Integrating Social Epidemiology Into Public Health Research and Practice for Maternal Depression

摘要

The impact of maternal depression on women and their families has been well documented. Given the prevalence and impact of this problem, one important strategy is to strengthen and expand our public health approaches. Although principles of social epidemiology are increasingly used in the field of maternal and child health, few public health efforts to address maternal mental health have incorporated ecosocial frameworks such as community connectedness, quality of social relationships, and social capital. One method to augment current public health approaches to maternal depression is through the incorporation of a perspective focusing on community, cohesion, group membership, and connectedness—a concept often described as social capital. We describe the relevance of this ecosocial perspective for mental health promotion programs for mothers. DEPRESSION IS THE LEADING cause of disability for all ages and both sexes worldwide. 1 The public health significance of depression in women is undeniable, with lifetime rates between 10% and 25%. 2 , 3 The childbearing years are a particularly high-risk period for major depression in women because the increase in the risk of depression rises steeply for females just as they enter the fertile period of their lives. 2 , 3 Evidence shows that mothers of young children and new mothers have rates of depressive symptoms ranging from 12% to 20%, with even higher rates for adolescent and low-income minority women. 4 – 7 Despite the availability of effective treatments, depression remains undertreated. 8 – 11 In primary care settings, close to 75% of depressed women of childbearing age do not receive any mental health treatment. 9 , 10 , 12 Three public health approaches to address depression in pregnant and parenting women are commonly used. The first approach, screening for depression in obstetrical settings, has been recommended in the research literature, 13 adopted as a best practice guideline, 14 and mandated as a standard medical practice in some states. 15 Despite the plausibility of this approach, studies from other general health care settings do not generally show that patient outcomes improve as a result of screening. 16 , 17 Recent studies with diverse samples of pregnant and postpartum women have found that screening has either no or minimal effect in ameliorating depressive symptoms or increasing use of behavioral health care. 18 – 20 The second approach to maternal depression has focused on the provision of social support through home visitation. 21 The third approach has focused on the promotion of help-seeking for maternal depression via large-scale media campaigns. 22 With the exception of home visitation conducted in the postnatal period by trained health care professionals, 23 the effectiveness of each of these strategies has been limited. 21 – 25 The limited effectiveness of current public health approaches means that new strategies must be developed to address depression in women. Depression constitutes one of the largest public health problems facing women of reproductive age. This fact, and the need for new public health approaches, necessitates the development of communitywide public health promotion efforts to reduce the burden of depression in mothers.