Postpartum depression and engagement with VA care among Veterans

Abstract: INTRODUCTION: Since 2012, the Veterans Health Administration (VA) has offered the Maternity Care Coordination-Telephone Care Program (MCC-TCP) to pregnant Veterans to bridge community obstetrical care with ongoing VA care. Currently, over 160 Maternity Care Coordinators, primarily comprised of nurses and social workers, serve all VA facilities. Veterans report high satisfaction with the MCC-TCP, which historically included one postpartum contact. In October 2023, in response to the Protecting Moms Who Served Act (P.L. 117-69), the VA expanded the MCC-TCP by increasing the number of postpartum contacts from one to five in the first year following delivery. This expansion will augment care for postpartum Veterans, a vulnerable period given the risk for the development of postpartum depression (PPD). Past studies have shown that nearly 1/3 of Veterans exhibited depression symptoms during pregnancy and a quarter of Veterans are diagnosed with PPD. However, PPD and rates of postpartum engagement with VA mental healthcare have not been previously examined. METHODS: Postpartum Veterans were identified from an existing cohort of Veterans receiving VA care from one of 15 facilities nationwide. All participants delivered a newborn between April 2016 and August 2021. Sociodemographic and health data were obtained from surveys and the VA electronic health record. PPD symptoms were ascertained through the Edinburgh Postnatal Depression Scale (EPDS) administered during a postpartum survey. We conducted two sets of adjusted logistic regression models: the first examining associations between sociodemographic factors and postpartum depression symptoms (EPDS ≥ 10); the second examining associations between sociodemographic factors and receipt of postpartum mental healthcare (defined as 1+ visit with a VA mental health provider or receipt of a 30 + day antidepressant prescription). All analyses were conducted in SAS Enterprise Guide 8.3. RESULTS: In our sample of 860 Veterans, 15.5% (n = 133) had an EPDS ≥ 10. By 1 year postpartum, 50% and 65% of Veterans with EPDS ≥ 10 received an antidepressant prescription or had a VA mental healthcare visit, respectively; however, 23.3% of Veterans with EPDS ≥ 10 did not receive any VA mental healthcare in the first postpartum year. We found that Veterans of color (aOR 1.71; 95% CI 1.04–2.80, vs. White Veterans), Veterans who had experienced military sexual trauma (MST; aOR 2.24; 95% CI 1.31–3.85, vs. no MST), and Veterans with a history of depression (aOR 2.47; 95% CI 1.43–4.27, vs. no depression history) were more likely to have EPDS ≥ 10. Engagement with mental healthcare during pregnancy, either in the form of mental health visits or receipt of an antidepressant prescription(s), was the only significant predictor of receiving care in the first postpartum year. These results were consistent for our entire cohort (aOR 9.42; 95% CI 6.28–14.11, engagement vs. no engagement) and when examining only Veterans with EPDS ≥ 10 (aOR 7.56; 95% CI 2.56–22.34, engagement vs. no engagement). DISCUSSION: We found that PPD symptoms varied among Veterans by race, military sexual trauma experience, and history of depression. These findings are similar to our past work, although we identified symptoms in a smaller proportion of Veterans than we anticipated. Furthermore, we found that 1/5 of Veterans with EPDS ≥ 10 received no VA care in the first year postpartum, with the strongest predictor of receiving any VA postpartum mental healthcare being receipt of mental healthcare during pregnancy. These findings may suggest that Veterans who are not previously engaged with mental healthcare may be less likely to access care in the postpartum period. As the number of PPD screenings will increase with the MCC-TCP expansion, there may be opportunities to connect more postpartum Veterans with care as needed. Aside from increased referrals to VA mental healthcare providers, there are several potential areas to target for decreasing postpartum depression symptoms. These include support groups, which we found to be acceptable to and desired by the perinatal Veteran population, and increased availability throughout the VA of interventions such as ROSE and Survivor Moms’ Companion, psychoeducation programs for PPD and posttraumatic stress that are currently being piloted throughout the VA system. Focusing resources on those who may need care the most, particularly minority Veteran populations, those with trauma histories, and Veterans without existing VA mental healthcare, will be important considerations for these new policy efforts.