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An article in today's Washington Post covered the release of the final recommendations from the U.S. Preventative Services Task Force on Screening for Depression in Adults. The Task Force recommends that all American adults be screened for depression as part of their normal health-care routine. The final recommendation statement also includes pregnant and postpartum women in their screening recommendation.

Millions of Women Suffer with Postpartum Depression

The birth of a child is a joyous and exciting time for most families. But following childbirth, some women may experience postpartum depressive disorders that can adversely affect a woman’s mental health and their child.

Being a mom is hard. For some, being a mom is especially difficult. Mothers commonly experience what is called “the baby blues,” mood swings that are the result of high hormonal fluctuations that occur during and immediately after childbirth. They may also experience more serious mental health disorders such as postpartum depression, birth-related posttraumatic stress disorder or a severe but rare condition called postpartum psychosis.

What is Postpartum Depression?

Postpartum (or postnatal or maternal) depression is characterized by feelings of hopelessness, agitation, sadness, despondency, suicidal ideation, and a perceived inadequacy in caring for the infant (Born, Zinga, & Steiner, 2004).

It is defined by the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a major or minor depressive episode affecting women within four weeks after childbirth (American Psychiatric Association, 2013). However, this definition is often expanded by clinicians and researchers to occur anytime within the first year postpartum (Stowe, Hosetter, & Newport, 2005).

The symptoms of postpartum depression are similar to symptoms for depression, but they also include:

• Trouble sleeping when the baby sleeps (more than the lack of sleep new moms usually get).
• Feeling numb or disconnected from your baby.
• Having scary or negative thoughts about the baby, like thinking someone will take your baby away or hurt your baby.
• Worrying that you will hurt the baby.
• Feeling guilty about not being a good mom, or ashamed that you cannot care for your baby.

Postpartum depression does not have a single cause, but likely results from a combination of physical and emotional factors. Postpartum depression does not occur because of something a mother does or does not do.

After childbirth, the levels of hormones (estrogen and progesterone) in a woman’s body quickly drop. This leads to chemical changes in her brain that may trigger mood swings. In addition, many mothers are unable to get the rest they need to fully recover from giving birth. Constant sleep deprivation can lead to physical discomfort and exhaustion, which can contribute to the symptoms of postpartum depression.

Suffering with Postpartum Depression

Over 1 in 7 women will suffer from postpartum depression or a related illness. In lower socio-economic areas, that number rises to 1 in 4. Women who experience postpartum depression without receiving adequate treatment are at a greater risk of suffering chronic and recurrent depression throughout life, which can be profoundly disabling (Patel et al., 2012). For example, suicide as a result of postpartum depression and other mental disorders is a leading cause of death among women in the postpartum period.

In general, clinical depression occurs in approximately 15 to 25 percent of the population, and women are twice as likely as men to experience depression. Because women are most likely to experience depression during the primary reproductive years (ages 25 to 45), they are especially vulnerable to developing depression during pregnancy and after childbirth. Women who develop these disorders should not need to feel ashamed or alone; treatment and support are available and they effective in making recovery possible.

More women will suffer from postpartum depression and related illnesses in a year than the combined number of new cases for men and women of tuberculosis, leukemia, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, lupus, and epilepsy.

The annual cost of not treating a mother with depression [in lost income and productivity alone] is $7,200. {Note: If you extrapolate that out to 800,000 mothers each year, that means the annual cost of untreated maternal depression in the U.S. is $5.7 billion dollars (Wilder Research).

Depression is a particularly serious problem for lower-income mothers, since it can create two generations of suffering, for the mother and her children (Urban Institute).

Women during their childbearing years account for the largest group of Americans with depression (American College of Obstetricians & Gynecologists).

Over 55 percent of ever-depressed women have their first episode of depression during their first postpartum year (National Institute for Healthcare Management).

Despite the frequency of depression among new mothers, large numbers of affected individuals may not be identified as having a treatable condition, and only 15 percent obtain professional care (Harvard Center on the Developing Child).

Suicide accounts for about 20% of postpartum deaths and is the second most common cause of mortality in postpartum women (Archives of Women's Mental Health).

There is “… robust evidence that maternal mental illness places families with young children at risk for homelessness” (American Journal of Public Health).

Maternal Mental Illness Affects Children & Families in Significant Ways

Not only women who experience postpartum depression suffer its consequences. This disorder is associated with weak maternal-infant attachment and delays in children’s cognitive and emotional development. It is also associated with early cessation of breastfeeding, which contributes to malnutrition and diarrheal diseases in infants, especially in low- and middle-income countries. Postpartum depression and anxiety is a stronger risk factor for child behavior problems than smoking, binge drinking and emotional or physical domestic abuse (National Center for Children in Poverty).

Children who experience maternal depression early in life may experience lasting effects on their brain architecture and persistent disruption of their stress response systems (Harvard Center on the Developing Child).

Untreated postpartum depression has been associated with serious consequences, most notably impaired mother-infant bonding and long-term effects on emotional behavior and cognitive skills (National Research Council).

As compared to non-depressed mothers, mothers with postpartum depression are less likely to consistently use a car seat (67% vs. 84%), more likely to bring their babies to the emergency room (26% vs. 16%) and less likely to have their infant use the back sleep position (60% vs 79%) (Balbierz et al, Maternal Child Health Journal, November 2014).

Older children of mothers depressed during infancy show poor self-control, aggression, poor peer relationships, and difficulty in school.

What makes the harm to children and their parents so distressing is the depression is usually treatable – and thus, the damage to children is preventable (Urban Institute).

Women who suffer from depression during pregnancy and their infants are at risk for costly complications. Nearly $15 billion dollars is spent on childbirth-related hospitalizations and half of these costs are billed to private insurance (National Business Group on Health).

Children of depressed mothers have higher medical claims than do children of healthy women because they bear a higher burden of illness, use health care services more frequently and have more medical office and emergency department visits than do children of non-depressed mothers (National Business Group on Health).

New studies show that postpartum depression may also affect children’s physical health, particularly their risk of childhood obesity. Many obese children become obese adults and are burdened by adverse health conditions, including type II diabetes, hypertension, and certain forms of cancer.

A new study has reviewed associations between a mothers’ depressive symptoms and their kindergarten-age children’s eating practices. Postpartum depressive symptoms are associated with poor eating habits, based on comparisons of the consumption patterns of kindergarten-age children. Over seven days, children whose mothers report depressive symptoms consume vegetables less often (64 percent every day) than children of mothers reporting no depressive symptoms (67 percent every day); milk less often (14.3 times a week; 81 percent every day) than children of mothers reporting no depressive symptoms (15.0 times a week; 85 percent every day); sweetened beverages more often (5.1 times a week; 33 percent every day) than children of mothers reporting no depressive symptoms (4.1 times a week; 26 percent every day); and sweet snacks more often (6.6 times a week; 49 percent every day) than children of mothers reporting no depressive symptoms (6.0 times a week; 44 percent every day) (Urban Institute, 2015)

Maternal depression can create problems that can continue into adolescence. Adolescents with a history of exposure to maternal depression have higher rates of major depression and other disorders such as anxiety, conduct disorders and substance abuse disorders. This is of particular concern because depression that begins early in life is associated with a greater severity of illness and a higher risk of suicide and other violent behavior than later onset depression (National Business Group on Health).


What Can Be Done to Help Mothers?

Postpartum depression is common. If you are worried about the way you have been feeling, it is important to tell your doctor or nurse about your concerns. You you are not alone. There are treatments to help you feel better. Talk to your doctor so you can feel like yourself again.

The following two questions may help you determine if what you are experiencing is postpartum depression:

1. During the past few weeks, how often have you been bothered by any of the following problems?

• Little interest or pleasure in doing things?
Not at all.
Several days.
More than half the days.
Nearly every day.
• Feeling down, depressed, or hopeless?
Not at all.
Several days.
More than half the days.
Nearly every day.

If you answered “more than half the days” or “nearly every day” to either question, you may have postpartum depression and should seek help from a provider. A mental health provider can help figure out whether you have depression or not, and he or she can help find the best treatment for you.

2. If I don’t do anything about my depression, will it eventually go away on its own?

It is possible that the depression could eventually go away without help. It could also get worse, instead of better. There are effective treatments for depression that may include medication or talking with a mental health counselor. The best way to deal with depression is to see a mental health provider like a mental health counselor. The earlier you seek help, the better you may do.

Only mental health and health care providers can diagnose a woman with postpartum depression. Because symptoms of this condition are broad and may vary between women, a provider can help a woman figure out whether the symptoms she is feeling are due to postpartum depression or something else.

What Can Policymakers Do to Address the Problem?

Government agencies should highlight education and training for health care providers and the development of a policy framework as core strategies to address maternal mental health.

Materials that build on providers’ existing conceptualizations of postpartum depression need to be developed and incorporated into professional training so that women’s full range of needs can be addressed throughout pregnancy as well as postpartum.

Policy makers should consider expanding existing mental health care policies by identifying actions that prioritize the care of women who experience postpartum depression, as well as establishing clinical practice guidelines that specifically address maternal mental health problems.

The intersection of mental health with maternal health needs to be recognized by health professionals and policymakers, who play a key role in the well-being of women, children and families.

Conclusion: Health Care Reform Will Help Depressed Lower-Income and Moderate-Income Mothers Get Treatment

Postpartum depression is widespread, particularly among lower- and moderate-income mothers. Studies find that many lower-income mothers with young children experienced a major depressive episode in the past year and more than two-thirds of them were having difficulty coping with daily tasks (Urban Institute).

Postpartum depression is a two-generation problem because the children of depressed mothers also suffer. In the most severe circumstances, they may be neglected or abused. Further, these problems are often hidden due to stigma associated with mental health problems or fear of losing custody of children.

The good news is that when postpartum depression is identified, there are many effective treatments, including talk therapies and drug therapies. However, 40 percent of depressed lower-income mothers with infants report that they did no get any treatment.

An important reason for the lack of mental health treatment is that lower-income mothers often lack health insurance coverage or have poor access to mental health providers.

The Affordable Care Act (ACA) offers the best hope for helping these mothers get treatment because it will provide new insurance coverage to many with lower- and moderate-incomes who are uninsured.

A recent study from Oregon published in the New England Journal of Medicine showed that providing Medicaid to previously uninsured lower-income adults reduced their depression. If all states expanded Medicaid under the ACA, we could address postpartum depression in a profound way.

Many moderate-income mothers have also gained health insurance coverage through state health insurance marketplaces and exchanges where health plans are required to provide mental health benefits that include a range of services such as screening, outpatient services and prescription medications.

The ACA includes provisions to improve the connection between primary care and mental health care. These two sectors have historically been in separate “silos,” with little communication between providers.

Lower-income mothers often have frequent contact with their child’s provider, but pediatricians may not have been trained (or do not have time) to screen for postpartum depression and provide mental health counseling and drug therapy for adults.

New initiatives (many funded by the ACA) are experimenting with placing mental health providers including mental health counselors in primary care providers’ offices to help mothers find the help they need.

Depression is a serious problem that many mothers are struggling with now, but we have reason for optimism that health care reform and new health care delivery mechanisms – such as health homes and patient-centered medical homes – will improve their opportunities for getting treatment.