SUPPORTING MOTHERS WITH MENTAL ILLNESS: POSTPARTUM MENTAL HEALTH SERVICE LINKAGE AS A MATTER OF PUBLIC HEALTH AND CHILD WELFARE POLICY.

• Author: Krohn, Jesse
• Position: Medical condition overview

1. INTRODUCTION 3 II. CONSEQUENCES OF TREATMENT DISCONTINUITY 4 III. MOTHERS AT HEIGHTENED RISK OF TREATMENT DISCONTINUITY 7 IV. ROOT CAUSES OF TREATMENT DISCONTINUITY 10 V. CONCLUSION: POLICY PROBLEMS, POLICY SOLUTIONS 13 I. INTRODUCTION

   Jalisa (1) was diagnosed with schizophrenia when she was nineteen. Her condition was well-managed by antipsychotic medications, and with the help of Supplemental Security Income ("SSI"), she was able to live independently and maintain a clean one-bedroom apartment. This all changed when she became pregnant. Although research increasingly demonstrates that antipsychotics are safe during pregnancy, (2) due to overlapping physical health challenges (preexisting hypertension and pregnancy-related elevated blood sugar levels), Jalisa's doctor recommended that she taper off of her medication for the duration of her pregnancy.

   Although at first Jalisa attended all of her prenatal appointments and appeared to be doing well, during her third trimester, she began missing appointments and her condition deteriorated quickly. Neighbors contacted Jalisa's mother after they smelled smoke coming from the apartment and pushed their way in. They found that Jalisa had set the curtains on fire, and was sitting quietly, not reacting. They put out the fire and tried to speak to her, but she was experiencing auditory hallucinations and her speech was disorganized. Jalisa's mother was not helpful in arranging care for her daughter. She also had schizophrenia, and although she and Jalisa were tightly bonded, Jalisa had spent much of her youth in out-of-home placements.

   Jalisa was hospitalized for several weeks, during which time she delivered a healthy baby boy. Although Jalisa's condition improved markedly once she was again receiving antipsychotic medication, she had no recollection of setting the fire. Child welfare authorities placed the child with the father, with the social worker advising the father not to permit Jalisa any access to the child once she was released. Jalisa was released just weeks after the delivery. Deeply depressed and discharged without a feasible plan to bridge services from her inpatient placement to her return to the smoke-stained apartment, (3) Jalisa stopped taking her medication. She had to be hospitalized again, further jeopardizing her chances of reunifying with her infant son.

   Evidence suggests that the perinatal and postpartum periods feature high levels of health care fragmentation, particularly for low-income mothers of color like Jalisa. (4) For mothers with mental health conditions, this can result in treatment discontinuity in the postpartum period. This treatment discontinuity places mothers at risk for poor health outcomes and maladaptive parenting approaches; threatens the health and safety of infants; and triggers often costly and stressful child welfare involvement. (5) This article will explore the negative consequences and root causes of treatment discontinuity, as well as particularized population vulnerabilities for treatment discontinuity, including mothers who, like Jalisa, have had involvement with child welfare as parents and also when they were children. This article will also explore the manner in which patient protection policies may aggravate the experience of treatment discontinuities, and provide public health and child welfare policy solutions for reducing treatment discontinuity and improving mental and physical health outcomes for new mothers and infants.

2. CONSEQUENCES OF TREATMENT DISCONTINUITY

   While treatment discontinuity in pregnancy is medically necessary under some circumstances, it is not without risks and may occur at a rate that exceeds medical necessity due to maternal safety concerns. (6) Furthermore, treatment discontinuity that begins or extends into the postpartum period presents significant challenges for maternal health and parenting outcomes. For example, for mothers with schizophrenia, the duration of untreated psychosis has been found to be, among a broad range of factors, the strongest predictor of symptom severity after treatment is resumed, even controlling for the baseline severity of symptoms. (7) Mothers with depression who experience treatment interruptions during pregnancy present a variety of adverse health outcomes, (8) including, unsurprisingly, substantially higher rates of relapse. (9) Similarly, disruption of treatment with lithium or other mood stabilizers for mothers with bipolar disorder is associated with a high risk of early relapse and suicide; putting them at further risk, pregnant women actually experience a higher proportion of depressive or mixed episodes after discontinuing lithium than nonpregnant comparators, even after controlling for differences in factors such as the age of onset, duration of illness, and number of prior episodes. (10) Mothers with untreated mental illness are also more likely to engage in risky behavior such as engaging in substance abuse or self-harm. (11)

   Compounding the problem of mothers with mental illness being harmed by not receiving treatment during pregnancy or in the postpartum period is the coinciding problem of missed or delayed diagnosis. Pregnant women are less likely than other women to have symptoms of mental illness identified as such; they are also less likely to receive treatment than other women once diagnosed, with pregnant women from already-marginalized groups (young mothers, mothers of color) being particularly poorly served. (12)

   Of course, when pregnant women and mothers with mental illness go without treatment it is not only the mothers, but also the children, who are at risk of poor health outcomes. Mothers who self-medicate with drugs and alcohol during pregnancy deliver infants presenting with a host of related physical health issues, including low birth weight; fetal alcohol syndrome; withdrawal; neurobehavior abnormalities; hyperactivity, and other behavioral issues. (13) The health of the mother directly affects the health of the fetus, but the risk to children does not end at birth, as treatment discontinuity places mothers at risk of adopting a host of maladaptive parenting approaches. (14) Mothers with depression in the postpartum period are less likely to engage with their children, adversely affecting development, and are less likely to follow daily routines. (15) Mothers with psychiatric disorders are more likely than other mothers to engage in poor home safety practices, and commit acts of physical abuse and neglect. (16) With respect to poor home safety practices, mothers with depression are, for example, less likely to lay their children down in the back sleeping position, to consistently use a car seat, and to supplement an infant's diet with water, juice, or cereal inappropriately early; they are more likely to rely on the emergency room for their children's health care. (17) With respect to physical abuse, anecdotal evidence from child fatality review suggests that treatment discontinuity has played a role in infant deaths. (18)

   Consider the case of Toccara, a young, low-income, African American mother with bipolar disorder and a chaotic family history. Toccara was found wandering nude in the frigid February air in the area surrounding Temple University, nearly six miles from her home in the impoverished Point Breeze neighborhood of Philadelphia. Less than a year postpartum with her third child in as many years, Toccara was off her medication. She was hospitalized, and a social worker and police officer were dispatched to her home, where she had left her three children alone with two older cousins. One of Toccara's children was dead, his body placed on the stairs. The oldest child present, just eight years old, described how Toccara had been "hugging" the boy for hours, crying, then left the house. When the police confronted Toccara in the hospital, it became apparent that she had not even realized the child was dead, and that her "hugging" had smothered him.

   While this is an extreme example, it highlights not only the severe consequences of maternal treatment discontinuity on children, but also the important complicating factors of poverty and race. The relationship of mental health and poverty is bidirectional. Mental health problems are known to increase the probability of poverty, while at the same time, mothers in poverty are more likely to experience mental health problems, including depression. (19) This is most severe for non-Hispanic black mothers like Toccara, among whom disproportionately high rates of depression and co-occurring financial adversity are coupled with low rates of mental health service receipt. (20)

   Treatment discontinuity imposes tremendous costs. The health and safety of mothers is threatened, as well as that of their children, due to heightened risk of harm in utero, and their mothers exhibiting maladaptive parenting characteristics after birth, including neglect (medical and otherwise), abuse, and inability to cope with grinding poverty. There are also social costs, in terms of expenditures on anti-poverty programs and already over-burdened child welfare infrastructure, which will be discussed further, infra.

3. MOTHERS AT HEIGHTENED RISK OF TREATMENT DISCONTINUITY

   Not all mothers with mental illness are at equal risk of treatment discontinuity. Low-income women like Toccara are more likely to experience treatment discontinuity than better resourced women. (21) This of course results in a racial disparity: due to the relatively weak economic position of women of color, they are more likely than white women to experience treatment discontinuity due to lack of resources. (22) Exacerbating the problem, low-income women of color are more likely than white women to experience postpartum depression to begin with. (23) However, even within the population of low-income mothers of color, there are subsets of women with particularized vulnerabilities.

   Young women are less likely than older...