The number of women with perinatal mood and anxiety disorder (PMAD) has spiked sharply in the United States. A new study explores trends by state and time period.

Between 2008 and 2020, in a national cohort of 750,004 commercially insured women with a live birth, nearly one in five (144,037 [19.2%]) were diagnosed with PMAD, according to a paper published in Health Affairs. PMAD diagnoses among privately insured women increased by 93.3% over those years, wrote lead author Kara Zivin, PhD, of the University of Michigan, Veterans Affairs Ann Arbor Healthcare System, and colleagues.

PMAD describes a spectrum of emotional complications with mild to severe symptoms that can affect women while pregnant and through the first year after giving birth.

The total number of perinatal women decreased from a high of 64,842 in 2008 to a low of 52,479 in 2020, a 19.1% decrease, but over the same time, women with diagnosed PMAD increased 56.4% from 9520 in 2008 to 14,890 in 2020. Prevalence of PMAD doubled from 1468 per 10,000 deliveries to 2837 per 10,000 deliveries in 2020, according to the analysis.

Differences by State

Increases differed substantially by state. Though average annual changes across all states reached 109 additional PMAD diagnoses per 10,000 deliveries, Iowa had the greatest increase with an additional 163 PMAD diagnoses per 10,000 deliveries annually. New Mexico had the smallest annual growth, at an additional 49 per 10,000 deliveries.

The increases were accompanied by maternal health improvement efforts. The Affordable Care Act (ACA) required insurance companies to cover maternity and preventive services, which likely increased PMAD screening and detection, the researchers noted.

“Diagnosis of PMAD is rising due to increased awareness and in all likelihood, decrease in stigma, but availability of providers is so challenging,” said Lee S. Cohen, MD, who was not part of the study. Dr Cohen is director of the Ammon-Pinizzotto Center for Women’s Mental Health and Perinatal and Reproductive Psychiatry at Massachusetts General Hospital in Boston. “The navigation to providers by women who are suffering is beyond challenging,” he said.

The authors reported that all states except Vermont saw increasing rates of PMAD diagnoses post-ACA vs pre-ACA. The researchers also found that relative to the period from 2008 to 2014, psychotherapy rates continued rising from 2015 to 2020 and suicidality (suicidal ideation or self-harm diagnoses) rates declined.

States’ Suicidality Rates Vary Widely

“Overall, access to psychotherapy may have stemmed suicidality despite increasing PMAD diagnoses. But although more PMAD diagnoses may have led to increased psychotherapy, therapy access depends on provider availability, which varies by geographic region and insurance coverage network,” the authors wrote.

Suicidality rates differed greatly by state. Louisiana’s annual rate of increase was greatest, at 22 per 10,000 while Maryland had the greatest negative annual rate of change, at −15 per 10,000 deliveries, the authors explained.

“Observed trends in PMAD diagnoses among privately insured people during 2008-2020 and in associated suicidality and psychotherapy use suggest an increasingly rapid worsening of US maternal mental health,” the authors wrote.

The authors noted that this study did not include those on public insurance, a group that may experience disproportionate maternal morbidity and mortality burden, and urged that future studies include them.

Strengths of Study

Kimberly McKee, PhD, MPH, assistant professor in the department of family medicine at University of Michigan in Ann Arbor, who was not part of this research, said this paper gives a broader look than prior work because it includes the year before and after birth, rather than delivery and hospitalization.

“It’s really important to look out at least 12 months postpartum,” she noted.

Another strength is that the study was able to look at use of services such as psychotherapy before and post ACA. She noted the increased use of psychotherapy and the decrease in suicidal ideation was an association, but said, “I think it’s reasonable to assume that there was a benefit.”

She noted that these data go through 2020 and the COVID-19 pandemic has even further stressed the healthcare system, which could affect these numbers.

Primary Care’s Role

“The opportunity for primary care to really be the medical home for reproductive-age women is key here,” Dr McKee said, adding that primary care can provide the continuity if women go off and on insurance around pregnancy and make sure the women get follow-up care and referrals to specialty care.

Models that integrate behavioral health and primary care are particularly promising, she said. Inclusion of social workers at the point of care can also help meet needs regarding social determinants of health.

Telehealth is another avenue for expansion extending the reach for following perinatal women, she said. “Using every tool we have to reach individuals where they are can allow for more frequent check-ins, which is really important here.”

Dr McKee said the paper highlights an important reality: Mental health is a leading cause and contributor to maternal mortality, which “is 100% preventable.” Yet, current literature continues to show increases.

“This is a fairly common problem that affects not just women, but the fetus, their children, their families,” she noted.

The authors and Dr Cohen and Dr McKee reported no relevant financial relationships.

This article originally appeared on, part of the Medscape Professional Network.

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