Obstetrician Archives - World of Psychology

Bremner's False Claims about Postpartum Depression Psychiatrist J. Douglas Bremner has weighed in on the Melanie Blocker Stokes MOTHERS Act, an effort to provide voluntary screenings to pregnant women to help identify postpartum depression before it becomes overwhelming. I’ll let Bremner speak for himself:

The problem with this is the attitude that being a mother is a risk factor for a psychiatric disorder. First of all, there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum depression. So to screen all moms as if giving birth is a risk factor for depression is ridiculous.

My BS alert goes off whenever someone tries to change the argument from a reasonable effort to help increase education and information about a stigmatized mental health issue, to hyperbole, suggesting that a piece of legislation is trying to turn motherhood into a psychiatric disorder. It goes off again when a professional makes an extraordinary claim like, “there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum [sic] depression.” Really? Absolutely no evidence? That’s quite a strong statement, and easily proven false with a literature review.

Where shall we begin? (I have limited space and you have a limited attention span, so I’ll just highlight a few studies…)

Ross & Dennis (2009), for instance, in a literature review found that both substance use and current or past experiences of abuse are associated with increased risk for postpartum depression (PPD).

In urban South African women, Ramchandani and colleagues (2009) found the strongest predictors of postnatal depression were exposure to extreme societal stressors (e.g., witnessing a violent crime/danger of being killed) and reporting difficulties with their partner.

Robertson et al. (2004), in a large meta-analysis of research to-date, found that a previous history of depression and anxiety (not just during pregnancy) was predictive of postpartum depression. But they also found that simply experiencing a stressful life event during pregnancy or low levels of social support (e.g., not having any emotional support from your friends or family) could also lead to postpartum depression.

Beck’s (2001) meta-analysis of 84 studies found:

13 significant predictors of postpartum depression: prenatal depression, self-esteem, childcare stress, prenatal anxiety, life stress, social support, marital relationships, depression history, infant temperament, maternity blues, marital status, SES, and unplanned/unwanted pregnancy. 10 of the 13 risk factors had moderate effect sizes while 3 predictors had small effect sizes.

Look at all of those factors which are not depression or anxiety — I count 9. Even if 3 of those are small-effect size factors, that still leaves 6 factors which are not depression or anxiety.

What about the argument that if depressed women are the most at-risk, we should simply focus on them?

Ingram & Taylor (2007) found it wasn’t just a woman’s pre-birth depression severity that was important — poor emotional support and women who had more negative descriptions of their own childhood were additional risk factors that played a role in increased risk for postpartum depression. Who’s going to screen for these things, the obstetrician?

Well, no, because the obstetrician is already not doing a good job at screening for postpartum depression, even in high-risk women. Hatton et al. (2007) found that, among high-risk women, obstetric care providers may be overlooking up to one fifth of women with current major depression. Not exactly great numbers there. If obstetric care providers can’t deal with the obvious cases, I can only imagine how well they do with the more complex or less obvious ones.

Monk et al. (2008) sums the state of our knowledge on PPD:

Depression is relatively common during the perinatal period (Gavin et al. 2005; Ross and McLean 2006). Approximately 8.5 — 11% of women experience either a major or minor depression during pregnancy (Gaynes et al. 2005). Nearly 20% of women have a minor or major depression in the first 3 months following delivery (Gavin et al. 2005).

So up to 1 in 5 women have depression after giving birth, and this isn’t something worth noting or screening for? (For comparison’s sake, 1 in 10 men and women in the general population might have depression at any given time.) Giving birth doubles your risk of depression, and this isn’t an issue? Amazing.

But don’t just take my word for it. Zajicek-Farber’s (2009) study conducted on high-risk women for postpartum depression concluded that:

These findings provide additional supportive evidence that more efforts are needed to identify and assess women’s depressive symptoms to promote health and safety of young children.

These are objective researchers calling for more screenings. Not politicians. And not people (or professionals) with a political agenda.

Now, I understand Bremner’s point — let’s not medicalize and catastrophize ordinary motherhood. I agree. And of course a woman’s pre-birth depression or anxiety is strongly correlated to postpartum depression. But not exclusively, as Bremner claims.

Bremner claims, with no evidence, that all mental health screenings are simply pharmaceutical sales tactics to help increase prescriptions. That’s ridiculous. When I worked in community mental health, we ran annual mental health screenings in the clinic — with no funding from any pharmaceutical company — because it reduces stigma, decreases misinformation and increases education about mental health issues in the general population.

Sorry, but most people don’t have time to keep up with a dozen blogs or read monthly journals on the latest research in mental health. Most people know what they know about mental health largely through mainstream media, or their own first-hand experiences with an issue. How is the promotion of more information and education about mental health issues a bad thing?

Bremner uses teens as an example of screening gone wrong, but conveniently fails to mention the facts about teenagers and mental health. Teens are an “at-risk” population, hence the reason they are sometimes targeted for screenings. Teens are notorious for being limited in their treatment options (especially in the U.S., where their treatment may be covered by their family’s health insurance, meaning a talk with their parents about their mental health issues), and for peer pressure limiting their ability to accept or seek help. (Yes, sorry, if you’re seeing a therapist for depression as a teen, you’re typically not seen as a “cool” kid.)

Sadly, whether people want to admit it or not, mothers are another “at risk” population. Why? Because society has told mothers time and time again that giving birth is supposed to be a joyous, happy occasion. If you’re depressed after giving birth to a child, there must be something wrong with you. Don’t draw attention to yourself or your problems. Just try and deal with it, try and take care of the baby, and make it through each day. Mothers don’t know they might have something recognized as postpartum depression, much less that they can talk to someone about these feelings or that there’s treatment — psychotherapy or medication — readily available for it.

So respectfully, I disagree with Bremner’s assessment of the MOTHERS act and its need in today’s society. And if you’re not going to bother to do the legwork and just make general (false) pronouncements about what the research actually shows (or worse, suggest the all research that disagrees with you must be in pharma’s pocket), then that’s a lazy person’s argument. There are too many logical fallacies at work here to list, so I’ll just suggest that I expect more reasoned and professional arguments –based upon the actual research — about such important legislation.

Psych Central continues to support the Melanie Blocker Stokes MOTHERS Act because the research shows it would help in the efforts to increase education and correct mis-information about postpartum depression.

References:

Beck, C.T. (2001). Predictors of postpartum depression: An update. Nursing Research, 50(5), 275-285.

Hatton, D. C., Harrison-Hohner, J., Matarazzo, J., E.P., Lewy, A. & Davis .L. (2007). Missed antenatal depression among high risk women: A secondary analysis. Archives of Women’s Mental Health, 10(3), 121-123.

Ingram, J. & Taylor, J. (2007). Predictors of postnatal depression: Using an antenatal needs assessment discussion tool. Journal of Reproductive and Infant Psychology, 25(3), 210-222.

Monk, C., Leight, K.L. & Fang, Y. (2008). The relationship between women’s attachment style and perinatal mood disturbance: Implications for screening and treatment. Archives of Women’s Mental Health, 11(2), 117-129.

Ramchandani, P.G., Richter, L.M., Stein, A. & Norris, S.A. (2009). Predictors of postnatal depression in an urban South African cohort. Journal of Affective Disorders, 113(3), 279-284.

Robertson, E., Grace, S., Wallington, T., Stewart, D.E. (2004). Antenatal risk factors for postpartum depression: a synthesis of recent literature. General Hospital Psychiatry, 26(4), 289-295.

Ross, L. E. & Dennis, C-L. (2009). The prevalence of postpartum depression among women with substance use, an abuse history, or chronic illness: A systematic review (PDF). Journal of Women’s Health, 18(4), 475-486.

Zajicek-Farber, M.L. (2009). Postnatal depression and infant health practices among high-risk women. Journal of Child and Family Studies, 18(2), 236-245.

For decades, thousands of people in dozens of organizations have fought tirelessly to reduce the stigmatization and ignorance associated with mental health issues and mental disorders. Mental illness is not something you can just “get over,” nor is it an invention of the pharmaceutical companies (although I’m sure there are some who believe that).

Even within this dedicated group of people who are all fighting for the same things — recognition that mental illness is just as real as physical illness — they is within-group stigmatization. Some mental disorders get the short shrift, or are thought to be less “real” or serious than other disorders. The National Alliance on Mental Illness (NAMI), for instance, only lobbies and advocates for what it considers to be biologically-based mental disorders, such as schizophrenia and bipolar disorder. They have historically had far less interest in other disorders, such as anxiety or personality disorders.

This saddens me. And it saddens me even further to see people knock something like postpartum depression, a very real mental disorder that affects thousands of mothers every year who have just given birth to their child, and then feel overwhelmed with depression. They often are unable to do even basic child care for their newborn baby, and feel hopeless, despondent, and listless, without motivation or energy.

Moms are in need of being taken seriously, of having their concerns heard. You’d think nobody would be against mothers seeking to get proper diagnosis, treatment and care for something that is at the very core of having a healthy family.

But you’d be wrong.

Senator Robert Menendez of New Jersey introduced the Melanie Blocker Stokes MOTHERS Act in the Senate to try and reduce the stigmatization that goes on around postpartum depression, increasing funding for education and screening programs to catch more mothers in need. But one senator — an obstetrician no less — doesn’t like “disease-specific” legislation, and has used a senatorial hold to stop the legislation from moving forward, according to Katherine Stone’s entry over at Postpartum Progress:

Senator Menendez indicated that much of the strong opposition to this bill continues to come from Senator Tom Coburn of Oklahoma who refuses to pass any of what he calls “disease-specific” legislation. Here’s the part that absolutely kills me: Dr. Coburn specializes in family medicine and obstetrics. Dr. Coburn has personally delivered more than 4,000 babies, according to his bio.

Thanks Dr. Coburn! What a great way to show your forward-thinking efforts, at the very same time the e-patient movement is gaining steam and people are looking to replace the old paternalistic doctor who “always knows best” with empowered, educated patients who work as true partners with their doctors.

And why is this legislation so controversial? I have no idea. The legislation under consideration would increase federal efforts to combat postpartum depression by:

Encouraging Health and Human Services (HHS) to coordinate and continue research to expand the understanding of the causes of, and find treatments for, postpartum conditions.
Encouraging a National Public Awareness Campaign, to be administered by HHS, to increase awareness and knowledge of postpartum depression and psychosis.
Requiring the Secretary of HHS to conduct a study on the benefits of screening for postpartum depression and postpartum psychosis.
Creating a grant program to public or nonprofit private entities to deliver or enhance outpatient, inpatient and home-based health and support services, including case management and comprehensive treatment services for individuals with or at risk for postpartum conditions. Activities may also include providing education about postpartum conditions to new mothers and their families, including symptoms, methods of coping with the illness, and treatment resources, in order to promote earlier diagnosis and treatment.

It is estimated that postpartum depression (PPD) affects from 10 to 20 percent of new mothers. In the United States, there may be as many as 800,000 new cases of postpartum conditions each year. The cause of PPD isn’t known but changes in hormone levels, a difficult pregnancy or birth, and a family history of depression are considered possible factors.

Sounds good to me. But Philip Dawdy over at Furious Seasons remains skeptical:

Here’s the thing that makes my scratch my head, however: women have given birth for many thousands of years and many have experienced “baby blues,” until recently without mental health screenings or psych meds of any kind and without a bunch of arm waving about post-partum depression (the advocacy on this issue is a phenomenon of the last decade). Broadly speaking, the lack of such supposed benefits does not seem to have harmed society a bit, although there are obviously individual exceptions.

With that same logic, Philip could be scratching his head about a lot of disorders where, prior to their “invention,” people seemed to get along just fine in society — attention deficit disorder (ADHD), PTSD, panic attacks, autism, Asperger’s syndrome, etc. It’s no surprise to anyone who’s studied women’s history to understand how repressed their voices have been in society until the past few decades. So is it any wonder that history isn’t filled with their accounts of grappling with postpartum depression? A woman would be an outcast from their own family for admitting such a thing even 50 years ago. Even possibly disowned or institutionalized. It just wasn’t said or discussed much.

Perhaps the saddest thing of all, though, is that people — in this day and age of instant connectivity and all of the wonders the Internet has brought us — are still against basic, simple things like education and information about these concerns. “What? You want us to spend money educating future moms on postpartum depression!??! Ridiculous!” I just don’t get it.

Postpartum depression is real, it affects thousands of lives every year, and is one of those quiet disorders that have flown under the radar for far too long, while mothers lived in quiet desperation that someone would listen to them and believe them when they said they were depressed after just giving birth. To be listened to, to be understood, to be heard. That’s all these mothers ask.

Read the full entry: Senator Blocking MOTHERS Act Is Obstetrician (Seriously).

Obstetrician

Bremner’s False Claims about Postpartum Depression

Postpartum Depression: Real, But Still Stigmatized