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Postpartum Depression Can Occur Longer Than We Thought – and COVID-19 Makes it Harder

COVID-19 blog series

Postpartum mental health is a crucial piece of the family mental health landscape. Parental stress and depression can impede parent-child interactions, impacting children’s social-emotional and language development. Untreated maternal depression can increase the risk of child maltreatment as well as children’s own risk of depression, separation anxiety, and difficult behavior. As a result, the American Committee for Obstetrics and Gynecology (ACOG) recommends screening for depression at least once (and ideally multiple times) from pregnancy through the 12 months following delivery.

But a recent study published in Pediatrics makes a strong case for more frequent and longer-term assessment, finding that many mothers experience symptoms of depression up to 3 years after giving birth.

The research followed 5,000 mothers in New York and found that a quarter of women had elevated depressive symptoms at some point within 3 years after the birth of their child. Depression was found more often among young mothers, those without a college education, those who had gestational diabetes, and those with a history of mood disorders.

Notably, by following these mothers over 3 years, researchers identified four patterns in maternal depression.

  • Low-stable: low symptoms at all waves;
  • Low-increasing: initially low but increasing symptom;
  • Medium-decreasing: initially moderate but decreasing symptoms; and
  • High-persistent: high symptoms at all waves

These differing trajectories are important for medical practitioners and families to recognize that postpartum depression doesn’t always “look” a certain way, and that challenges can arise – and be successfully addressed – at any point in early parenthood.

This research makes a strong case for extending our existing supports for postpartum depression along a greater time frame – but the reality is that our current system of screening and treatment actually does not fully meet the needs of families. The CDC reports that about 10 percent of new mothers experience depressive symptoms, with higher rates among mothers on Medicaid, mothers whose babies were very low birthweight, and young mothers (ages 18-19) – but only about 20 percent of moms with high screener scores pursue follow-up treatment.

While many mental health conditions in the perinatal period require one-on-one therapeutic treatment and/or pharmacology intervention (this decision is best left to qualified medical professionals), less clinical treatments may be beneficial for mothers whose challenges are more situational and related to the range of challenges in early parenthood. This requires having a sufficient number and variety of accessible support programs which are shown to have an impact on maternal depression, which may include group-based pre-/post-natal care (like Centering Pregnancy), nurse home-visiting, and support groups. A dual-pronged strategy of building on existing infrastructure while also investing in the pipeline of specialized mental health care providers is key.

Most of what we know about maternal depression, including the recent study in Pediatrics, uses data from well before our current public health crisis; however, there is good reason to believe depression rates may be even higher due to COVID-19. One Canadian study fielded in April and May of this year, focused on women who were pregnant or within a year of delivery. Just 15 percent of respondents had a screener score equal to or greater than 13 (the study’s definition of likely depression) when they reflected pre-pandemic;  this figure increased to about 40 percent at the time of the study. “Moderate to high anxiety” was identified in 72 percent of participants at the time, compared to just 29 meeting this definition before the pandemic. At the same time, with restrictions on in-person meetings and differences in how medical visits are conducted, moms may be facing additional barriers to connecting with treatment.

In addition to formal interventions, emotional and material supports are important factors in “buffering” families as they face the stress of pregnancy, delivery, and newborn life. However, the pandemic has dramatically altered how people relate and connect. In their ongoing surveys of families during the pandemic, the Rapid Assessment of Pandemic Impact on Development Early Childhood (RAPID EC) project at the University of Oregon found dramatic changes in emotional support reported by parents, with significant losses of support among non-immediate relatives, friends, and coworkers (this research is not specific to families with a recent birth).

Financial hardship is linked to worse emotional well-being for caregivers, including higher reported experiences of stress, anxiety, depression, and loneliness. Children within the household are impacted by the stress of their caregivers (even if they do not know what the source is). This triggers what the RAPID EC researchers refer to as “a hardship chain reaction,” with higher rates of child emotional issues in households facing extreme financial challenges as well. Research evidence has long existed that shows a link between family economic conditions and child well-being, but this research shows the impact like a series of dominos falling in a matter of weeks, not years.

With COVID-19 cases in much of the U.S. reaching spring levels, how can we ensure that the continued health crisis does not create a wave of postpartum depression which stresses families for years to come?

The RAPID EC team recommends “a dual focus on enacting measures that prevent or reduce material hardship combined with efforts to promote and enhance emotional supports is absolutely essential to ensure the wellbeing of young children during the pandemic.”

Georgetown University’s Center for Children and Families notes that changes to Medicaid and Children’s Health Insurance Program (CHIP) coverage could go a long way to more effectively identify postpartum depression and connect families with services, tweaking existing mechanisms to better serve birthing families:

“State Medicaid agencies set periodicity schedules under Early and Periodic Screening, Diagnostic and Treatment (EPSDT), so agencies could use these findings to allow payment for maternal depression screenings through a child’s 30-month check-up….

Ensuring their health coverage also matters. With pregnancy Medicaid and CHIP coverage ending just 60 days after birth, many women do not have coverage for themselves, so a positive screening result at their child’s four- and six-month visits can lead to additional frustrations when attempting to get care….Extending coverage for one year or even longer would be another critical first step  to mitigate the emotional and economic stress facing many families.”

If you or someone you know may be struggling with postpartum depression, know that it is a common and treatable issue – and nothing to be ashamed of! Talk to your own doctor, or your child’s pediatrician, and how you are feeling – they can help connect you to local resources. Or, reach out to the mental health hotline operated by SAMHSA to get connected to resources now.

Megan Carolan

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