So, what stands in the way of getting treatment when it is recommended? There are no easy answers, but many of the usual suspects are present. Stigma, ignorance, and misguided conceptualizations of risk and benefit all play roles in the process.
There remains potent stigma with regard to all mental health issues, and this is particularly the case for pregnant and postpartum women. Succumbing to depression at a time when a woman is supposed to be joyous carries with it a sense of shame and inadequacy.
And there is always the problem of access to mental health care. Many women in this situation find it exceedingly difficult to locate clinicians with expertise in this highly specialized area. Others simply cannot afford the care they need.
The clinicians who care for this population also face certain challenges. In many ways, the explosion of data in the field of reproductive psychiatry may paradoxically make it more difficult for women to access care. Many studies examining the reproductive safety of antidepressants and other medications have yielded inconsistent or conflicting findings.
These studies are sometimes so nuanced and complex that it is extremely difficult for patients and their treaters to fully understand the clinical implications, leaving them confused about their treatment options. The situation is worsened by the publication of articles that either sensationalize bad outcomes or present only some of the available scientific data.
How can we help women to get the support and treatment they need? One way to move forward would be to avoid a dichotomous view of perinatal depression. The advent of depression screening gives the impression that women either do or do not need help, when in reality the best practice is to view these psychological challenges as existing along a wide and varied spectrum. Some women are clearly depressed and in need of immediate and aggressive treatment. Other women might simply be at increased risk based on their genetic or psychological profile and may benefit from relatively simple interventions, such as psychoeducation and increased levels of support.
We cannot afford to take a one-size-fits-all approach to this population. In our arsenal, we have many different and highly effective interventions to choose from: Peer support, group and individual psychotherapies, behavioral techniques, and medication. Matching the patient to the proper intervention is as important as the intervention itself.
As experts, we owe it to the clinicians in the trenches, and most importantly to the women they care for, to streamline our approach. Whereas a decade ago we had only a few studies to guide us, now we have hundreds. We need easy to follow, efficiently implemented, and evidence-based protocols. In short, we need to move our field from the world of academic inquiries to the pragmatism of clinical practice. This is our current and urgent calling.
Ruta Nonacs, MD, PhD, is a psychiatrist and a senior member of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston. She is also editor-in-chief of womensmentalhealth.org.