The maternal depression obsession

A prominent feature of today’s parenting culture is the ever-growing attention given to the problem of depression in both mothers and their children. The press discussion around two recently published studies provides a snapshot into the way things now are.

One study, published in the Journal of the American Medical Association (JAMA), focused on how the mental health of children is detrimentally affected by the state of mind of their mothers. Its main finding, as BBC News put it, is that ‘depression risk starts in the womb’. ‘Antenatal depression’, argue the report authors, was found to be an ‘independent risk factor’ for depression in offspring.

The other study was a report from Netmums, charity Tommy’s, the Institute of Health Visiting and the Royal College of Midwives. Based on a poll of 1,500 women who self-identified as depressed, this research found that many of these women reported ‘low mood and tearfulness’ and most frequently put their problems down to ‘trying to live up to unrealistic expectations’. The message communicated from these studies is that more must be done to help pregnant women and mothers with their feelings. One suggestion from the report authors is that pregnant women and midwives draw up a ‘wellbeing plan’ to promote ‘open discussions’ about a women’s feelings. The authors of the JAMA study argue for ‘interventions’ during pregnancy, aimed at ‘preventing depression in the offspring of depressed mothers’.

Both reports create the impression that pregnant women and mothers are more depressed than we assume, and that this depression affects the next generation. Yet, as I have argued elsewhere, there are good reasons to look more critically at studies and reports like this.

Measuring ‘the problem’

The starting point for studies like this is the measurement of depression in pregnant women and mothers. Yet when one looks closer, it becomes clear that measuring depression is an inexact science. Proportions of women said be depressed vary considerably. ‘One in 10’ is a statistic often cited, but other studies suggest ‘one in 12’ or ‘one in 15’, or even ‘one in four’. The Netmums report says ‘one in seven’. Those promoting maternal depression as a serious issue presumably intend the figures to highlight the size of the problem, but when the differences between sets of statistics are so pronounced, questions need to be asked.

So why are the figures so varied? Because the scales and reports used for maternal depression stats are varied and controversial. The most widely used scale (used by JAMA) is the Edinburgh Postnatal Depression Scale (EPDS), which involves a multiple-choice questionnaire. For example, the first question asks for responses to the statement ‘I have been able to laugh and see the funny side of things’. The female respondent then has to choose one of the following: ‘As much as I always could’; ‘Not quite as much so much now’; ‘Definitely less than I used to ‘; or ‘Hardly at all’. An overall score is then calculated by adding together scores for the 10 items.

While the responses may indicate something about the respondent’s mood and feelings, it is doubtful whether they form an adequate basis for a proper ‘diagnosis’. Indeed, over many years there have been questions raised about the number of ‘false positives’ (that is, women incorrectly diagnosed as depressed through use of the EPDS). Yet the authors of the JAMA study nowhere acknowledge this problem. The Netmums survey suffers from the same deficit. The 1,547 women who took part in it ‘self-selected to do so’, on the basis that they experienced ‘mental health problems’ which were either ‘diagnosed by a health professional or self-diagnosed’. It may be that the phenomenon of ‘false positives’ is even more at issue here than in the JAMA study.

Official guidance in the NHS advises the use by health professionals of what are known as ‘the Whooley questions’ (just two questions) to assess ante-natal and post-natal depression (PND) in the first instance. On the NHS Choices pages about diagnosing PND, it states: ‘Your GP should be able to diagnose postnatal depression by asking two questions: During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by taking little or no pleasure in doing things that normally make you happy?’

It is surely sensible to question whether these methods of assessment provide reliable evidence for encouraging a woman to think of herself as ‘depressed’ and become subject to drug treatment or other forms of therapy. Over the years, I have encountered significant hostility when calling into question the notion that it is simply ‘a good thing’ to generate more and more efforts to ‘identify’ and ‘treat’ post-natal and ante-natal depression through these sorts of procedures. There is both bemusement at the proposition that it may not actually help, and the suggestion that it is harsh and unfeeling not to want to do as much as possible to recognise the ordeal of pregnancy and motherhood and get health professionals to help.

Yet ‘diagnosis’ of mental illness is not something that should be taken lightly. It inevitably places an individual’s ways of coping into the hands of someone else and demands in particular that they ‘open up’ about the most intimate aspects of their life, namely their feelings about themselves and their baby, to a professional. This takes matters out of the domain of privacy and intimacy and into another realm, and in doing so a relationship of emotional dependency is created.

There is another more and more important reason for scepticism about the growing profile of maternal depression, too, and this is to do with the connections now routinely bandied about between depression and ‘damaged children’.

Prejudice about the child disguised as evidence

The study published in JAMA is titled ‘Maternal Depression During Pregnancy and the Postnatal Period, Risks and Possible Mechanisms for Offspring Depression’. As this title suggests, the hypothesis of the research is that there may be a relation between depression in mothers and that in their children which is in some way ‘passed on’. This is one of a very large and growing number of studies which use information collected from large numbers of parents over decades to look for associations and correlations between aspects of their lives, behaviour and practices and those identified in their children. (The dataset used in the case of the JAMAstudy is called the Avon Longitudinal Study of Parents and Children, ALSPAC.)

The JAMA authors claim their research identified antenatal depression as a ‘risk factor’ for depression in children that should be taken seriously and investigated more. Yet, as they themselves suggest, the risk identified through their number-crunching is ‘small’. Hence it may also be argued that given the issues raised above about how ‘depression’ in the parents in the study was identified, the findings can be taken into consideration, but should not be a cause for alarm or suggestions of any kind that depression is ‘passed on’. Other limitations to the study are usefully discussed usefully here.

Unfortunately, however, although sober assessment means the message could be ‘not that much to worry about’ or ‘we don’t know what there is to worry about yet’, the authors could not resist speculating about the ‘passing on’ of depression ‘in the womb’. They set up their paper by suggesting that a possible explanation for children of depressed mothers being themselves depressed is that ‘cortisol, elevated in depression, passes through the placenta and directly alters fetal neural development with long-term consequences’. Notably this gloomy speculation about the indelible ‘hard wiring’ of the fetal brain was something others then picked up on with abandon, eschewing any need to express even mild caution about the idea that it ‘all goes back to the womb’. One professor from Kings College London told BBC News that the development of an individual’s mental health started in the uterus, and that ‘the message is clear’. Celso Arango, a professor of psychiatry from Madrid, commented to the Guardian: ‘Researchers are only just beginning to realise that it is not psychiatrists, psychologists or neuroscientists that are having the biggest impact on preventing mental health issues, it is gynaecologists.’

This same presumption of certainty that what we become is determined before we are even born also preoccupies those behind the Netmums survey. The introduction to their report states: ‘The impacts of stress on the fetus and poor interactions post birth can both increase the risk that a child may experience a range of difficulties affecting every stage of their future life. These include depression, cognitive impairment, a greater risk of needing long-term mental-health services and greater risk of entering the criminal justice system’. This sort of commentary suggests that what mothers feel affects every stage of future life, going far beyond what any sensible or objective evaluation of evidence might tell us. It indicates a great deal about what is driving the depression obsession. It has nothing to do with science, but is, rather, a form of thinking called parental determinism, which construes parents – what they do, how they act and now also how they feel – as the cause of what the new generation becomes. It turn, it makes the next generation victims of the acts, witting or unwitting, of their mums and dads.

This way of thinking, as the sociologist Lachlan Story identifies, is routinely communicated to parents. He cites, for example, the following passage from parental advice book, Tomorrow’s Baby: the Art and Science of Parenting from Conception Through Infancy (2002): ‘Everything the pregnant mother feels or thinks is communicated through neurohormones to her unborn child, just as surely as alcohol and nicotine. Just as a computer virus gradually corrupts the software of any system it infects, so, too, maternal anxiety, depression or stress alters intelligence and personality by gradually rewiring the brain.’

As Story notes, the implications of this way of thinking are profound. As he suggests: ‘Birth becomes an increasingly insignificant event in terms of the status of the fetus’, and there develops the idea of ‘moving “parenting” of one’s “child” further and further back in the pre-birth process’. In Britain, this extension of parenting backwards is apparent in the thinking of policymakers and formalised in their ‘early intervention’ programmes. For example, in a document published with the UK Department of Education, the Wave Trust, enthusiastic proponents of the maximum ‘early intervention’ possible, call the period from conception to two years old the ‘age of opportunity’. The Wave Trust claims that this period of life is ‘crucial and fundamental to later outcomes and life chances’, and that ‘pregnancy is a particularly important period’ as the ‘wellbeing of the mother can have lifelong impacts on the child’.

Maybe it is sometimes well-meaning, but at the same time there is something most disturbing about much of today’s apparent concern for ‘depressed mothers’. There is obvious irony in claiming on the one hand to be concerned about the extent to which pregnant women and mothers find themselves anxious and worried about their babies, ‘feeling under pressure to do everything right’, and on the other endlessly heightening their concern about how much this damage this worry does to their babies. Most of all, when you think carefully about what is ultimately behind all this talk about mothers’ depression, it is a deeply fatalistic view of the next generation which ends up seeing the chemical balance in the mother’s womb as the deciding factor. This is something we all have every reason to contest and reject.

Ellie Lee is the director of the Centre for Parenting Culture Studies at the University of Kent and co-author of the forthcoming book, Parenting Culture Studies, published by Palgrave.