(USA TODAY) - Few people had heard of postpartum depression in 1994, when social worker Karen Kleiman co-wrote the first edition of her book, This Isn't What I Expected, about the struggles of new mothers.
Celebrities weren't speaking out about the problem. Doctors rarely screened new moms.
In some ways, it was a different era, Kleiman says. Twenty years ago, she could tell moms to splurge on a $3-an-hour babysitter, or listen to relaxation tapes on a portable cassette player.
Some of today's young moms have never even seen a cassette player. Yet Kleiman says she wishes she could point to more substantive changes regarding postpartum depression, which affects up to one in seven mothers in the first year after delivery.
When updating her advice for her book's second edition (Lifelong books, $17.99), published late last year, Kleiman says she and her co-author, physician Valerie Davis Raskin, were struck by how little progress the country has made in recognizing and treating postpartum depression, the most common complication of childbirth. Kleiman says she still provides help to many women who are afraid to acknowledge they feel depressed or overwhelmed at what is supposed to be the happiest time of their lives.
"The numbers are staggering," says Kleiman, founder of the Postpartum Stress Center in Philadelphia. "By now, we certainly thought moms would feel more comfortable talking about it. We hoped there would be new and better medications, with fewer side effects. We hoped there would be more legislation."
Postpartum depression can manifest in different ways, sometimes mimicking the anxiety, crying spells and mood swings of the "baby blues," a temporary condition that affects many mothers in the first days or weeks after delivery. The Mayo Clinic notes that the symptoms of depression typically are more intense and long-term, making it more difficult for women to care for their baby and handle other daily tasks. Symptoms of depression can include feelings of sadness, hopelessness, fatigue, irritability, difficulty bonding with the baby, social withdrawal and feelings of shame or inadequacy.
Many women feel guilty that they aren't doing a good enough job as a new mother, making it more difficult for them to acknowledge their feelings and seek help, Kleiman says.
Too many practitioners tell women with symptoms such as these "to go home and take a walk or have a glass of wine," Kleiman says. "There are still really good doctors who are telling women it's just the baby blues."
Actresses such as Brooke Shields, Courteney Cox and Gwyneth Paltrow, who have spoken publicly about their experiences with postpartum depression, have helped to raise awareness, says Jonathan Schaffir, an associate professor of obstetrics and gynecology at Ohio State University College of Medicine. Yet fewer than half of medical schools include any formal instruction on postpartum depression during students' obstetrics and gynecology rotations, says Schaffir, who conducted a survey on the question.
Heidi Murkoff, author of the What to Expect series, has steadily increased her coverage of depression with each edition and new book. Still, Murkoff says the silence among affected women remains overwhelming. It's only when Murkoff mentions postpartum depression - either online or in person - that "the floodgates open," she says. "I hear stories I probably otherwise wouldn't have heard had I not opened the conversation."
For many moms, "their own feelings - physical or emotional - always seem to take a back seat to those of their families," Murkoff says. "There's a pervasive lack of awareness - and the shame and silence that shrouds PPD and pregnancy-related depression continues, which means that moms continue to suffer, babies continue to suffer, families continue to suffer."
The American College of Obstetricians and Gynecologists says treating depressed pregnant or postpartum women has big potential benefits, both for women and their babies. Infants of depressed mothers are more likely to have psychological, intellectual and physical delays, the group notes. Yet children's mental and behavioral health disorders improve when a mother's depression is effectively treated.
"Mental health, like general health, begins at the beginning - or even before the beginning," Murkoff says. "Good nutrition, good health care, a healthy lifestyle - these go a long way in nurturing a fetus, and then a baby and then a child.
"But take a nurturing mom out of the equation, because her ability to bond with her baby has been impaired by depression, and you have babies, children and teens who grow up with an emotional, cognitive, developmental deficit. These are the kids who may grow up without the ability to form attachments, without empathy, without nurturing skills of their own."
Depression screenings typically take only five to 10 minutes to complete, according to the ob-gyn group, which says screening postpartum women "should be strongly considered." Yet the society says there's not enough evidence to support a "firm recommendation" for universal depression screening, either before or after delivery.
Murkoff notes that it's easy for ob-gyns or midwives - who typically see new moms for a follow-up visit at 6 weeks post-delivery - to miss postpartum depression, which may not develop until months later. And fewer than half of new mothers attended recommended checkups after delivery, according to a January study from Johns Hopkins published in the Journal of General Internal Medicine.
Some suggest that pediatricians screen new moms and dads for depression. But Kleiman says surveys show that many parents are afraid to acknowledge their struggles to a pediatrician, for fear of being seen as a failure. "Postpartum moms are phenomenally good at looking good and keeping things under control," because of a strong desire to be a good mother, Kleiman says.
And Murkoff notes that pediatricians are busy enough with wriggling infants, and may lack the time and training to screen adults.
"Doctors don't always know what to do with it if they get a positive screen," Kleiman says. In some cases, "people aren't screening because they don't know where to send moms who are depressed. There are doctors who don't even want to know."
And even when doctors do screen their patients, women may not be able to find a psychiatrist who takes insurance, says Katherine Stone, founder of Postpartum Progress, a non-profit advocacy group. Many psychiatrists historically haven't accepted insurance, due to low reimbursement rates.
While there may be more support groups and self-help books, "there are still not enough mental health professionals who accept government-sponsored insurance or self-pay patients," Schaffir says.
Many mental health advocates hope that will change, now that the Department of Health and Human Services has issued guidelines for implementing a 2008 federal "parity" law requiring doctors and insurers to treat mental health and physical health the same. The Affordable Care Act also requires plans to cover mental health as an essential benefit.
In many cases, new moms see their child's pediatrician more often than they see their own doctor, prompting some doctors to suggest screening parents for depression during well-baby visits.
Media coverage over the past two decades hasn't always helped.
Sensational or inaccurate reporting can reinforce stereotypes, Kleiman says.
The murder trial of Andrea Yates, who drowned her five children in a bathtub in 2001, helped cement the image of women with postpartum depression as likely to hurt their children, Kleiman says.
The Connecticut woman who died in October after ramming her car into a White House gate - with her 1-year-old child in the back seat - was described in news reports as suffering from postpartum depression. Yet women with this sort of erratic behavior are more likely to suffer from a rare condition called postpartum psychosis, which affects only one to two in 1,000 postpartum women, Kleiman says.
"Unless they get their information straight, they (the media) can scare the hell out of women. That can increase a woman's tendency to isolate herself," Kleiman says. "Women with postpartum depression do not hurt their babies. Women with postpartum depression go to extreme measures to make sure that their scary thoughts do not come true. They will hurt themselves before they hurt their babies. If a baby is hurt, it's the bizarreness of the behavior that tells you psychotic thinking is involved."
The country will only make real progress in helping postpartum women, Kleiman says, when their symptoms are recognized to be as real as those of a sore throat or any other illness.
"Don't let shame get in the way," Kleiman advises women. "Don't let fear of judgment get in the way of letting you take care of yourself."