Preferences for mental health treatment for post-partum depression among new mothers

PPD is characterized by an inability to experience pleasure, anxiety symptoms, panic attacks, spontaneous crying, depressed mood, and sometimes accompanied by suicidal thoughts following the birth of an infant [1]. Epidemiological studies show that the prevalence of PPD among the general population in Western countries ranges between 9 and 17% [2, 3]. Risk factors identified from earlier studies include motherhood at a young age [4, 5], low levels of education and SES [6, 7]. A higher prevalence of PPD symptoms was reported among ethnic minorities and immigrant populations [8, 9].

Women who experience PPD often show signs of self-neglect and engage in risk-related behaviors such as the excessive consumption of alcohol, cigarettes, and illegal substances [5]. The newborn and the other family members can also be affected by the mother’s PPD. Studies have reported that untreated PPD may adversely affect infant–maternal attachment [10], the cognitive and motor development of the infant [10, 11] and was associated with behavioral and learning disorders during childhood and adolescence [12, 13].

Due to the negative effects of PPD symptoms on both the mother and infant, early detection of women with PPD symptoms is of great public health importance. In many Western countries, a routine depression screening is performed among postpartum populations [14]. In Israel, since 2013, nurses routinely assess depressive symptoms during the 26-28th week of pregnancy and 4–9 weeks post-partum in perinatal health visits [15] using a validated translation of the Edinburgh Postnatal Depression Scale (EPDS) [16]. Despite the early detection of mothers with PPD, a large proportion of the mothers are not actually treated for their PPD symptoms [17, 18]. Moreover, results from a study conducted in Australia showed that 20% of women, when screened for perinatal depression and anxiety did not respond honestly. Women who felt uncomfortable reporting PPD symptoms were much more likely to show symptoms of perinatal depression and anxiety [19].

Currently, the treatments offered to women diagnosed with PPD are antidepressants [18]; psychodynamic therapy [20]; interpersonal therapy [21]; and cognitive-behavioral therapies [22], which have all been shown effective in treating PPD.

Previous studies that have examined preferences for treating PPD and showed variations in preferences for type of health care professionals, type of treatment and place of treatment, which differed according to the demographic profile of the mother. For example, a study conducted in the United States showed that compared to younger mothers, older mothers were more likely to seek therapy for their PPD symptoms [23]. Another study found that compared to Caucasian mothers African-American mothers preferred to receive counseling for their PPD symptoms from religious figures in the community and expressed low confidence in medication [24]. Findings from another study showed that educated, married women, with high SES, preferred individual psychotherapy rather than group therapy for their PPD symptoms [25].

Our study population included postpartum women who, according to previous studies [26], were expected to experience mild postpartum “baby blues” (between 60 and 80% of mothers), those who experienced clinical postpartum depression (around 15% in most populations) and those who did not experience any symptoms of depression at all following childbirth. Thus, while it may be difficult to imagine how clinical depression feels, given that the vast majority of new mothers experience some symptoms, we ask them to speculate on what their preferences would be for treatment, given clinical post-partum depression. To the best of our knowledge, no previous studies have compared mothers with and without detected PPD as for their preferences for mental health treatment since it is clear that some women without reported or detected symptoms are still in need of effective and suitable PPD treatment. This was the rationale for the current study.

Our aim was to compare preferences for mental health treatment regarding a variety of mode, profession and place of treatment of mothers with and without PPD. We hypothesized that demographic variables will differ between mothers with and without PPD; we also hypothesized that mothers with PPD compared to those without symptoms would differ as to type of treatments preferences.

The data was analyzed using SPSS version 23.0 software. We conducted χ² and student t-tests with demographic, and treatment preference variables among mothers with and without PPD in order to identify salient variables affecting treatment preferences. In the second stage of analysis, we preformed Exploratory Factor Analysis (EFA (for the three types of treatment preferences. Variables were included in the analysis, if their loading was .40 and above. We then conducted student t-tests with treatment preference variables after EFA comparing mothers with and without PPD.

Among our participants 8.4% scored 10 or higher on EPDS. Ten (1%) mothers stated in response to question 10 that they considered hurting themselves.

In Table 2 we present treatment preferences among mothers with PPD compared to those without symptoms. The top three preferred places among mothers with PPD were private mental health practice [1], community health clinic (HMOs) [2], and MCHCs [3]. Mother with PPD ranked community treatment centers in second place compared with women without PPD who ranked it first (t (998) = − 2.55, p ≤ 0.05.

The preferred professionals were psychologists [1], alternative therapists [2], and family physicians [3]. The top three preferred services among women with PPD were personal meetings in a private office [1], home visits [2], and group meetings in the community under the guidance of a professional [3].

In the second stage, of analysis we preformed EFA for all forms of treatment preferences to examine whether the number of components in each preference could be reduced. The analysis showed three main factors in each type of preference. a. Place of treatment: community health clinic; psychiatric clinics; and private mental health practice (Appendix 1). b. Professionals: professionals in the community; mental health professionals; and paraprofessionals in the community (Appendix 2). c. Mode of treatment: personal psychotherapy; technology-mediated interventions; and group interventions (Appendix 3).

In Table 3, we present treatment preferences after the EFA among mothers with PPD compared to those without symptoms. Differences were found between mothers with and without PPD regarding preferences for community treatment centers. Mother with PPD ranked community treatment centers in second place compared with women without PPD who ranked it first (t (998) = − 2.71, p ≤ 0.01). No statistically significant differences were found for the other preferences. Mothers with PPD and mothers without PPD preferred private mental health practice (Ranking 1 and 2 respectively) and community treatment centers (Ranking 2 and 1 respectively) and were less likely to want to seek treatment in a psychiatric framework. They also preferred mental health care professionals, group interventions and personal psychotherapy interventions and not technologically mediated interventions.

This study examined comparatively preferences to psychological treatment of mothers with and without PPD. In terms of PPD symptoms, 8.4% of the participants scored 10 or higher. This finding is in accordance with findings of previous studies conducted in Israel among Jewish mothers reporting 9% at cut off point of 10 [8]. While the response rate in our study was high [29], there are still populations that were not represented in this sample, such as Arabic-speaking women whose rates of PPD have been reported as significantly higher than the rest of the population [8].

Our findings showed that women who immigrated to Israel were more likely to suffer from PPD than Israeli-born women. These findings are consistent with previous studies showing immigration as a risk factor for PPD [7, 9]. Women living with a partner had more symptoms of PPD than single or married women. This finding is supported by findings from previous studies [4, 17]. As in other studies we showed that women with poor economic status had more PPD symptoms [4, 30] and preferred to seek treatment less frequently in general [25]. Another finding was that mothers with a first child reported of more symptoms of PPD than mothers with second child and above. The findings in the literature are inconclusive regarding this topic. On the one hand, previous research has shown that women with a first child have more PPD symptoms than women with a second child [31]. However, another study showed a positive correlation between the number of children and PPD [32]. In other studies, however, there was no association between these variables [17, 33].

In the current study, mothers with and without PPD preferred to be treated in private mental health practice and in community treatment centers. They least preferred the option of psychiatric clinics. These findings are consistent with the findings of a previous study conducted in the US. There 90% of mothers preferred to receive primary care in private mental health practice and about 70% preferred to receive primary care in primary care clinics. Only one-fifth of mothers preferred to be treated in mental health care [25]. A possible explanation for our finding is that mothers feared social labeling of mental illness and the stigma associated with being a patient in a psychiatric setting [17, 18, 34]. In Israel, outpatient mental health care services from psychiatric hospitals were transferred in 2015 to HMOs in the community. Among other things, this was done to reduce the labeling of those with mental illness and to facilitate integration into the community of people suffering from mental difficulties. Our study was conducted during the implementation of this policy by the Ministry of Health and our findings support the rationale behind this change.

We also found that mothers preferred to be treated by professionals such as psychologists and family physicians and gave a lower priority for informal professionals such as volunteers and alternative caregivers. These findings are supported by a previous research conducted in Israel showing that about one-third of mothers with PPD symptoms sought treatment from professionals [17].

Our findings showed that women with PPD preferred group interventions and personal psychotherapy, such personal meetings and home visits compared to technology-mediated interventions. This finding is interesting because, as suggested in previous studies, women preferred more personal psychotherapy [20, 24, 25], and were less likely to prefer group interventions [25]. It is possible that group therapy enables mothers to develop better strategies for coping with PPD symptoms by learning from other mothers’ experiences. Group interventions can give mothers a feeling that they are not alone but rather part of a group coping with difficulties of PPD [35]. Women were less likely to prefer technologically mediated interventions, although this type of treatment can reduce the labeling of mental illness and protect their privacy [36]. Future research is warranted to examine this finding. Our findings also reinforce other studies that showed that women are very unlikely to prefer medications for treatment of PPD, which was ranked 12/13 [21, 37, 38].

We found that mothers with PPD compared to mothers without PPD were less likely to seek treatment in general. This finding was supported by previous studies in Israel and abroad [17, 18, 34]. It is possible that mothers with PPD may be afraid that seeking help for their symptoms will be construed as evidence of defective parenting capacity. Thus, the findings of previous studies have shown that fear of tagging as a “bad mother” reduced the reference to treat symptoms of PPD [39, 40]. It is also possible that mothers with PPD symptoms have less energy in general to move outside of their personal realm and initiate help seeking, which reinforces the need for identifying these mothers and bringing treatment to them, through home visits or other means.

It is important to identify the factors that hinder accessing treatment among women with PPD. This behavior raises concerns and emphasizes the need for active reaching out to engage these mothers, to overcome their fear of excess stigmatization in the health and welfare care systems.

The primary limitation of this study is that it is cross-sectional and did not include Arabic-speaking mothers. Future studies should include the attitudes and behavioral intentions of other sectors of Israeli society as well.

Mothers with PPD represent a high-risk population who can benefit greatly from appropriate treatment. Our findings show that mothers with PPD have unique preferences. Mothers with PPD preferred private mental health practice and community treatment centers by mental healthcare professionals, and preferred group interventions and personal psychotherapy rather than technology-based interventions. We also found that mothers with PPD compared to mothers without PPD were less likely to seek treatment in general.

On the practical level, sharing the findings of this study with professionals, such as nurses at family health centers or physicians, in professional training sessions, lectures, seminars and journals, can increase awareness of their role in providing formal support for mothers who require treatment for PPD.

Our findings may assist professionals to develop relevant policies and programs designed to promote the health of mothers by reaching a deeper understanding of their preferences. As a result, therapy alternatives can be developed to better suit diverse groups of mothers in Israel who cope with the impacts of PPD, for the benefit of mothers, children, and entire families.