Perinatal Mood and Anxiety Disorders in Latina Moms
Why we need better efforts to reach women at higher risk
Pregnancy and new motherhood is filled with joy and wonder – and rife with challenges. Everyday tasks can seem overwhelming, especially when coupled with a lack of sleep, hormonal surges, and concerns about a new baby's well-being. So it's easy to understand why nearly 80 percent of women experience the baby blues after delivery – a period of weepiness, sadness, or generally feeling emotional that usually goes away without treatment after one to two weeks. But up to 20 percent of women in the United States develop a perinatal mood or anxiety disorder (PMAD), such as anxiety, depression, obsessive-compulsive disorder, or (rarely) postpartum psychosis.
And when it comes to Latina women in the United States, that statistic triples or even quadruples. Research published in the Journal of Immigrant and Minority Health in 2004 studied nearly 4,000 Hispanic women in three major U.S. cities (New York, Miami, and San Francisco) and found that 43 percent of women who had just delivered were experiencing symptoms of depression. Other studies estimate that figure is more than 50 percent.
Experts are still researching the reasons behind these alarming statistics, but many believe there are several key sources. For example, many Latina women are in low socioeconomic strata (low-SES), and the factors associated with this (low income, less than a high school education, and limited access to medical care) increase stress, which has a strong influence on developing a PMAD.
In addition, "some investigators have suggested that Latina women feel pressure to be a perfect mother, a martyr mother, just like the Virgin Mary, a concept called marianismo," says Sandraluz Lara-Cinisomo, PhD, assistant professor in the department of kinesiology and community health at University of Illinois at Urbana-Champaign who has studied PMADs in Latinas. Failure to live up to the self-sacrificing ideal can result in feelings of inadequacy and make it less likely that women will recognize when they are experiencing symptoms of depression or anxiety – and be less likely to speak up even if they do feel that something is not right.
Enriqueta Reyes, 44, a Mexican American mother of three in Covina, California, felt very isolated when she developed depression after the birth of her third child. "Things weren't going well with my marriage, and my husband left me while I was pregnant. I found myself alone with a newborn and two young kids, and things went down from there," she recalls.
Reyes became so depressed that she stopped eating and had difficulty caring for her new daughter, much less bonding with her. "I had thoughts of dying, but I kept it hidden. I felt so guilty. In my culture, you have to be strong and suck it up." Ultimately, her sisters and mother recognized that Reyes needed help and stepped in to take over parenting duties for several months. Meanwhile, Reyes coped with depression by speaking to a friend at work and through prayer. "I didn't consult a therapist. What got me through this was my faith."
Research shows that women of color are less likely than white women to visit a mental healthcare professional or consider taking medication. For Reyes, mistrust in the healthcare and pharmaceutical industries kept her away from evidenced-based treatments such as psychotherapy or antidepressant medication. That sentiment is common among Latinas, says Lara-Cinisomo, but also understandable. "The distrust of safety of drugs is partly a lack of understanding how medicines impact the mind and body, but historically minorities have been manipulated by researchers."
Instead, Latina women are more likely to put their trust in friends, family, or a clergy member, like Reyes did. "Minority and immigrant women are more likely to trust a clergy person, a trusted elder figure in the community, another peer, or a social worker versus a psychologist or psychiatrist," says Lucy Puryear, MD, medical director of The Women's Place: Center for Reproductive Psychiatry.
Puryear oversees a pilot program in Houston clinics that aims to increase mental health screening and access to treatment for women in low-SES and minority communities. She has worked with the clergy in Houston to spread the message about PMADs. "We did a slide show presentation on perinatal mood disorders and invited clergy from all over Houston. It was very well received," says Puryear. "We should be talking about people's perception of God and mental health – that needing medication doesn't mean you're spiritually weak or that you have to give up a reliance on God."
Many health services and screenings are not offered in Spanish, which is another barrier to treatment for immigrants and Latinas who do not speak English. And for those who have recently arrived in the States, the stress of the immigration process and adapting to a new country and home can increase the risk of a PMAD. "There's a stress that comes with adapting to life in a new country, [learning] a new language and navigating a healthcare system, and that can also put women at risk for depression or anxiety during the perinatal period," says Lara-Cinisomo. Depending on their immigration status, some Latina women may also fear being deported or having their children taken away if they seek mental healthcare.
The importance of culturally competent care
To overcome these barriers, clinics would do well to follow the approach of the Pavilion for Women at the Texas Children's Hospital in Houston, Texas, where a pilot program (directed by Puryear) was launched several years ago at two clinics in low-SES, minority communities. The program screens 100 percent of pregnant and postpartum women for depression and anxiety to improve early recognition of maternal depression and to increase access to treatment.
"We've made a point to hire therapists and doctors who are ethnically diverse and some who are fluent in Spanish," says Stephanie Chapman, PhD, a psychologist who works in one of the clinics. Having a Spanish speaker do the screening may be especially important because he or she may be more sensitive to culturally acceptable terminology for mental health disorders. "For example, healthcare providers should start by asking a woman how 'stressed' she may be feeling," says Lara-Cinisomo. (Stress is a more acceptable and recognizable term than depression.) "Then they can segue into a discussion about how one of the consequences of stress is to make you feel depressed."
Chapman says she also tries to involve the families in the therapy process. "The Latina culture is very inclusive of immediate and extended family in decision-making – often they're sharing living spaces – so we try to educate all the family members about the diagnosis and treatment so they can be more supportive in the patient's life," she explains. (She also notes that the patient always makes the decision about who is and isn't involved.)
Adds Lara-Cinisomo: "There's a lot of joy that comes from having a baby in Latina culture, and being able to talk about depression and stress in a group and with extended families is key. The Latina community does a good job of rallying around new moms and babies."
The clinics emphasize interpersonal and cognitive behavioral therapy rather than medication. In part, that's because Latina women are less likely to try antidepressants, even when they may be indicated, says Chapman. One benefit of "talk" therapies is that they boost a woman's ability to problem solve, and Latinas show a preference for self-coping strategies above other treatment options for perinatal depression, according to a 2014 study conducted by Lara-Cinisomo and colleagues at Northwestern University.
Study participants favored seeking help from a trusted friend or healthcare worker, redirecting worries into a positive and constructive activity (such as knitting a baby hat or planning the nursery), and making use of appropriate emotional disengagement when needed (meaning the disengagement doesn't turn into social isolation).
Another coping strategy Latinas in the study preferred was having a trusted nurse visit the home or a familiar community health worker (known as a promotora) reach out. This option is especially appealing to those who are worried about immigration status. And although behavioral therapy wasn't at the top of the list (because women worried about being judged by the psychologist or pressured to take medication), study participants did say they would be more open to psychotherapy if someone they trusted recommended a mental health care professional.
This trust factor is one reason that the Houston clinics have a woman's ob-gyn introduce her to a social worker or therapist. Healthcare providers actually walk the patient to a social worker or therapist and the introduction is made in person, says Chapman. Having an ob-gyn, social worker, and psychiatrist that all practice in the same place – and making them available to the patient at the same visit – increases the chances that women will start treatment and get well. Not only does this type of integrated care save time for busy women, but having only one co-pay also eases the financial burden.
In addition to providing an integrated setting, like The Women's Place pilot programs in Houston, clinics should strive to make services and materials available in Spanish and to educate healthcare workers about community traditions and culturally sensitive language.
Offering flexible clinic hours – staying open in the evenings and on weekends – can increase a woman's access to mental health services, as does providing on-site childcare for women who cannot afford daycare.
Finally, recognizing the value that Latinas place on what they view as "supportive talk" from healthcare providers can help doctors and other providers treat their patients effectively. One study found that Hispanic patients valued a doctor's ability to understand, believe, and comfort them as much as their ability to help with physical problems.
Ultimately, striving to help Latina women understand that being sad or depressed doesn't make you "crazy" or mean that you are a bad mother will benefit everyone. "The message should be that you can coexist as a mother and have depression, but you don't have to – it is treatable. And that women with support do end up getting better," says Lara-Cinisomo.