From 2006 to 2017, suicidality among commercially insured women increased from 0.2% to 0.6%.

Kara Zivin, Ph.D., M.S., M.A., M.F.A., recently served as senior author and principal investigator on a study about suicidality and pregnancy. She frequently emphasizes the importance of talking about mental health, suicidality, and pregnancy. Yet despite her background, she still finds it difficult to discuss her own story: When she was pregnant, she experienced depression and attempted suicide.

“As much as it’s really difficult to write about, it’s incumbent on me to shine light on these issues,” said Zivin, a professor of psychiatry and obstetrics and gynecology at the University of Michigan Medical School. She recently talked about her experience on the podcast “Anamnesis.”

Few people discuss depression and suicidality openly, making it that much more difficult for the women with perinatal mental illnesses to come forward with their stories. “You see glowing pregnant women sitting next to you at work, and everything seems perfect for them, and that’s not you,” she said. “It’s easy to blame yourself and try to hide what you’re going through. In some ways it’s concerning to hear about other people’s struggles, but it’s also helpful to realize that, in fact, you’re not alone.”

In a study Zivin and her colleagues published in JAMA Psychiatry, they found that, from 2006 to 2017, the prevalence of suicidal ideation and intentional self-harm among childbearing women in the year before or after they gave birth increased substantially.

The topic of maternal suicidality, and maternal mental health in general, does not get the attention it deserves, Zivin said. “Many people have heard of postpartum depression, but how many have heard of perinatal depression?” she said. “Anxiety is far more common than depression, as well, even before COVID, which adds a whole new dynamic to the experience of pregnancy.”

Zivin and colleagues conducted the Maternal Behavioral Health Policy Evaluation study to evaluate suicidality trends from 2006 to 2017 among childbearing individuals aged 15 to 44. They used Optum Clinformatics Data Mart, which included medical claims data from a national, commercially insured population from all 50 states. The researchers compared participants with or without a suicidality diagnosis (defined as a diagnosis of suicidal ideation and/or intentional self-harm in inpatient or outpatient settings) in the year before and after giving birth. The authors also identified whether the patients had clinical comorbidities, including depression, anxiety, bipolar disorder, psychosis, and substance use disorders.

They identified 698,239 deliveries among 595,237 commercially insured women during the study period. Of these participants, 2,683 individuals were diagnosed with suicidal ideation or intentional self-harm one year before or after giving birth. Other findings, as described by the authors, include the following:

• Suicidality increased from 0.2% in 2006 to 0.6% in 2017.
• Suicidal ideation increased from 0.1% in 2006 to 0.5% in 2017.
• Intentional self-harm increased from 0.1% in 2006 to 0.2% in 2017.
• Suicidality with comorbid depression or anxiety increased from 1.2% in 2006 to 2.6% in 2017.
• Suicidality with comorbid psychotic disorders increased from 7.1% in 2006 to 47.6% in 2017.

The authors found health inequities, as well. Black women, those with lower incomes, and younger women experienced the largest increases in suicidality. “Given the severe maternal mortality crisis among racial/ethnic minority individuals, especially Black women, it is imperative to include psychiatric risks in predictive models and practice guidelines,” the authors wrote.

The authors noted a study limitation in that it is difficult to determine whether the rise in suicidality was due to an actual increase or to greater detection of suicidality. “But either way, what this study says is that this is really common,” said Jennifer Payne, M.D., an associate professor of psychiatry and behavioral sciences and the director of the Women’s Mood Disorders Center at Johns Hopkins Medicine. “Even if we’re detecting it more, we’re probably still not detecting it 100% of the time.”

She said the findings point to the need to improve the mental health system so that it is prepared to support pregnant women. “We encourage OB-GYNs and primary care physicians to screen for suicidality, but if they detect it, what do they do then? We don’t have the mental health system in this country that we need, and it’s getting worse during the pandemic.”

Zivin said more research needs to be conducted to determine if the increase in suicidality that she and her colleagues identified is due to greater prevalence or detection. She hypothesizes that it is both. “Women are trying to do everything, and that wears on them,” she said. “I think there is a societal piece to this, as well as a measurement piece.”

The study was funded by a grant from the National Institute of Mental Health and the Office of Research on Women’s Health. ■

“Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017” is posted here.