How Public Health Has Failed to Identify Postpartum Depression (PPD) in the United States – Kristina DePeau
Background and overview of Postpartum Depression
In the United States, women between 18 and 45 years of age carry the highest prevalence rates for depression (1). Following birth, women often experience temporary bouts of crying and sadness, or “postpartum blues” (2). The “blues” can persist and worsen, presenting a serious risk factor for clinical depression (2). The DSM-IV criteria for postpartum depression (PPD) distinguish PPD as clinical depression that develops in the postpartum period after birth (3). Thirteen percent of women experience PPD within 6 months after giving birth (4), yet screening identifies less than half of women who suffer with PPD (5). By focusing on PPD as an individual-level, biological phenomenon without recognizing the social and behavioral contributions to PPD, public health has failed to screen for and identify women with PPD.
According to the DSM-IV criteria, depression is a complex condition marked by physical and/or psychological disturbances (3). Symptoms include: depressed mood, reduced interest in doing pleasurable things, significant weight loss, difficulty sleeping, feelings of worthlessness, and/or recurrent thoughts of suicide (3). Important risk factors for PPD include prenatal depression, parental or life stress, lack of social support (either perceived or actual), marital dissatisfaction, and prenatal anxiety (6). When properly identified, women undergo a range of treatments including psychotherapy, pharmacotherapy, or a combination of the two (7).
Researchers and clinicians have documented the physical, psychological, and emotional ramifications of PPD on maternal and child functioning (8-14). Depression reduces maternal self-efficacy (8), resulting in lower functional status (9), impaired transition into the maternal role (10) and reduced ability to bond with offspring (11). Women with PPD who employ either intrusive or withdrawn ways of parenting alter the balance of infant neural circuitry during postnatal growth (12). Women with PPD also tend to be more anxious and exhibit less playing behavior with their children, leading to insecure attachment (13). Children experience a wide range of poor outcomes as a consequence of maternal PPD including eating and sleeping problems (14).
The current public health approach to screening in the United States fails to identify PPD because of its neglect or improper use of social science theories at the level of 1) the development of screening tools 2) the implementation of screening tools and 3) the use of the Health Belief Model in national screening.
The failure to develop screening tools: limited, culturally-insensitive, not geared towards women’s emotional needs
Public health has failed to develop multi-dimensional screening tools for PPD. A wide range of symptoms for co-morbid mental illness exists during the postpartum period when PPD is common (15); yet, most contemporary screens examine depression in the postpartum period according to DSM-IV criteria. The most common of co-morbid disorders includes obsessive-compulsive disorder (OCD) and generalized anxiety disorder (16). One of the most frequently administered postpartum-specific depression screening tools, the Edinburgh Postnatal Depression Scale (EPDS), does have a subscale measuring anxiety; however, EPDS does not have a component measuring OCD (17). Further, the EPDS has been criticized as not being predictive of postpartum depression (18). PPD remains undetected not only because PPD screens overlook co-morbidity, but also because the determination of PPD status is based upon which screen is used (19). Finally, validated PPD screens are rarely, if at all, used in practice (20).
Public health has also failed to consider cultural and social components of depression in designing tools, despite the variability among cross-cultural definitions of (21), experiences with (22) and prevalence of PPD (23). Considering that people from different cultures describe depression differently (21), current screens may be inadequate for those who describe depression in Non-Western terms. Next, screens do not account for religious components of depression, despite the fact that a study of Jewish Jerusalem women reported religiosity to be significantly associated with PPD (24). Contemporary screening tools focus on how women feel according to DSM-IV criteria, although underlying reasons for (25) and symptoms of depression vary across ethnicity (25,26). In other words, by not accounting for different definitions of and experiences with depression, those who do not meet DSM-IV criteria for PPD may be left unidentified, despite having depression. The fact that little is known about vulnerable groups outside of high-risk minority women including Hispanic populations (23) suggests that more research on the relationship between culture and depression needs to be completed.
Finally, contemporary screening tools fail to consider women’s emotional needs when experiencing symptoms of depression. As captured well by Beck (27), “women with PPD sometimes don’t divulge their feelings or discuss their symptoms; the stigma of depression—and the belief that all mothers should be happy—can cause shame, fear, or embarrassment.” Mothers experience anxiety associated with bringing an infant into the world (28); however, in the United States, there is stigma associated with mothers not being fully satisfied with motherhood (27). Mothers with PPD are unlikely to seek treatment for a variety of reasons including the fact that they may feel ashamed about their feelings of sadness at a time when they are expected to be happy (27). Because women lack postnatal support systems in the United States (29), when they do turn to the health care system for screening, they may feel ashamed and unsupported; thus, women with PPD may not reveal their true experiences with depression to health care providers (27).
Failures in implementation: what happens when women come to appointments, and who screens for women with PPD?
Screening programs, both local and national, are not geared towards women who experience feelings of stigma related to PPD, nor are the programs timed for the period in which women may be most likely to turn to a health care provider for help. Public health has failed to implement screening in a time-appropriate manner with trained professionals, as well as to consider the consequences of inappropriate screening.
The timing with which PPD screening is done varies from shortly after birth in hospitals to months later in gynecologic offices (20). Some researchers have suggested that because high-risk populations, including individuals with eating disorders, are particularly prone to PPD, that screening should take place during prenatal visits (30). According to the Guidelines for Perinatal Care published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, providers should give PPD education to pregnant women during their third trimester (31). Researchers have suggested that because PPD can develop at any point postpartum and the most appropriate place for postpartum screening is at well-child visits; however, most women are screened at gynecologic visits (20). At gynecologic visits, however, women may be unwilling to talk to physicians who already perceive that screening takes too much time (20).
Next, public health has failed to consistently incorporate knowledge of PPD into medical training for physicians (29). Pediatricians might be an appropriate target group to help mothers with PPD due to the role that they play in promoting maternal and child health; however, barriers to the identification and treatment with this group include limited provider knowledge about postpartum depression, underestimation of PPD prevalence, and limited resources available to address PPD (32). It is difficult to believe physicians who are not trained in mental health and who believe that screening is time-consuming (20) would be an ideal professional population to implement screening.
Finally, public health has failed to consider the consequences of overlooking or inappropriately screening for women who need critical care. Insurance plans in the United States vary in terms of reimbursement for mental health screening (29), although early detection and treatment could potentially lead to benefits for the entire health care system. Aside from costs, the consequences of overlooking PPD include feeding the problem of medical mistrust. When women finally seek out care during a critical “struggling to survive” stage of PPD (27) and are turned away from the health care system, the same women may not seek out care in the future, leading to the exacerbation of other health complications.
National Depression and the Health Belief Model: overlooking socio-cultural factors, actual barriers, and environmental stress
As the supreme example of how public health has failed to identify PPD, National Depression Screening Day has failed to identify PPD in the United States. National Depression Screening Day, a free national service administered annually, prides itself on a 16-year old history of detecting depression, among a number of mental illnesses, in the general U.S. population (1). Eli Lilly, Forest Laboratories, and GlaxoSmith Kline provide the funding for this program (1). Ultimately, even with its efforts to reach out to women with PPD in 2005 (33), National Depression Screening Day fails to identify women with PPD because it is based upon the Health Belief Model. The model upon which National Depression Screening Day is based does not account for socio-cultural factors that relate to women’s perceptions of severity and risk of PPD, while overlooking social norms and actual barriers that influence women’s decision and ability to seek out screening for PPD.
The Health Belief Model, designed by Becker et al (34) determines that individuals intend to (and presumably do) perform a behavior after weighing their perceived severity and risk of disease against perceived barriers and benefits to seeking out care. The model assumes mothers with PPD make rational decisions. National Depression Screening Day assumes that individuals will seek out screening if the “benefits” of addressing perceived severity and risk of PPD outweigh the “costs” of perceived barriers to being screened. Unfortunately, despite the fact that many screening programs are based upon the Health Belief Model, women with PPD are unlikely to conform to this model.
In terms of perceived barriers to seeking out care, the Health Belief Model does not account for the wide variations in perceived barriers to care among women at risk for PPD, nor does it account for the nature of stigma. Considering the perceived severity and risk of disease, women with PPD are unlikely to have a realistic understanding of their risk of PPD, because the health care system fails to educate women (35). Clinicians frequently provide pregnant women with general information about experiencing postpartum blues as a normal part of reproduction, yet many women fail to understand the transition from postpartum blues to PPD (27). When faced with serious symptoms of depression, women may downplay the severity of their condition, believing they are a “normal” part of giving birth. Further, the aforementioned cross-cultural variations in definitions of PPD may lead to women of different cultural backgrounds ascribing various levels of severity/risk to their conditions (23). Based upon their cultural threshold for pain, many women may choose to cope with PPD on their own without appreciating the risks of doing so.
Further, women with PPD experience barriers to care including socioeconomic factors of poverty and insurance status (23) for which the Health Belief Model fails to account. While screening for National Depression Screening Day is free, marketing messages for the campaign only mention this briefly (1). Even when women with PPD know that the screening is free, their mistrust of the healthcare system may override their desires to seek care, as in the case of minority women not accessing early breast cancer screening services (36). Lower income women assume there are punitive consequences of seeking care, including losing their children after being considered unfit as mothers (37). Women with insurance plans that do not cover mental health screening lack the opportunity to get screened at regular medical appointments (29) and therefore may not show up on at a free screening due to their frustration with the health care system. By basing the campaign on a model that ignores actual barriers to screening, National Depression Screening Day essentially markets its program to those who have not experienced significant barriers in the health care system and in obtaining screening.
In failing to account for socio-cultural factors in the Health Belief Model, the program overlooks stress and environmental conditions. Qualitative research has highlighted the notion that stress and strain contribute to maternal role collapse, which fuels maternal depression (38). In transitioning to motherhood, women may experience conditions (i.e. social circumstances) that make it difficult to adapt to the “blues” (38). Role stress includes physical or emotional hardships like insufficient education or confidence in being a mother (38). Role strain explains that when women react emotionally to stressful experiences in motherhood, they can become withdrawn or less productive (38). Maternal role collapse, or the breakdown that leads to PPD resulting from role stress and strain, takes place when women feel they “lack support” or that “the support systems have failed them” (36). National Depression Screening Day does not include in its marketing or screening these notions of role collapse, stress, or strain.
Even assuming women at risk for PPD rationally weigh decisions, adhere to the Health Belief Model, and undergo screening, the screens used and the ways in which screening is done necessarily impact whether a women is willing to reveal private information about her mental health. At the heart of the community kit provided to facilities volunteering to screen for depression on National Mental Health Screening Day is a tool known as HANDS (1,39), a 10-question tool designed for quick and easy use by individuals not necessarily trained in mental health screening. This nonspecific tool detects major depressive disorder of any type (39) and ignores the postpartum-specific nature of PPD, cross-cultural variations in women’s descriptions of and experiences with depression, as well as the social stigma and actual barriers to care women with PPD face. In relation to how National Depression Screening Day does screening, only Spanish-speaking screeners are available, and only at some facilities; no other language interpreters are apparently available (1). Without adequate PPD screening tools and without language interpreters, some mothers may not open up to providers about their symptoms. Without population-specific tools being used for screening, the mistrust of the health care system these women possess will be fueled at a time when they finally seek care.
All of the aforementioned problems with PPD screening are consolidated in the evidence that current methods of depression screening in the United States are failing to capture women with PPD (5). Beyond the fact that there are significant socio-cultural factors not being considered in the nature and implementation of screening tools, there is also poor physician follow-up on patients who do get adequately screened and identified (40). Inadequate information provided to patients (35), followed by culturally insensitive screening and poor follow-up, could contribute to women’s distrust of the medical system and lead to substantial negative consequences on maternal and child health.
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