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Maternal Depression: You Can’t Judge A Book By Its Cover

Posted on | February 28, 2008 | No Comments

A call for universal screeningA health care professional once told me a story about her bout with postpartum depression.  She talked about spending months in her pajamas, never leaving the house and struggling to function in her role as a new mother.  She talked about barely being able to care for her baby and about being negligent in her own personal care. The things we all take for granted as daily activities such as eating, bathing and dressing were marginally attended to.  Her minimal energy reserves were used to do these things for her infant.  One day, when she knew she could no longer continue living as she had been, she decided to seek help.  She told me it took every ounce of strength in her body to shower and put on her skirt, shoes and suit jacket which were once her daily garb.  Tall, thin, beautiful and articulate, this woman looked once again like the consummate young professional but on the inside she was suffering.  Each step she took on her way to her appointment felt like she was running a marathon.  Her short trip left her feeling as jet lagged as a world traveler. 

Finally, in full apprehension, she reached her destination.  She walked into the physician’s office telling her self to remember to wear the social face of a smile and the words of please and thank you.  She is educated and well bred and was able to muster up the proper social affectations common to her milieu.  She extended her hand to greet her doctor being careful to make a good impression.  She sat down in the chair and smiled politely.  On the inside she was shaking and wondering if she would be able to sit long enough to get through the consultation.  Her thoughts raced as she sat in silence while his eyes made an erudite decision after sizing her up.  In what seemed to her like an eternity but was surely only a matter of seconds he broke the silence.  What she told me he said to her is on the surface astounding.  She told me he said,” I can tell by looking at you that you are not depressed”.  Her heart sank.  She was going to have to go elsewhere to find the help she badly needed and in the end she did just that.

This is not an uncommon story. Wilen and Mounts in their article, Women with Depression – “You Can’t Tell by Looking” suggest that when screening for depression in the health care setting is based on clinical observation alone, 50% of women suffering from depression are missed.  In a study of 888 pediatricians, Olson et al conclude that even during the postpartum period when pediatricians have frequent contact with mothers and babies, pediatricians rarely identify maternal depression through a routine inquiry about symptoms or through family history.  In fact, the most common identification method reported was the physician’s overall impression or the impression in combination with 1 or 2 questions about the mother’s symptoms. Only 4% of the physicians in this study reported using formal diagnostic criteria to identify maternal depression while none reported using a validated screening tool to identify maternal depression.  

Universal screening is a necessary prerequisite towards the identification and treatment of maternal depression and this is not a responsibility specific to any one discipline.  Whether we are discussing perinatal depression, which is depression during pregnancy and the postpartum period, or depression at any time throughout the life course, systematic and universal screening is the most effective way to identify depression.  Of interest is a study which utilized a 2 question screen of mothers during well child visits. One group of mothers received the screen on paper while the other group was screened by means of a scripted interview.  Although both methods were proven to require very little time, the paper screen was verified to be a more effective model.  

Maternal depression not only has devastating consequences for the health of women, it also has a profound effect on child health and developmental outcomes.  The identification and treatment of maternal depression offers promise as a preventive 2 generational intervention which has the potential to change the life course of women suffering from depression and that of their children.  Since we can’t trust clinical observation to tell us which women might be at risk, the universal application of a brief screening tool in the primary care setting, during well child visits and during prenatal and postpartum visits is a good place to begin to address the problem of maternal depression.  Depression can linger, undiagnosed and untreated, under the veil of a smile and freshly washed clothes.   It is within the hidden narrative of a book’s chapters where a person’s individual story will begin to unfold.  Universal screening is a way to initiate articulation and dialogue around the issue of maternal depression. Only then will we be able to address feasible treatment options.

(Amy Gagliardi is a writer and researcher based at Yale University. She can be reached at amyd.gagliardi@gmail.com. Opinions expressed by Health Commentary guest bloggers do not necessarily represent the views of Health Commentary.)  

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