A first reflex in taking in a tragedy of the rarity, horror and sadness of the suspected murder-suicide that occurred last week in St. Louis is to sift through the ashes looking for clues to warning signs that might have helped prevent it. Whether any signs are found may depend on whether Mary Jo Trokey — the new mother suspected of killing her family and herself — was ever screened for a perinatal mental health condition; if screened, whether she accessed treatment; and if treated, whether the treatment was optimized to meet the demands of any catastrophic mental health condition. Any adverse event that stems from a new parent’s unrecognized or untreated mental health condition should serve as a warning signal that our community and our health systems can do better.
Perhaps it is not widely known, but The American College of Obstetricians and Gynecologists recommends screening at least once during the perinatal period — which spans pregnancy and the first year after a baby’s birth. And the American Academy of Pediatrics recommends screening at the 1-, 2-, 4-, and 6-month well-baby checkup visits.
Most important, validated screening tools exist at each of these stages to identify nearly all parental psychiatric syndromes, most notably postpartum depression in mothers. Such screenings take only minutes to complete but typically are not paid for by health insurers and, therefore, occur inconsistently, though many conscientious obstetricians and pediatricians do their best to adhere to the guidelines.
Inconsistent screening levels, however, are not nearly adequate to identify mental health conditions that commonly (on the order of 20 percent of all live births) endanger mothers and their infants in less spectacular but nevertheless enduring and catastrophic ways — ranging from chronic depression to maternal suicide to infant neglect or abuse — and that disproportionately affect the tens of thousands of U.S. mothers whose temporary pregnancy insurance — primarily through Medicaid — expires 60 days after their babies are born. Screening is a necessity, as research shows that a majority of women with these symptoms will not report them on their own.
Currently, in Jefferson City, we have an opportunity to address this sad state of affairs by extending the period of Medicaid coverage for new mothers who are otherwise uninsured. Evidence from the United Kingdom shows that the cost of untreated postpartum mental health conditions is £8.1 billion — more than $11 billion — per year, while the annual cost of effective treatment is 15 percent of that total, suggesting a true opportunity for significant cost savings.
Despite a lack of medical insurance reimbursement, over the past five years BJC HealthCare has piloted early universal screening (during pregnancy and upon delivery) under the auspices of the Washington University Perinatal Behavioral Health Service. We have shown that screening, referral and initial psychotherapy services whenever necessary can be delivered at a cost of about $285 per screened family.
This effort materialized on the basis of generous support from the Steward Family Foundation, Generate Health, the Missouri Foundation for Health, the Foundation for Barnes-Jewish Hospital, the St. Louis Children’s Hospital Foundation, the St. Louis County Children’s Service Fund, Eden’s Army, the Ollie Hinkle Heart Foundation and private donors — all of whom had the foresight to invest in a model that standardized the delivery of mental health screening and treatment services for all new mothers.
Other community agencies and providers have followed suit, many with support from the Perinatal Behavioral Health Initiative launched by Generate Health in 2017, the central goal of which is to create a standardized screening and referral protocol for the entire region.
The opportunity is upon us to make comprehensive screening at regular intervals the standard of care, to ensure that such screenings are paid for, and that all mothers who screen positive have access to the mental health interventions that will adequately support them, their newborn babies and their families.
Dr. Cynthia Rogers and Dr. John N. Constantino work in the Department of Psychiatry at the Washington University School of Medicine and St. Louis Children’s Hospital.