by Alison McCulloch
This is the second in a series of articles looking at post-natal depression in Aotearoa New Zealand.
Ask someone what causes post-natal depression and they’re likely to mutter something about hormones and the stress of having a new baby. If they’ve thought about it a bit more, they might throw in a few “risk factors”, anything from “being poor” or “being a career woman” to “being a teacher”, “being an older mum” or “a younger mum”.
Why some women suffer from PND, how it should be treated, and even what to call it are far from settled issues. Similarly, there’s little agreement about who’s at most risk and whether or not mandatory screening is a good idea.
Take the word “depression”: for many women with PND, the word conjures up an experience that bears no relation to what they’re going through.
A Spiral of Insomnia
June* says that while ‘depressed’ was where she ended up, it wasn’t where she began. “I think there maybe a little bit too much emphasis on depression, like there are other concerning states you can be in whether that is insomnia or anxiety or a whole spectrum of other things.”
June*’s starting point was a vicious spiral of insomnia and anxiety during pregnancy, but she couldn’t get the help she needed because, as she put it, “you basically have to be scoring almost full points on the whatever depression scale they use for you to get into see them”.
June*’s experience gels with what Kumeu GP William Ferguson has seen in many of his patients. Any kind of depression – but particularly depression in maternity – really has to be “dug out of a consultation”, he says. “The woman would often say ‘but I’m not depressed’, because that’s not what they’re experiencing at all. What they are experiencing is, they’ve got overwhelming fatigue, and … getting through the day is requiring gargantuan effort, and they may have high levels of irritability and anxiety or whatever, but that’s all just part of the many manifestations of the condition.”
Post-natal depression often begins ante-natally – while a woman is pregnant – but isn’t recognised because, as Ferguson explains, it’s “brilliantly concealed by the many travails of the pregnancy”: “Of course you’re tired – of course you’re anxious – there’s an explanation for everything and even more so in pregnancy,” he says. One of the most accurate predictors he’s identified is a woman having multiple ante-natal doctor appointments. “It doesn’t matter why, but the mere fact that that’s happened is indicative that something’s not right.”
Research shows again and again how few cases of post- and ante-natal depression are detected by professionals, or even recognised by women themselves. One U.S. study found only 15 percent of new mothers who had suffered a mood disorder had sought help, been prescribed medication or had hospital contact, while 2006 research in New Zealand concluded PND “goes largely untreated in the community”. Both studies called for some form of screening.
The Screening Question
In a shift on screening in the United States, the Preventative Services Task Force, which advises the government on preventative services, this year recommended all women be screened for depression during and after pregnancy. The recommendation followed an investigation into the harms and benefits of perinatal screening that found it can help reduce symptoms and prevalence of depression, with the only potential harm being a small risk associated with using antidepressants during pregnancy.
But while some mental health experts here would like to see mandatory screening, others are cautious. Asked about screening specifically for postnatal depression, the Director of Mental Health, Dr. John Crawshaw, said the Ministry of Health had no plans to introduce mandatory screening, and supported the use of the three-question PHQ-3 questionnaire.
That questionnaire is the tool recommended for Well Child Tamariki Ora (WCTO) providers – most of whom are Plunket nurses – who are required to “review the mental health of the parent/caregiver as part of checking their wellbeing”. Whether or not postnatal depression checks are being done is not measured from a national perspective. While the WCTO service tracks around 27 indicators for quality improvement – things like how many children receive their core visits and their before-school checks – postnatal depression is not among them. Crawshaw said that’s because the focus of those indicators is on the health of children, not maternal health.
Guidelines for midwives also include a maternal mental health component, but as noted in the first article in this series, a 2010 survey showed, nearly 40 percent of the midwives surveyed reported that there was either no referral pathway for women with mental health problems, or, if there was one, they didn’t know what it was, while a third “felt maternal mental health services were overwhelmed, poorly coordinated or insufficient”.
In the end, it appears that what’s true for services is also true for screening: what you get it depends on where you live and who your health-care provider is.
Cause of Death
It can come as a surprise to those not steeped in the issue that suicide is the leading indirect cause of maternal death in New Zealand (and is over 7 times more common here than in the UK), and although the numbers are not large — 22 from 2006 to 2013 — the fact that suicide tops medical causes of maternal death is significant.
The latest review of infant and maternal mortality, issued in June this year, included a review of maternal suicides, and found that many of those 22 women had risk factors, including for “major affective disorder”, that were not recognised, two-thirds had a prior psychiatric history, and there was also a “lack of communication between services (primary and secondary and across disciplines)”.
As well as the risk to mothers of undiagnosed and untreated depression, there’s increasing evidence that PND can have a negative impact on their children, from higher rates of emotional and behavioural issues to social problems. Some healthcare providers are reluctant to highlight that side of the equation, for fear the associated guilt and anxiety will only intensify the very condition they’re aiming to alleviate.
But whether or not women have read the latest study on risks to infants, or been told about it by their doctors or midwives, they appear to be pre-loaded with more than enough fear and guilt to go around. All the mothers interviewed for these articles talked about it, from July*, who described a “real sense of shame and guilt associated with [post-natal depression] and … a real sense of failure. I felt that I had really failed my daughter and I hadn’t even begun the journey of motherhood”, to January*, who says she feels guilt “about how I didn’t love [my son] so much in the first few months”. “I just felt I was going through the motions with him for the first few months with no real feeling behind it. So now I’m really soft with him and he’s a total mummy’s boy.”
‘Consistency in Screening’
“Consistency in screening”, which would include a woman’s history as well as her current state, was one of the recommendations of the Perinatal and Maternal Mortality Review Committee’s 2016 report – that and “consistency of maternal mental health access pathways”. Because even if there’s screening in place, it’s of little use if the screeners – be they midwives or Plunket or Tamariki Ora nurses – don’t have clear options for follow-up care.
And it’s that follow-up – or lack of it – that’s at the heart of many concerns about mandatory screening. If services are already stretched and piecemeal, how could they possibly cope with scores more positive diagnoses? “Mandatory screening hasn’t really been shown to have that many benefits, so the screening itself is just screening. Then what do you do with it?,” says Mark Huthwaite, a perinatal psychiatrist in the Regional Specialist Maternal Mental Health Service in Wellington.
Alison Eddy of the New Zealand College of Midwives agrees. “What do you do when you pick up depression, or potential depression in a woman?” she says. The next steps aren’t well defined, and “it’s not always easy to engage women in the services that are available for them”.
She also says the stigma of mental health problems coupled with all the “mother guilt stuff that goes on” makes some women particularly reluctant to acknowledge they’ve got depression.
But screening can be made to work in New Zealand. Spearheaded by Ferguson, the Auckland general practitioner network Procare undertook its own PND screening and treatment programme in 2003. They used the Edinburgh Postnatal Depression Scale – a better screening tool than the PHQ-3 – and carried out the screenings at two of a baby’s three immunisation visits, which take place at 6 weeks, 3 months and 5 months. Fifty-five percent – or 101 – of the network’s general practices took part, carrying out more than 14,000 screenings, which resulted in more than 1,700 “positives”, or a rate of 12 percent. The practices followed up nearly all the patients (less than 10 percent declined treatment) and concluded there was “a pressing need” for a screening programme, but – again – it needed to come with treatment and follow-up options.
Funding for the programme ran out after a few years, but some practices continued the screening on their own, including Ferguson’s own, where practice nurses continue to administer the Edinburgh survey during immunisation visits.
Practice nurse Lesley Clapshaw says when a woman comes in for her baby’s 6-week immunisation, it’s often the first time she’s been to the practice – “we don’t know what the mum’s like the mum doesn’t know us”. “After you’ve gained their trust, you hope, that’s when I tend to have a bit of a chat about how they’re going and the things to be watching out for.” Clapshaw said she’d only had one woman who didn’t want to do the Edinburgh check list.
‘I Was In Denial’
Several of the women interviewed for these articles pressed on for some time despite quite debilitating symptoms, believing what they were going through was “normal”. It was only when the suffering – and the toll they feared it was taking on their babies – became intolerable that they sought or received the support they needed.
September* said it took a while for her to admit she needed help. “I was in denial for such a long time, and just told everyone I was fine when I was anything but,” she said. “My experience of PND is based around the lack of bond with my son,” she says. “I still to this day do not feel that I have fully bonded with my son although I am coming to believe that the bond is there and always has been, it’s just that it’s hidden behind the pain, exhaustion, and lack of day-to-day support.”
At her lowest point, September* also had intrusive, desperate thoughts. “I would fantasise and plan ways that I could escape or end it all, but the guilt stopped me. I even had thoughts about driving off a cliff with my baby in the backseat. Terrible thoughts. But just thoughts.”
(Intrusive and disturbing thoughts are very common among sufferers of PND, and women are reluctant to talk about them, often for fear of having their babies taken away. Such thoughts are not, as one maternal mental health expert explains, about “a wish or urge to harm the baby just a fear that you might”.)
“Eventually after breaking down at the GP’s office she prescribed me Escitalopram which I am still taking. I also started seeing a PND counsellor,” September* said.
April* said she could tell something wasn’t right, “but you hear the stories of people having postnatal depression and you go, ‘No that’s not me I don’t have that’. And then you think, ‘Well if I do have that, does that make me a bad mother’, because you know people think you’re a bad mother when you have something wrong with you.”
‘Look for Those Women’
Rotorua clinical psychologist Tina Berryman-Kamp says it’s a challenge to remind Well-Child nurses to “look for those women”. “You can’t just do your screening questionnaires of ‘How have you been feeling?’ because these women typically will say ‘I’m OK’. That, to me, is an ongoing frustration because they get missed, and they’re not picked up by other services, they don’t meet the criteria for most other services.”
And don’t even think about using the words ‘baby blues’, she says. “I am really, really annoyed of people talking about the ‘baby blues’, when we’re talking about perinatal mental health issues,” she says. “Please do not use those words … if people say, oh, everybody gets the baby blues, it’s normal, I might then tolerate living with a serious mental illness thinking it’s normal.”
But that was precisely the experience of November*, who had a history of depression, and thought she was well-prepared for the emotional rollercoaster of becoming a mum.
“My midwife kept telling me, ‘oh it’s hormones after you have your baby. Up until 6 weeks, it’s just baby blues’. But I now know that’s actually – three weeks is the cut off apparently,” November* said. “On reflection in fact, my midwife, I loved her, but she’d been a midwife for 30 years and that’s what I loved about her, I trusted every word she said – but on reflection now, she contributed to quite a lot of my anxiety.”
November* said her midwife also told her if she wanted to go on medication for depression, she would have to stop breast-feeding, “which is not true”. “I don’t know if it was true back in the day, so I was terrified to go to get treatment because I was a really good breast-feeder, really lucky heaps of milk. It was the only thing I felt like I was doing right.” In the end, November*’s family pushed her to get help, “and it turned out I could breastfeed with the medication I had always used”.
Confusion, and Disagreement
There’s a lot of confusion — and a fair amount of disagreement — about what causes PND, who’s most at risk and what the best treatments are. Most broadly, the culprits are lumped together in two groups: physiological (things like hormones and brain chemistry) and psychosocial (things like social pressure, ethnicity, socioeconomic status).
Ferguson is firmly convinced psychosocial factors play no direct causal role, which isn’t to say they aren’t important and don’t need to be dealt with. But, to his mind, some of so-called risk factors are effects of the illness, not causes.
Take the link between PND and relationship problems. “My enduring long term observation of this is that it was an effect of the condition, not the cause, because everything would come right again when the mother recovered,” he says. “As I would always say to the couple, ‘undiagnosed and untreated PND eats up relationships and spits them out'”.
Ferguson says post-natal depression was pivotal in his “reframing and starting to think differently about mental health generally”. “Probably my first 10 years I saw it very much in a psychosocial model, but by the time I’d really watched the condition for as long as I had, I started to really understand that what we were looking at here was much more fundamentally biological and biochemical.”
Ferguson believes postnatal depression – of all the depressions out there – responds particularly well to antidepressants, and he’s been critical of guidelines for treatment that downplay the medication option. In a submission to a draft of the Ministry of Health’s “Identification of Common Mental Disorders and Management of Depression in Primary Care”, he wrote that: “As it stands the guideline underestimates the value of anti-depressant medication, particularly postnatally, and gives the misleading impression that advising women with post-natal depression to exercise or have counselling is a viable form of treatment.”
Those guidelines were finalized and issued in 2008, and advise doctors that, “Nonpharmacological interventions such as enhanced social support and/or a psychological intervention should be considered before prescribing medication for antenatal or postnatal depression”.
Medication and Guilt
Taking medication was problematic for several of the women interviewed for these articles, who had concerns ranging from fear of the effect on their babies to feeling they had “failed” if they went on antidepressants.
January* said she wasn’t keen to go on medication “particularly because I was still breastfeeding him and … that made me feel guilty as well: ‘Gosh, I’ll be feeding him and this medication’s going through.’ But in my head, I was like, well that’s the best option, I can’t go on feeling resentful towards my children and not liking my daughter and not enjoying being their mum. I have to try and get better.”
In the end, she said while medication was important, she believes it was a combination of things that helped her get well, including also counselling, listening groups and the Facebook page run by a PND support group.
Both June* and November* had taken medication for depression in the past but came off it when they got pregnant. While November* got through her pregnancy OK, June* suffered, and in retrospect says she shouldn’t have stopped taking it during pregnancy. “Looking back, I probably didn’t need to,” she said. Her GP told her it was up to her, but June* says she didn’t get enough advice and “I probably should have done some more research”.
February*, who has been diagnosed with social anxiety disorder and OCD – not the type where you have to clean things manically, she says, but the kind that brings on intrusive thoughts – says as well as medication, she has used cognitive behaviour therapy with good success. Several mothers said mindfulness had also helped.
Dr. Sue Cowie
Clinical psychologist and senior tutor at the University of Auckland, Dr. Sue Cowie, is wary of medicalised approaches and says that while studies have shown antidepressants provide a small improvement in mood, it’s “not dramatic”. “Mostly, women need a lot more support than just antidepressants, is the point,” she says.
Cowie, who interviewed 24 women for a Ph.D. thesis on PND, sees unrealistic expectations around motherhood as a factor, as well as the neoliberal notion that it’s up to the individual mother to successfully do everything for her child – “that idea that it takes a village to raise a child is not how it’s viewed”.
“I don’t think they’d have postnatal depression if they had realistic expectations of what it was about. I think a lot of it is about overwhelming responsibility for, and not being prepared for, what it means. It’s very hard to know how it’s going to be until you’re in it because it is such a transformational thing in terms of your role as a woman.”
She says even talking about postnatal depression is problematic “because it becomes an entity that’s to do with biology, and what can you do about that? It’s a comfort in the sense that ‘it’s not me it’s my biology’, but it’s not a comfort if you’re thinking, ‘well how can I stop this from happening again’?”
“The good thing I saw women do was, as they came through their distress, was that they could have a story that wasn’t just about a biological story. Even though 18 out of 24 took medication and most of them thought it was useful, they still could have a story that was about all these contextual issues that made it so much harder,” she said. “They had very much more of a realistic idea about the potential for difficult things to happen, and plan for how they would manage it.”
*Pseudonyms are used where anonymity has been requested.
Other articles in this series:
Articles in this series were supported by a grant from the Scoop Foundation for Public Interest Journalism.
This investigative journalism project by Alison McCulloch was funded entirely by member donations to the Scoop Foundation for Public Interest Journalism. If you want to see more quality public interest journalism like this please donate to, or become a member of, the Scoop Foundation here.
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Alison McCulloch will be interviewed by Kim Hill on Kim’s RNZ Saturday morning show at 9.05am on 22nd October, and that interview will be subsequently available on the RNZ website.