Health teams must recognise depression
A national approach is planned to help women who don’t warm to their babies the way society expects. Kellie Bisset reports
HOLLIE Cavanagh was 29 when one night where she just wanted to die. Asleep in the nursery was twomonth-old Alex — a good baby who ate well, slept well and was easy on his parents. But Cavanagh just couldn’t warm to him, and things continued to deteriorate until that night, when she woke her husband to tell him she was having suicidal thoughts.
‘‘ I basically got to the point that if there was a button to press to evaporate from the planet, I would have pressed it,’’ Cavanagh says. ‘‘ Every time Alex cried or made noise or indicated he needed me, I had a buzz of anxiety in my tummy. Doing everything for him was a chore, not a joy in the beginning. I was not honest about the fact that I did not want to hug my child, or comfort him.’’
Cavanagh was diagnosed with postnatal depression (PND), a debilitating condition that affects about 15 per cent of childbearing women — and one which beyondblue, the national depression initiative, is taking very seriously with a national action plan due to be completed within the next few months.
Cavanagh was fortunate that her child health nurse had kept a close eye on her, and insisted she see a GP with an interest in mental health. But it’s been a year-long road to recovery. With the help of counselling, a PND support group, and antidepressant medication, Cavanagh is back to her old self — and is madly in love with her baby.
She’s now writing a book on other women’s experiences of the condition in an effort to make those who suffer from it feel a little less alone in their despair.
‘‘ It is a mental torture,’’ Cavanagh says. ‘‘ You wake up and feel this dread of facing the day and it pulls you down even more. You still have to try and get through the day and pretend you are fine. I wanted to read about women who came through it. People said it would get better, but I did not believe it. It would have helped to hear that from women themselves.’’
Cavanagh is yet to find a publisher, but she’s not aiming to make any money. Her goal is to distribute her work to maternal and child health nurses, who may be able to pass it on to their patients.
And for those women, she can’t stress enough the importance of seeking help. ‘‘ The biggest reason that I am still here is that I was honest about having suicidal thoughts. It is not something you want to tell people.’’
Cavanagh had suffered several episodes of depression in the past, and raised these with her obstetrician during pregnancy. He played the risk down. She was told PND was just another word for the adjustment phase following childbirth. In fact, 75 per cent of studies show women who have experienced a previous depressive episode are more likely to suffer PND.
‘‘ If my education had started back then, my experience would have been very different,’’ she says. ‘‘ I was eventually referred to someone who was described as a ‘ depressionfriendly’ doctor — but all doctors should be ‘ depression-friendly’.’’
Training health professionals to recognise and manage depression in pregnant women and new mothers is something that has also caught the attention of beyondblue. In launching beyondblue’s national action plan earlier this year, Parliamentary Secretary for Health Brett Mason said most women with this problem remained unidentified and untreated.
This can have long-term consequences, says professor Anne Buist, director of women’s mental health at the University of Melbourne and consultant to the beyondblue program. ‘‘ With a depressed mum you don’t get as secure [mother-child] attachment, and insecure attachments are associated with depression in later life,’’ Buist says. ‘‘ The chances of the child having anxiety disorders, conduct disorders and behavioural disorders are substantially increased. The ripple effect from maternal depression is enormous.’’
Beyondblue’s action plan will include routine assessment for depression and related problems during pregnancy, and in the first postnatal year. Beyondblue says it will ensure affected women receive relevant information and prompt professional help — wherever they live, whatever their circumstances. This may prove to be a tough ask. Psychiatry and psychology services are not always readily available, particularly in rural areas where GPs are also under massive workforce pressures.
Buist agrees the solutions are complex and that different areas may need different models of care. But at the core, she says, is ‘‘ the ability to pick it up, the ability to refer and the ability to treat — we have to have all three’’.
Buist would particularly like to see more early postgraduate training in perinatal depression, particularly for obstetricians and midwives. It’s not a matter of teaching them to be psychiatrists, she says, but instilling the importance of referring women on — and doing it early.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has also reiterated the need for its members to be aware of the condition. Last month it endorsed a policy on postnatal/perinatal depression that stressed the need for all members of pregnancy care teams to identify clinical features that may predispose to PND. It also said pregnancy carers should initiate a care plan that allowed for early recognition and treatment.
As for maternal and community child health nurses, they appear to be the best trained, she argues, and GPs are somewhere in the middle, although she agrees education is not the total answer.
Professor Jane Gunn is convinced it’s not the answer, particularly when it comes to general practice. The chair of primary care research in the University of Melbourne’s department of general practice says she knows of no evidence that GPs are missing PND.
‘‘ GPs don’t say they really need help to identify the problem or don’t understand what it is,’’ Gunn says. ‘‘ The issue is, when you come across a woman with a big problem, where do you send her? Women need child care, occasional care, home help, mothers’ groups, access to counselling, couple counselling for those experiencing partner violence — as the GP in the community, these services are not that easy to find. You are left with doing what you can.’’
Another potential hurdle of any national action plan is the idea of screening women for PND. Gunn says this is a controversial and vexed area, with some experts having questioned whether screening could do more harm than good. In the UK, she says, routine screening has been stopped.
Director of the Centre for Mother and Child Health Research at La Trobe University, Professor Judith Lumley, urges extreme caution on any form of routine screening.
‘‘ We don’t know whether screening is a good thing or not,’’ she says. ‘‘ Unless we have tested what we want to do and shown it makes a difference, it is quite wrong to intervene. What does it take to change in order to make a real difference? We don’t know that.’’
Lumley says the incidence of PND appears to be stable, but there is a huge range of severity, from more milder forms to situations where the mother is at real risk of harming her baby — making treatment complex.
A former chairwoman of the Royal Australian College of General Practitioners, Melbourne GP Leanne Rowe, says there is stigma attached to PND for many women and it can be difficult for patients to accept the diagnosis.
Research in 2005 by University of Adelaide PhD student Victoria Williamson backs this up. She found that PND sufferers often wore a ‘‘ mask’’ to hide their true condition, afraid that their reality was so different from image of supermums.
Hollie Cavanagh can relate to this, and she says admissions from ‘‘ celebrity mums’’ such as newsreader Jessica Rowe that they have experienced PND are extremely helpful in combating the ‘‘ new mum baby joy’’ stories found in many women’s magazines.
In the end though, she mainly wants other women to know that there is hope they can emerge from the dark. ‘‘ I have seen the blackest holes and been at the bottom of them — and coming out is like being reborn.’’
Through the blackness: Hollie Cavanagh has known post-natal depression and now wants to help others recover