Shortly after the birth of her daughter, Andrea became severely depressed. She was 17 at the time and she didn’t fully understand what she was going through; she just felt like a failure. “I felt like I didn’t want to be alive,” she recalls. “I felt like I didn’t deserve to be alive. I felt like a bad person and a bad mother, and I was never going to get any better.”
Postpartum depressions are often assumed to be associated with hormonal changes in women. In fact, only a small fraction of them are hormonally based.
When her baby persisted in crying, she felt her frustration mount quickly. “I was hitting a boiling point,” she says. “I was at a point where I didn’t want to deal with anything.
Sometimes I would just let her cry — but then I would feel very bad afterwards.”
Depression is the most common health problem women face. In the United States, outside of obstetrics, it is the leading cause of hospitalizations among women ages 15 to 44.
It’s estimated that 20 percent to 25 percent of women will experience depression during their lifetimes, and about one in seven will experience postpartum depression. For low-income women, the rates are about twice as high. As my colleague Tina Rosenberg has reported, the World Health Organization ranks depression as the most burdensome of all health conditions affecting women (as measured by lost years of productive life).
Postpartum depressions are often assumed to be associated with hormonal changes in women. In fact, only a small fraction of them are hormonally based, said Cindy-Lee Dennis, a professor at the University of Toronto and a senior scientist at Women’s College Research Institute, who holds a Canada Research Chair in Perinatal Community Health.
The misconception is itself a major obstacle, she adds. Postpartum depression is often not an isolated form of depression; nor is it typical. “We now consider depression to be a chronic condition,” Dennis says. “It reoccurs in approximately 30 to 50 percent of individuals. And a significant proportion of postpartum depression starts during the pregnancy but is not detected or treated to remission. We need to identify symptoms as early as possible, ideally long before birth.”
The major predictors include previous incidents of depression, as well as a woman’s past and current life stresses, like childhood trauma or abuse, conflicts with a partner or family members, lack of social support or coping skills, and poverty.
Only about 20 percent to 30 percent of women who experience postpartum depression in the United States get proper treatment, and for low-income mothers, the rate is considerably lower, says Robert T. Ammerman, a professor of pediatrics at Cincinnati Children’s Hospital Medical Center who is the scientific director of Every Child Succeeds, a home visiting program for vulnerable first-time mothers.
The consequences for both mother and child can be devastating. If left untreated, postpartum depression can develop into severe clinical depression. In addition to feeling listless, anxious, guilty, lonely and frequently suicidal, mothers who are clinically depressed in pregnancy are three to four times more likely to have a premature delivery or deliver a low-birth-weight baby (both predictors of serious developmental and medical problems for the child) and, just as urgent, less likely to form healthy attachments with their children. Their children are more likely to have attention deficits, difficulties controlling their emotions and behavior, language delays and lower I.Q.s — and they are themselves at increased risk of becoming depressed later in life (PDF).
“We have this idea that during motherhood struggling with emotional issues is normal,” Ammerman says. “The message that a lot of moms hear from families and friends and even professionals who may not know much about perinatal depression is ‘be tough and fight your way through it’ — and they don’t seek help.”
Ammerman says that while it’s true that many mothers have or develop depression, it’s not a normal or typical response to the challenges of parenting. There are effective treatments. They include medication as well as a range of therapies – like cognitive behavioral therapy (C.B.T.), which helps people learn how to counter negative thoughts and their associated emotions, and interpersonal psychotherapy (I.P.T.), which focuses on improving the quality of personal relationships and the satisfaction that is gained from them. About a third of women who get treated for chronic or recurrent depression achieve remission, and more than half see an improvement in their symptoms.
Today, several states, including Illinois, New Jersey, West Virginia and Washington, have initiated mandatory screening for perinatal depression (something that is done nationally in Australia). But inadequate screening is only part of the problem. Cost and access barriers and stigmatization – and an overall lack of awareness among health professionals – are what prevent most mothers who need help from getting it. Many primary care doctors fail to recognize when their patients are depressed. And when they do, they often don’t know how to provide the most effective treatments. They also can’t ensure that patients will follow up with mental health professionals (many of whom do not accept Medicaid). And communication between doctors is notoriously problematic.
“When people are referred to mental health professionals from primary care settings, the vast majority of the referral slips go into the garbage,” says Katherine L. Wisner, director of the Asher Center for the Study and Treatment of Depressive Disorders at Northwestern University.
Given the scope of the problem, new outreach and treatment models are urgently needed. The three that I’m highlighting today are in early stages of development, but they are noteworthy because they demonstrate promise and illustrate pathways for potentially broader system changes.
The first is a collaborative care model called DAWN being pioneered at two urban obstetrics and gynecology (ob-gyn) clinics that are part of the University of Washington system. The innovation here is that mental health care is being integrated directly into ob-gyn care. Why is this such an important idea? About a third of women in the country see their ob-gyn physicians for their primary care, explains Wayne Katon, vice chair of the department of psychiatry and behavioral sciences at the University of Washington School of Medicine. When depression screening and treatment are handled in the same place as primary care, it’s more likely that women will get effective help.
Through the DAWN program, when a woman comes in for care, she is screened for depression using a standard questionnaire known as PHQ-9. If her score indicates a likelihood of major depression, she is assigned a care manager who is trained to educate her about depression, explore real or perceived barriers in her life and motivate her to pursue treatment.
It’s important that treatments are designed to fit with a patient’s preferences. “They’re given the choice to start with a form of therapy or an antidepressant,” Katon says.
“Some say, ‘I’m pregnant, I’d rather not be on medication.’ Some want to take medication.” They can also choose in-person visits or telephone consultations. Physician-supervised care managers follow up regularly for a year, tracking patients’ progress. If their symptoms persist, they adjust or increase the intensity of treatment.
In two studies published this year, women experienced significant improvements in depressive symptoms. The gains were particularly notable among women who were uninsured or received public insurance, such as Medicaid. “The women were more satisfied with the care they got and the ob-gyn doctors were more satisfied because their patients got better,” Katon adds.
The second model was developed by Every Child Succeeds, a home visiting program for vulnerable first-time mothers based out of the Cincinnati Children’s Hospital Medical Center. In recent years, as I have reported in this column, home visiting programs have spread across the country as a result of a $1.5 billion appropriation in the Affordable Care Act. This summer, a study of families served by the Nurse-Family Partnership found, remarkably, that the mothers and children assisted by the program had significantly lower death rates over a 20-year period.
But home visiting programs have one notable limitation. As recent research indicates, when mothers are clinically depressed, they don’t benefit as much from the visits. “A mother who is depressed has very little to give her child,” said Judith B. Van Ginkel, the founder of Every Child Succeeds, which has worked with 22,000 families. “We found that half of the mothers we were working with were depressed, and three-quarters had witnessed or been victims of violence.”
With the leadership of Robert Ammerman and others, Every Child Succeeds has developed a program called Moving Beyond Depression, to train therapists to deliver C.B.T. in conjunction with home visitation.
This is how Andrea was able to receive treatment. Shortly after her home visits started, Andrea, who lives just north of Cincinnati and works in a call center, was asked to fill out a questionnaire. (I have changed her name.) She learned that she was depressed. “I had been in denial,” she said. For months, conflicts with her mother had been getting worse. Her mother suffered from mental illness and depression, had used drugs, and had long counted on, and expected, Andrea to take care of her.
But now Andrea needed every ounce of her strength to care for her baby, and her mother reacted angrily. Over 15 sessions, the therapist helped Andrea develop strategies to manage her feelings and interact with her mother — rather than being thrown repeatedly to anger, negative thoughts and guilt.
Last year, results from a clinical trial funded by the National Institute of Mental Health showed that mothers receiving Moving Beyond Depression’s in-home C.B.T. model experienced subtantial improvements in depressive symptoms and decreased diagnosis of major depressive disorder following treatment relative to a control group. The model has spread to several states, including Connecticut, Massachusetts, Kentucky and Kansas, and has been used to assist 600 mothers.
The third model grows out of Cindy-Lee Dennis’s research in Canada, and is important because it illustrates the potential of treating women through interventions over the phone. It thus reduces one of the biggest barriers low-income or rural women face in accessing treatment: transportation to and from treatment and scheduling appointments.
In one clinical trial, 700 women in the first two weeks after giving birth, who had been identified as being at a high risk of postpartum depression, were given telephone-based peer support from other mothers — volunteers from the community who had previously experienced and recovered from self-reported postpartum depression (and received four hours of training).
“We created a support network for the mothers early in the postpartum period,” Dennis explains. “It cut the risk of depression by 50 percent.” On average, each mother received just eight contacts — calls or messages, and the calls averaged 14 minutes. Over 80 percent of the mothers said they would recommend this support to a friend.
In another clinical trial conducted by Dennis, trained nurses provided interpersonal psychotherapy (I.P.T.) over the phone to 240 clinically depressed mothers across Canada.
The calls were scheduled at the mothers’ convenience. The results have not been published yet, but Dennis says the treatment was highly effective. Treatment compliance rates were greater than 85 percent. Dennis is currently working with health officials to pilot test the model in New York City.
“We underestimate very simple interventions,” she says. “We have this huge bias that face to face is the most effective way to provide care. But we have to be innovative about how we offer help to women.”
Andrea, who is now 19, remains grateful for the help she received. “I can actually focus on my daughter and be with her the way I want to be with her, and teach her things,” she says. “I feel like now that I’ve been through the program — and distanced myself from people I needed to — I can focus on what I need to focus on rather than everybody else’s problems. There’s more out there than just being depressed.”