February 01, 2013

New Strategies for Responding to Maternal Depression

Claire Chiamulera

The views expressed herein have not been approved by the House of Delegates or the Board of Governors of the American Bar Association, and accordingly, should not be construed as representing the policy of the American Bar Association.

  • A baby’s cries go unattended as her mother, deep in depression, lies in bed unable to get up.
  • An immigrant mother juggling two jobs and four children avoids getting help for her depression for fear of losing her jobs and getting deported. Sometimes her burden is so great she cannot get her children to school.
  • A young mother’s lack of insurance prevents her from getting psychiatric care for her depression, leaving her vulnerable to feelings of hopelessness and mood swings that affect her care for her two-year old son.

These stories show the double impact maternal depression has on mothers and their children. While maternal depression is highly treatable, many mothers do not get help, according to experts at the Urban Institute’s forum “Helping Depressed Low-Income Mothers Give Their Young Children a Good Start,” held in Washington, DC on December 12, 2012.

“There’s a very big public health opportunity,” said Olivia Golden, an Urban Institute fellow and former director of the District of Columbia Department of Children and Family Services. Golden, who moderated the forum, added that, “Maternal depression is a problem that is causing damage to adults and children, yet there are big gaps in policy and service systems around getting moms in treatment,” she said.

The experts met to explore those gaps. Golden set the following themes for discussion:

  • How to solve system and policy problems to provide treatment to low-income mothers suffering severe depression?
  • How to break down barriers between systems serving children and adults?
  • How to break down barriers between health, mental health, and children and family services systems?

New Research

Marla McDaniel, senior research associate at the Urban Institute, set the stage by sharing draft results from a current national Urban Institute study. The findings reiterate that many low-income mothers with severe depression are not receiving treatment. Among those receiving treatment, insurance coverage affects what treatments are received and how mothers view treatment quality.

The study used data from the National Survey of Drug Use and Health to look at treatment among low-income mothers with children age 0-5 who suffered severe depression. It identified characteristics of the mothers and how they viewed treatment quality.

Mothers in the study had at least five of nine dimensions of depression as defined by the DSM-IV for two weeks or more (e.g., loss of interest in activities, mood changes, depressed mood, significant weight loss/gain, insomnia).

Characteristics of Mothers

Findings revealed that 8.8% (roughly 750,000) of low-income mothers with children age 0-5 had severe depression in the last year. Among these mothers:

  • About 70% experienced a severe impact on daily functioning.
  • About 40% were between ages 18-25.
  • About 59% were White, 15% Black, and 22% Latino.
  • 40% were married, and 40% were never married.

Treatment Received

Many mothers were not receiving treatment (40% received no treatment). Low-income mothers were the least likely to receive treatment even though they were most likely to suffer severe depression. Insurance coverage was highly associated with receiving treatment:

  • 50% of uninsured mothers did not receive treatment.
  • 35% of the mothers who received treatment were on Medicaid.
  • 30% of the mothers who received treatment had private insurance.

Treatment Type

Psychiatric care—Type of treatment received also varied based on the mother’s insurance coverage. Higher income mothers with insurance were more likely to receive psychiatric care:

  • 10% of low-income mothers received treatment from a psychiatrist, compared to about 20% for higher-income mothers.
  • About 13-16% of mothers who received help from a psychiatrist were on Medicaid or private insurance, compared to roughly 7% for mothers who lacked insurance.

Prescription medicine—Among mothers who received prescription medicine:

  • About 42% of low-income mothers received medicine, compared to about 57% of higher income mothers.
  • 47% of mothers receiving medicine received Medicaid, and 54% had private insurance.

Counseling - Receiving counseling for severe depression from a social worker, counselor or other mental health professional was more common among low-income than higher-income mothers:

  • 7% of low-income mothers received help from a social worker, compared to 2% of higher-income mothers.
  • 8% of mothers who received social worker help were on Medicaid, which was significantly higher than mothers receiving private insurance (no percentage provided), and 5% of mothers who were uninsured.

Treatment Quality

Little information was gleaned about treatment quality since the study measures did not indicate duration, intensity, or general quality. However the research did explore the mothers’ perceptions of treatment quality, finding:

Among mothers receiving prescription medication:

  • About 21% of low-income mothers found it extremely effective, compared with about 36% of high-income mothers.
  • 19% of mothers receiving Medicaid, 36% with private insurance, and 17% who were uninsured found the prescription medication extremely effective.

Among mothers receiving counseling:

  • 20% of low-income mothers, compared to 28% of higher income mothers, found the counseling they received very effective.

What Systems Can Do

Before joining the federal government seven years ago, Larke Huang served on the Action Network on Maternal Depression. The Action Network held focus groups throughout the country to identify social supports needed by low-income women.

These focus groups found that many low-income women had either low-lying or full-blown depression and were not seeking services. Some of these women were refugees who were trying to make it in this country and thought it was their burden to carry and would not seek help. The Action Network, wanting to make a difference, held congressional hearings, advocated for an Institute of Medicine report, and got foundation support.

The Health Resources and Services Administration ultimately supported the Institute of Medicine report, Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment and Prevention, which became a signature document calling attention to how maternal depression is widespread among low-income women. It also highlighted the availability of treatments that work and the successful outcomes and recoveries for women who receive treatment.

When Huang entered federal government, her interest in the topic carried over. She is now a senior adviser to the Office of Policy Planning and Innovation and director of the Office of Behavioral Health Equity at the Substance Abuse and Mental Health Services Administration. She has been looking at how to leverage federal resources and policies to improve the infrastructure for care for these low-income women. Some creative efforts have resulted:

Multi-agency outreach

Federal agencies within the Department of Health and Human Services (DHHS) are joining with agencies outside DHHS to explore how they can work together to address maternal depression among low-income women and how doing so helps them meet program goals.

One way this is working is to build maternal health screening into programs that already reach low-income women. For example, the Department of Agriculture (USDA) runs the Women Infants and Children (WIC) program, which reaches 50% of all children born in the United States. Research shows that between 30-50% of women enrolled in WIC have depression. DHHS is working with WIC programs to implement maternal depression screening to identify mothers so they can be helped. Helping mothers in this way also helps WIC programs meet their goals of healthy nutrition and safe environments for children and families.

Similar outreach through other early care and development programs that reach low-income mothers is being explored, such as the Home Visiting program, Head Start/ Early Head Start, and Zero to Three. Women helped by these programs aren’t necessarily coming for their own care, said Huang, but they are invested in what is happening with their children. Helping them see that their care impacts their children may give them an incentive to address their depression.

Reforming health care policies

Reforming health care policies to better respond to low-income mothers with depression is another area where progress is being made, according to Huang. Incorporating quality care measures for women into the Affordable Care Act and electronic health records is being explored.

Huang explained that the U.S. Preventive Services Task Force, convened by the Centers for Disease Control, sets quality care measures and recommends screening for depression in adults in primary care settings. These measures have been on the books for some time, but have not been enforced. Now, with the new Affordable Care Act’s focus on finance reform and quality, efforts are starting to look at what the quality measures are and how to move them into actual service delivery. The National Quality Forum also has a maternal depression measure that is used in pediatric care settings but does not go into the mother’s medical record, so that is another promising area for focus.

Closing insurance gaps

Expanded coverage in the Affordable Care Act, the Medicaid expansion, and the new state health insurance exchanges (established in six states, with 14 other states developing them), are helping to broaden insurance coverage to include low-income women and provide improved funding mechanisms for health care.

Addressing Barriers

Deborah Perry, associate professor, Center for Child and Human Development, Georgetown University, has an on-the-ground service provider perspective. Her work at Georgetown, in partnership with George Washington and Johns Hopkins Universities and community health care service providers, addresses barriers to assisting mothers with depression.

Reaching mothers where they are

Perry’s team is tapping community service providers that already work with low-income mothers to provide screening and interventions for maternal depression. One example is a collaboration with the Mary Center, a federally qualified health care center in Washington, DC that reaches low-income mothers through its WIC program. Efforts are focusing on screening for maternal depression through a simple two-part questionnaire with specific steps for follow-up by program workers. If program workers identify maternal depression, they intervene immediately to help the mother get the help she needs. This changes past practice where workers had no clear action plan for helping mothers identified with depression.

Reaching mothers who don’t qualify for help

One challenge, according to Perry, is that many mothers have symptoms for depression that do not qualify them for services. Since the mental health system is highly diagnosis-focused, these mothers may not be eligible for treatment. Expanding diagnostic criteria to be more inclusive is a promising area for reform.

Addressing stigma and myths

Other barriers that Perry says are very real are the stigma and myths that surround accessing mental health services for women. She shared that many women are concerned that child protective services will take their children if they seek help for depression.

Immigrant mothers face the added fear of deportation if they seek help. Many mothers believe that they must be strong for their families and children and that seeking help is a sign of weakness. Community providers can help these mothers see that seeking help is not what causes CPS to intervene; rather, it is a sign of strength to get help so they can be better parents.

Helping children through prevention

Perry emphasized the need to reach mothers through prevention before their symptoms worsen and their caregiving suffers. “Prevention for the mom is treatment for the child,” she said. “To the extent that we can really reduce the toll that depressive symptoms take on parents who are parenting young children [it] is going to be the number one intervention . . .for very young children’s mental health.”

Perry and her team are addressing prevention by developing an evidence-based intervention for use with women enrolled in WIC, home visiting, and prenatal care programs. They are teaching women at high risk for depression mood management skills so they can monitor how their thoughts, activities, and contacts with others affect their mood. They have found that women who use these mood management skills have fewer depressive symptoms and major depressive episodes.

Conclusion

Depression grips many low-income mothers and its effects trickle down to their children and families. Sound treatments exist, but barriers block many mothers from them. Some barriers can be addressed by reforming systems, practices, and policies. Others call for educating mothers about the benefits of treatment and removing myths and stigma surrounding treatment. As the forum’s experts shared, many creative efforts are underway to rethink and respond creatively to these mothers’ needs.

Claire Chiamulera, Editor, ABA Center on Children and the Law, is CLP’s editor.

Video

To watch the video recording of the Urban Institute forum, visit: http://urban.org/events/Maternal-Depression.cfm

Advocacy Tips

Advocates can help address maternal depression by:

  • Supporting screening and intervention for maternal depression in community programs that serve low-income mothers.
  • Staying informed of changes in health care policies, at the federal and state levels, and how they impact access to health care for low-income clients.
  • Advocating for expanded diagnostic criteria for mental health treatment and services for mothers with depression.
  • Educating mothers about the importance of seeking treatment for depression to help them be better parents, and addressing fears about CPS intervention, job loss, deportation, etc.
  • Incorporating evidence-based interventions that help mothers manage depression before it severely impacts their children and families.

Federal Partners for Maternal Depression

Federal agencies working to addresss maternal depression:

Department of Health and Human Services:

  • Substance Abuse and Mental Health Services Administration (SAMHSA)
  • Health Resources and Services Administration (HRSA)
  • Administration for Children and Families (ACF)

Other Agencies:

  • United States Department of Agriculture (USDA)
  • Department of Labor (DOL)
  • Department of Housing and Urban Development (HUD)