Apr 20, 2016

Texas Lags Behind in Screening New Moms for Depression

Reporting Texas

Before the birth of their first child five years ago, Amy Tucker and her husband, Mark, did everything they could  to prepare. “We did all of the child classes, read all the books,” she explained.

Yet nothing Tucker did — nor that doctors mentioned in prenatal care — braced her for the one aspect of motherhood that would cause her the most heartache. Shortly after giving birth, Tucker developed severe postpartum depression (PPD).

“That’s when things became very scary,” she recalled recently. She experienced loss of appetite, panic attacks and, most disturbing of all, intrusive thoughts that something bad would happen to her or the baby. When Tucker visited her doctor’s office, a nurse practitioner dismissed her concerns as the side effects of a new mother’s sleepless nights.

“She said, ‘Go home and take a Benadryl,’ and did nothing,” Tucker said, adding: “The next morning, I woke up and felt 10 times worse.”

The Centers for Disease Control estimates that as many as 19 percent of new mothers in the U.S. experience symptoms of PPD, making it the most common complication after pregnancy. In January, the U.S. Preventive  Services Task Force, a government-appointed health panel, recommended that all pregnant and postpartum women be screened for depression. The recommendation came in the wake of mounting scientific evidence that screening pregnant women improves detection and treatment outcomes. A report from the Journal of the American Medical Association compared six trials that showed 18 percent to 59 percent relative reductions in PPD through screening programs.

Even so, many expectant and new moms in Texas aren’t being screened. Typically, the 10-question survey, known as the Edinburgh Postnatal Depression Scale, is easy for healthcare providers to administer. But while the state has taken steps to increase awareness about PPD among expectant mothers and healthcare professionals in recent years, Texas does not require depression screenings.

It’s harder to mandate screening that is more complicated than just a simple blood test,” said Dr. Robyn Horsager-Boehrer of the UT Southwestern Medical Center in Dallas.Choosing an appropriate screen, administering the test correctly, and then knowing what to do with the results all are variables that make this more complex than other types of screening.”

These obstacles may prevent some OB-GYNs from asking about mental health, even though The American Congress of Obstetricians and Gynecologists recommends that women be evaluated at least once after the birth of the baby. Horsager-Boehrer believes it’s important to follow this guideline so that the diagnosis and treatment of depression becomes part of routine medical care.

In 2003, the state Legislature took action after a Houston mother, Andrea Yates, confessed to drowning her five children while experiencing postpartum psychosis, a rare disorder. It required hospitals, birthing centers and physicians to provide information about postpartum depression and other postpartum illnesses. In 2015, the Legislature passed a bill making May of this year the first Postpartum Awareness Month.

Despite a growing awareness and increased availability of information, it is often left to the women to broach the subject with their healthcare providers. And admitting feelings of extreme anxiety or depression after birth can be difficult for new mothers, like Tucker, who had been eagerly anticipating the birth of her first child.  “I placed so much guilt on myself and truly began to believe that I was a terrible mother for feeling this way,” she said.

Many women experience mood changes due to a rapid drop in hormone levels in the two weeks after delivery, but for women who experience PPD, the symptoms are even more acute. According to Children At Risk, a Houston-based nonprofit that researches issues affecting parents and children in Texas, an estimated 79,000 women across the state experience PPD each year.

Tucker, now 37, went 13 months without treatment before her symptoms began to subside. The prescription for women with PPD is typically psychotherapy, which can sometimes be combined with medication. Determined not to fall through the cracks again before the birth of her second child, Tucker armed herself with information and connected with a therapist. Even now, she still sometimes struggles with anxiety. “I thought: ‘How is this happening to women all the time [and] not one person ever talked about it?’” she said.

Tucker’s experiences inspired her to leave her career in corporate marketing to become a certified postpartum doula, someone who provides technical and emotional support to new mothers during and after pregnancy. She now works with the Pregnancy and Postpartum Health Alliance (PPHA) in Austin, a nonprofit organization that connects women with mental healthcare services. PPHA also offers a volunteer doula program, which Tucker helps coordinate, to provide free services to mothers unable to afford them.

“A lot of times the doula is the first person to ask the mom how they’re feeling after birth,” Tucker said. But she believes healthcare professionals should really be the first line of defense against PPD. “If I would have known how common this is and been able to put a name on it, I could’ve had a conversation with my doctor about what to do,” Tucker said.

“It’s up to us as physicians to keep reminding patients that this is very serious,” said Dr. Kimberly-Coleman Henderson, an OB-GYN with Lone Star Circle of Care in Austin. Her practice provides healthcare services to patients in Central Texas who may be uninsured or underinsured. Coleman-Henderson explained that her office screens pregnant women and new mothers using the Edinburgh Postnatal Depression Scale but that when she worked previously for private practices in Texas and Georgia, the offices did not use the screening. That experience is consistent with a 2014 postpartum depression report from Children At Risk, which revealed that “screening practices vary across and within organizations, and many practitioners are not using validated screening tools.”

Coleman-Henderson said considering that only 20 percent of women report symptoms of PPD to their doctor, the screening scale can be a useful tool in starting the conversation. “When they (patients) do that scale, they think about symptoms that they may have had that they thought were normal,” she said.

Elaine Cavazos, clinical director at the Postpartum Health Alliance, hopes that women and healthcare providers understand the consequences of not screening women for postpartum depression. “It is an illness, just as if the woman developed gestational diabetes or anything else,” Cavazos said. “It requires treatment.”

Texas’ mental health resources are limited. CHIP Perinatal, a state program for uninsured pregnant women, does not cover mental health services for the mother. The wait to see a therapist or psychiatrist, even for insured women, can take months, and a visit can cost upward of $400 if insurance isn’t billed. With the help of PPHA, patients can typically be seen within two weeks and qualify for  financial assistance for appointments through the organization’s voucher program.

Cavazos hopes that increased screening practices, along with awareness, will help women overcome the stigma of PPD that keeps many women from seeking treatment. “We have to get them into see people who can create that environment of trust where they can say thoughts out loud,” Cavazos said, “and to have somebody say, ‘It’s normal to be having those thoughts … and we can get you help.’”