The Problems with the Screening Process for Postpartum Depression
This week, a writer for the New York Times' Motherlode blog tackled the issue of screening for postpartum depression.Sarah Gonser, a documentary filmmaker, wrote about asking for help from her obstetrician when she felt something was wrong after having her baby. Instead of getting help, she was brushed off and sent on her way.
Gonser went on to do research on the policies of obstetricians and pediatricians when it comes to postpartum depression screening and found that there is little consistency when it comes to identifying and treating struggling mothers.
This is nothing new, but it's not discussed nearly enough. Gonser points out correctly that women are falling through the cracks all over the place. And it's not just that all women aren't being screened for postpartum depression, which is true, but also that they're not screened by enough people at the right times or in the right way.
So what are the problems with postpartum depression screening, and how are they impacting mothers?
Everyone is Doing It
Write about PPD screening and you'll immediately hear from lots of nurses, obstetricians, pediatricians, midwives and family physicians that they all know about it, consider it important and do it on a regular basis. "It's standard practice!" In some places that's true. In many more places it isn't. I reached out to the 5,000-strong Facebook fan page for Postpartum Progress and heard from mom after mom who never received screening of any sort.
Among those mothers who gathered the courage to speak up anyway and ask for help from their healthcare providers, one said she was told she was just stressed out and needed to change her lifestyle. She ended up in the emergency room at 14 months postpartum because she was having full-blown panic attacks. Another was told she just needed to get used to the new routine of being a mom, and ended up being hospitalized in a psychiatric unit for an entire week after her symptoms worsened. Yet another was told that since her symptoms were beyond the six-week postpartum mark she couldn't have PPD, and, "… needed to stop blaming it on having the baby." Others were instructed that if they weren't considering killing themselves or their babies then they were good to go.
The stories of people who should know better normalizing serious symptoms of perinatal mental illness and sending moms on their way to figure it out for themselves were endless. Mom Kate Weldon Leblanc shared how, "A nurse and social worker at my practice brushed off my severe anxiety and insomnia as just a 'worried mom' who should take Benadryl to help me sleep."
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I heard from other mothers who had a history of depression or bipolar disorder prior to pregnancy and fully informed their OB practices of this fact but still were never screened or given any special monitoring or education about perinatal mood and anxiety disorders. This should be shocking to everyone given that a previous history of mental illness is a clear indicator of PPD risk, and in the case of bipolar disorder, postpartum psychosis risk.
Some doctors are convinced they don't need to conduct a screening test because they know their patients well enough to identify those who may have PPD. A family physician comment on the >Motherlode piece reflects this: "I don't need any 'screening tools' or 'depression scales' - I know my patients." Fact is, research shows that doctors who identify patients with PPD by observation alone miss half of all the cases. Half.
For those that are screening, when and how often that screening is administered makes a big impact. Many hospital maternity units have adopted screening, usually at the behest of nurses who insist their employers do more to help moms, but it's difficult to identify moms with PPD just a day or so after they've had a baby. While some moms with or heading toward PPD may be identified, quite a few won't be. Even the six-week postpartum appointment with the obstetrician, though important, shouldn't be the one and only screen mothers get, since even at six weeks many still don't recognize they have a problem. Anne Marie did have to fill out a questionnaire about PPD at her six-week OB appointment but said, "I was fine at six weeks. It was later when things took a turn for the worst." She wasn't the only one who expressed not recognizing her symptoms or realizing they were serious enough to require treatment until later in the first year. This is why in an ideal world mothers should be screened in the hospital, at the six-week OB checkup, and by their pediatrician throughout the first 12 postpartum months.
Screens Are Not Lie Detector Tests
Even if a health care provider conducts postpartum depression screening, that doesn't mean the mom will answer truthfully. One mom told me, "To be perfectly honest I probably wouldn't have admitted to my daughter's pediatrician that I wasn't doing well … I got screenings from the hospital and my OB-GYN and always said what I thought I should be feeling, not what I was actually feeling. I was in total denial." Mom Kristine Brite McCormick agrees, stating, "I lied because I was terrified if I answered 'incorrectly' they'd take my baby."
I remember when I first told a therapist about the intrusive thoughts I was having. I was convinced she'd call the police the minute I articulated what had been going through my mind for weeks. The only reason I decided to lay it all out in the open was because I was sure my life was over anyway, and I didn't care anymore what the outcome was of telling the truth. I was in so much pain I just wanted it to stop.
Women are afraid to speak up about their symptoms for many reasons, from fearing having their children taken away from them by Child Protective Services, to worrying about how a diagnosis would affect their health insurance or employment, to being asked to utilize treatments they aren't comfortable taking, to the general stigma that persists. Denise Spencer says she's seen so much judgment about mental illness from family and friends that she didn't speak up. "Every time you heard about postpartum depression, it was for something negative in the news, and I didn't want there to be 'something wrong with me.' So I ignored it until the problem got so huge that I needed the help," said Spencer. "I'm so sorry that I didn't ask for it sooner because it's ruined the first few years with my son."
Until we eliminate that stigma and ensure moms they will be protected when they speak up, some will continue to deny they have a problem. Still, whether or not they feel safe telling the truth, therapist Kate DeStefano-Torres, LPC, says providers should ask the questions anyway. "Even if a woman lies we need to ask her, because later she may realize she can't do this alone and remember that we cared enough to ask in the first place and may seek help from us at that point," explained DeStefano-Torres.
Screening Not A Direct Path to Help and Recovery
For those physicians that have made screening part of their normal process, what comes next is as crucial as conducting the screening itself.
If the mother's answers indicate she may have PPD, does her doctor just whip out a prescription pad and send her on her way? If so, that's a problem. If she's not comfortable with medication as a treatment she's unlikely to fill that prescription, or mention her continuing, untreated problems to that doctor ever again. "I reached out to the nurses at the hospital and was ignored. I went to my six-week postpartum checkup and I was told that if I was indeed depressed then I should give up breast feeding immediately and go on meds," reported Erin Nanney. "I didn't want to stop nursing and wanted an explanation for how I was feeling, not just 'take this and you will feel better.'"
If the doc doesn't explain how long it may take the medication to take effect, or what the potential side effects are, or what to do if the medication doesn't work at all, or that there are alternatives to taking medication, or follow up in any way, moms say they feel like they've gotten no help at all. Jessica Strickland said, "I was one of the rare cases of a woman scheduling an appointment to go in just for the fact that I knew I was suffering from postpartum depression and anxiety and I wanted to seek help. My doctor still brushed me off and sent me on my way with a prescription and nothing more." Adds Chrissy Pate, "I was screened at my six-week appointment. I was truthful because as soon as the doctor walked in I was bawling. They said that I needed some medicine and that I would feel better. They gave me Celexa and said to see them in six months. Obviously this didn't work." So she's supposed to go away for six months and hope for the best?
Unacceptable.
Even if a mother is comfortable with taking medication, it may be that some of the reasons she has PPD are psychosocial, the kinds of things that medication doesn't fix. If she has no social support, is under severe financial stress or is in a difficult situation at home, for example, she's going to need help from someone like a social worker or therapist who can teach her the tools for coping with those situations in a healthy way. If the prescription pad without follow up or psychiatric referral is the standard, we are doing moms a major disservice.
Doctors will argue that part of the problem is lack of informed specialists to refer to, and they are right. Therapist DeStefano-Torres, LPC, affirmed, "Once they identify these symptoms in women they do not know where to refer them because our mental health system is so broken." Even if they do know where to refer it doesn't mean mom will get the help she needs when she needs it. Melissa Barbehenn said, "I was referred to a psychiatrist but had to wait six weeks for an appointment. I told them that I didn't think I would live that long." Others I heard from had to wait much longer.
Screening At Its Best
I'm thankful that among the many horror stories I read this week were stories of people who are getting it right. Some moms, like Jen Sieve Hicks, said they were screened, educated and supported and it made a huge difference in their lives. "When I called my doctor's office with a suspicion of PPD, he got me in that day to be seen. I scored so high on the screening test that he said it would be irresponsible to allow me to leave the clinic without a prescription," said Hicks. "His nurse also arranged my first appointment with the therapist, so I left that initial office visit with medication and an appointment already scheduled. I was also ordered to return to the clinic in two weeks to re-evaluate. Later, he delivered both subsequent babies and was very supportive and aware of my previous PPD during both subsequent postpartum periods."
This is how it should be. Mothers need consistent, comprehensive postpartum depression and anxiety screening, both in pregnancy and throughout the first year postpartum. They need screening to be done in a compassionate way that focuses on the mom and her needs, not a quick check and a move on. They need explanations of these illnesses, the various treatments and what to expect. They need referral systems that connect them to informed, experienced mental health care providers who are available and accessible. And they need follow up, so that they don't fall through the cracks.
Until then, we're not where we need to be.
- By Katherine Stone
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