt, R., Burkhard, J., Murphy, C., & Childers, A. (2023, November). Maternal Mental Health Provider Shortages & Population Risk Report. Policy Center for Maternal Mental Health. https://policycentermmh.org/maternal-mental-health-provider-shortages-population-risk-report/
Masters, G. A., Yuan, Y., Li, N. C., Straus, J., Moore Simas, T. A., & Byatt, N. (2023). Improving front-line clinician capacity to address depression and bipolar disorder among perinatal individuals: a longitudinal analysis of the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms. Archives of Women’s Mental Health, 26(3), 401–410. https://doi.org/10.1007/s00737-023-01324-1
LAMMHA is a five-year program funded by The California Health Care Foundation (CHCF) to support Los Angeles County community health centers in the identification and treatment of common perinatal mental disorders in primary care. For more information and/or to apply for an upcoming LAMMHA cohort, please visit the CCALAC LAMMHA program page and our previous blog posts on the LAMMHA program and the LAMMHA ECHO series. For more information and resources around maternal mental health in California, please visit the California Department of Public Health – Maternal Mental Health page.
*LAMMHA program partners: Community Clinic Association of Los Angeles County (CCALAC), Elevation Health Partners (EHP), Maternal Mental Health Now (MMHN), Concert Health, University of Pennsylvania (UPenn), University of California, Los Angeles (UCLA) and the Department of Psychiatry and Behavioral Sciences at the University of Washington (UW).
Co-Authors
Dr. Amritha Bhat MBBS, MD, MPH is a perinatal psychiatrist and Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington.
Dr. Emily C Dossett, MD, MTS, DFAPA is the Medical Director for PROMISE Perinatal Psychiatry Access Line, Los Angeles County Dept of Health Services.