This national study of access to outpatient treatment for maternal depression contributes important new findings to the literature. While this study found that most mothers with depression in the US received some form of treatment for depression, more than 65% of mothers who reported being depressed did not receive adequate treatment for their disease. Notably, this study shows that significant employment, racial, ethnic, educational, insurance-related, and geographic disparities exist in the receipt of adequate treatment for maternal depression.
First, mothers in the paid workforce were less likely to receive treatment. While previous studies have also reported an association between being employed and lower mental healthcare use,26, 27
this study clarifies that mothers in the paid workforce were less likely to receive both any and adequate treatment. Long work hours limit employees’ ability to interact with the healthcare system,28
and women specifically report that they delay or go without healthcare because they are unable to take time off work or have child care problems.29
Although employer sponsored counseling services, such as Employee Assistance Programs (EAP) are effective, widely available depression treatment strategies, 30, 31
they tend to be underutilized due to employee unawareness or confidentiality concerns.32, 33
In addition, EAPs differ dramatically in the services they offer34
and primarily provide short-term counseling and/or referrals for additional care.35
Standardization and positive promotion of EAP benefits may improve depression intervention for working mothers who lack the time or resources to access mental health care from another source.
Additionally, this study found that black (non-Hispanic) and other (non-Hispanic) mothers were less likely to get any treatment and all minority mothers were less likely to get adequate treatment than White (non-Hispanic) mothers. While the differences found in this study may be due to racial bias, evidence for this in mental healthcare is conflicting. Research shows that provider bias occurs in the medical setting36, 37
and while it is plausible that these findings may extend to the mental healthcare setting, one study found provider bias did not have an effect on diagnosis and management of late-life depression.38
Treatment initiation and patient-provider communication may also influence receipt of adequate care by minorities.16, 39
Studies show that there are ethnic and racial differences in help-seeking behavior, the use of informal support networks, and treatment preferences among women and mothers.40-45
In order to better understand the disparity seen in the adequacy of depression treatment between White and minority mothers, it will be important to focus on barriers to treatment initiation and the possible role of racial bias and patient-provider communication.
Consistent with previous studies, 46-48
these results indicate mothers with a higher level of education, worse self-reported mental health, or comorbid mental health conditions were more likely to receive treatment. While the relationship between education and the likelihood of some treatment was not significant, a trend between increasing education and the receipt of adequate treatment was observed. More highly educated mothers may be more health literate and have increased knowledge about the diagnosis of depression and the importance of adequate treatment. They may also be better equipped with the knowledge and skills necessary to interact with the health care system. Mothers with depression and low educational attainment are a subgroup at risk for not receiving adequate treatment and may benefit from interventions to improve their health literacy.
Mothers with either public or private insurance were more likely to get some treatment or adequate treatment as compared with their uninsured counterparts. Although these findings suggest the importance of insurance coverage in the receipt of some and adequate mental health treatment for mothers, the generosity of mental healthcare benefits could not be explored. Other national studies have also found that private and public health insurance increases use of mental health services,46
yet in this study more than 80% of mothers who did not receive any treatment reported having insurance. This finding demonstrates that having health insurance does not automatically ensure the receipt of high-quality care. Key points of vulnerability in the health care system at which the gap between access to insurance coverage and delivery of high-quality health services can widen have been identified.49
Future research is needed to examine these points of vulnerability and other barriers to receiving treatment among mothers with insurance.
Finally, important differences were found in the receipt of adequate treatment for maternal depression by geographic region of the US. Consistent with previous studies of regional variation in receipt of general health care,50
mothers residing in the West were significantly less likely to receive adequate treatment for depression than mothers residing in all other regions. Regional variation in the receipt of adequate care may reflect patient preferences, provider bias, or disparities in access to primary care, which is the source of treatment for at least 30% of people with depression.51, 52
Alternatively, regional variation could reflect differences in practice patterns, medical culture, or available technology. While no known study specifically demonstrates this, such differences have been previously observed with other primary care services.50
Addressing the causes of regional variation in receiving adequate treatment for maternal depression is an important objective for researchers and policy makers alike.
Mothers’ under and untreated depression could adversely impact the health and well-being of their family members, particularly children. Numerous clinical studies consistently have shown that parental clinical depression is associated with children’s psychiatric and other morbidity,4, 5, 53-57
poor health status and development,58-60
worse prevention practices for children (i.e., not using a car seat),61, 62
and increased use and costs of pediatric health and mental health care.59, 60, 63, 64
Moreover, similar findings have been reported on the impact of poor mental health on spouses and other family members.65, 66
This study has several limitations. First, the measure of treatment adequacy was based on American Psychiatric Association (APA) guidelines and captured only the use of treatment. Therefore the quality of or adherence to prescribed treatment plans could not be assessed. Moreover, the type and duration of each psychotherapy or mental health counseling session could not be assessed in this study which limits the ability to determine the quality of the treatment. Additionally, depression treatment measurements were annualized and therefore these analyses could not examine the length of treatment time. Second, mothers with depression were identified through household informant reports instead of clinical diagnoses and therefore these results may not be generalizable to diagnosed patients. Finally, specific information about depression severity could not be measured in this analysis. However, general measures of functional status, comorbid mental health, and chronic medical conditions were included to address this issue.
This study has important strengths. First, the results are based on national, population-based data, providing policy-makers and practitioners with a picture of the groups of mothers who are not receiving adequate treatment for their depression. Additionally, due to the large sample size and rich data set that 10 years of the MEPS provided, several key predictors of depression treatment could be investigated together in one model, allowing for adjusted estimates of the contributing effect of each characteristic.