Postpartum Depression Screening: Prevention or Problem?

If we see disease and disorder as something to “fight” and symptoms as something to suppress, then having someone up in the watchtower looking out for intruders is a wonderful idea, right? Screening and conventional preventive efforts seem to fit the bill. The sooner we can “catch” it, the sooner we can treat it, and the more likely we are to beat it.

What does postpartum depression screening mean, in the ever more relevant field of Psychiatry, though? Psychiatric screening is not a biological metric that has been assumed to predict the future in a linear manner. It’s not an image that portends bodily degeneration. It’s a series of subjective questions. It is, in short, a survey.

One of the only fields to use such an impressionistic diagnostic system, Psychiatry’s Diagnostic and Statistical Manual has come under great scrutiny in the past several years. As exposed by a former chair of the DSM Task Force, conflicts of interest are the norm and the dictionary of pathological labels highly subject to influence.

Screening implies that we have arrived at a state of diagnostic validity and that our interventions have been proven over time and across statistical methodologies to improve outcomes. It has taken years for the dangers of overdiagnosis and overtreatment to emerge in the cancer arena, for example.

The United States Preventive Services Task Force seems to feel that we have this necessary science under our belts in recommending universal screening for depression in pregnant and postpartum women.

As a fellowship-trained reproductive psychiatrist, I used to believe that “access to care” was of paramount importance. Care most typically implied medication management and exploration, with a given patient, of the known (and unknown) risks of fetal and infant medication exposure.

What I have learned in the intervening 8 years has raised grave concerns around this fantasy-like desire to help women through better access to mental health services. Here are some of my considerations:

• With such an impressionist diagnostic system, depression can be a wastebasket term for many physiologic processes including thyroid dysfunction, autoimmune and inflammatory flares, and micronutrientdeficiency. Depression is often a symptom of reversible bodily imbalance.
• When it’s not physiologic in origin, what if it is cultural in origin? What if women are departing too radically from what their evolutionary expectations demand? Community and family support and nurturing. If women are feeling isolated and disconnected, alone and hopeless, is medication or therapy getting at the root of this larger societal issue or is it blaming the victim?
• At my last review, there were 3 randomized, placebo-controlled trials of antidepressants in the postpartum population. At a time of immense complexity with regard to psychoneuroendocrine and immunologic shifts, introduction of a poorly studied medication that has known side effects of agitation and impulsivity, seems premature at best. Where is the data that demonstrates better outcomes with treatment?

Perhaps we are hoping and wishing to help this growing cohort of women, so desperately that we are offering to turn off their smoke alarm without putting out the fire raging through their life experience.

There is a story about Psychiatry that conflicts significantly with the story I was told through my 9 years of medical training. The naturalistic and longitudinal data raises a signal of harm for long-term treatment, emergent risks for short-term treatment, and a profoundly disappointing picture of inefficacy over active placebo.

There is another way to help women thrive and embrace this next chapter in their lives and it has to do with listening to depression’s message. It requires that we view this symptom as a sign of “evolutionary mismatch” and give the body back what it expects – sound nutrition, a non-toxic/immunostimulatory environment, movement, physiologic birth, breastfeeding, stress response support, and community engagement.

Sometimes doing something proactively appears defensible and logical when, at its root, lies a hubris that we may soon come to regret.