August 24, 2018

Ministry of Health

Government of Saskatchewan

Room 204, Legislative Building

2405 Legislative Drive

Regina, SK, Canada, S4S 0B3

Re: The development of a Canadian Maternal Mental Health Strategy as an agenda item at the 2019 Provincial and Territorial Ministers of Health Meeting in Regina, SK

Dear Honourable Minister Ottenbreit and Honourable Minister Reiter,

Tragic maternal suicides and infanticide by women suffering from severe postpartum depression and postpartum psychosis make news headlines and destroy families. These extreme examples are thankfully rare, but depression is common and is predicted to be the second leading cause of disease globally by 2020 and is twice as common in women than men. In Canada, perinatal depression affects one in five women. The World Health Organization states that “[t]here is no health without mental health” and improving maternal mental health is one of their Millennium Development Goals.

The Facts:

­In Canada and worldwide, 20% of women and 10% of men suffer from a perinatal mental illness. Perinatal Mood and Anxiety Disorders (PMADs) are the most common obstetrical complication making it a significant public health concern.

­Poor mental health affects the expectant and new mother’s overall emotional and physical well-being, but also impacts unborn, newborn, and developing children, partners, family, friends, and society as a whole.

­Exposure to Adverse Childhood Experiences, of which parental depression is one, results in high levels of toxic stress on a child’s developing brain that increases the likelihood of poor mental and physical health outcomes later in life.

­Suicide is a leading cause of maternal death. Despite limitations in Canadian data, suicide is the fourth leading cause of death. One in 19 maternal deaths in Ontario can be attributed to suicide.

­Maternal depression and anxiety are stronger risk factors for child behaviour problems than smoking, binge drinking, and emotional or physical domestic abuse.

­More women suffer from  PMADs than there are new cases of breast cancer and the combined new cases (all genders) of tuberculosis, leukemia, Multiple Sclerosis, Parkinson’s and Alzheimer’s Diseases, Lupus, and epilepsy annually.

­Cost estimates for untreated mothers and children affected by perinatal mental illness is estimated at $150,000 per mother with 72% of costs allocated to the child, which can be reduced to $5,000 if we screen and treat. Eighty-five percent of mothers are not properly treated and the result if an annual economic cost to Canada of approximately $11 billion dollars.

­Stigma, lack of public and professional awareness, and leaving the onus on the mothers to reach out for help, results in only 15% of mothers who experience a PMAD receiving professional treatment. Some countries, such as the UK and Australia, have a Maternal Mental Health Strategy with screening programs in place.

A Mother's Story

After the birth of my daughter I felt constantly drained of energy and was suffocating with constant anxiety; even more than during my pregnancy. The most awful aspect of my depression and anxiety were my fits of rages and how I would take them out on my husband and daughter. I felt defeated as a mother because I could not calm and comfort my baby. I was a shell of a person who just did not have the tools to move forward. I struggled alone for over six months with anxiety, paranoia, and anger. In those moments, I needed to hear from a medical professional that I was legitimately having a difficult time and that there was help. I truly believe that consistent screening and adequate supports would have prevented the extent of my suffering, and the effects on my family. The most important lesson I have learned throughout my experience with maternal depression is that, just as it takes a village to raise a child, it takes that same village to raise a mother.

Canada Today:

Some jurisdictions and professional organizations have recognized the importance of Maternal Mental Health: Saskatchewan has had MotherFirst: Maternal Mental Health Strategy since 2010, British Columbia developed Best Practice Guidelines for Mental Health Disorders in the Perinatal Period in 2014, and the Northern Ontario Postpartum Mood Disorder Strategy was launched in 2015. Other provinces may have strategies in development. The Society of Obstetricians and Gynecologists of Canada has affirmed the importance of mental health to reduce maternal morbidity and mortality and is expected to soon publicly endorse the Australian Guidelines. Through research and multiple consultations, the four key policy areas of: (1) awareness, (2) screening, (3) treatment and (4) accountability, have significantly improved maternal mental health in Saskatchewan:

1)    Awareness:

­Materials for mothers and professionals created and distributed through the Saskatchewan Prevention Institute

­   Maternal mental health is in the curriculum of medicine and nursing

­   Public, media, and professional presentations (Dr. Bowen has spoken approximately 200 times in Saskatchewan)

­   Successfully engaged the press who contact us for updates

­   Proclaimed Maternal Mental Health Day (first Wednesday in May), which is now also an international event known as World Maternal Mental Health Day

­   Developed a DVD and Tool Kit for mothers and professionals

­   Partnered with the Canadian Mental Health Association (SK) to host Our Mothers, Our Future conference, in May 2018 in Saskatoon, SK, which provided a two-day Postpartum Support International Certificate Course

2)    Screening:

­   Edinburgh Postnatal Depression Scale (EPDS) to screen women at two and six months at child health check visits

­   Care guidelines based on EPDS scores for health care professionals and community workers

­   New perinatal form includes universal screening with EPDS in pregnancy to one month postpartum

3)    Treatment:

­   Prioritization of perinatal women in Mental Health Services (in most but not all health areas)

­   HealthLine 811 provides a Maternal Wellness Program for assessment and short-term counselling; as well, public health nurses can refer women with a callback service for group only. There are requests to extend the service to other practitioners, postpartum mothers, and First Nations' communities

­   Online Cognitive Behavioural Therapy was validated in postpartum women

­   Some maternal mental health programs with specialist psychiatrists (nurses, social workers, psychologists)

4)    Accountability:

­   The original committee continues to meet provincially and have now engaged with the Perinatal Mental Health Coalition Canada

­   Twelve health regions have now merged into the new Saskatchewan Health Authority, in which co-chairs of the Saskatchewan MotherFirst Strategy will meet to ensure that maternal mental health remains a priority

­   Regular in-person updates with the Minister of Health since 2009

Next Steps:

We ask for the Ministers of Health across Canada to work with us to develop a Canadian Maternal Mental Health Strategy that builds on the Saskatchewan MotherFirst Strategy to include public and professional awareness, universal mandatory screening, and increased access to treatment options such as support groups, medication, counselling,  and hospitalization to all pregnant and postpartum women experiencing a maternal mental illness and their families. Thus, we kindly request to be included on the agenda to address the 2019 Provincial and Territorial Ministers of Health Meeting.

Respectfully submitted,

Perinatal Mental Health Coalition Canada

A grassroots coalition of mothers, advocates, and professionals from across Canada

References:

Bauer, A., Parsonage, M., Knapp, M., Iemmi, V., Adelaja, B., & Hogg, S. (2014). The costs of perinatal mental health problems. Centre for Mental Health. /doi.org/10.13140/2.1.4731.61.

Bowen, A., Bowen, R., Butt, P., Rahman, K., & Muhajarine, N. (2012). Patterns of Depression and Treatment in Pregnant and Postpartum Women.  Can J Psychiatry, 57(3),161-7.

Globe and Mail. Canada must find ways to prevent postpartum-depression deaths2013. Available from: http://www.theglobeandmail.com/globe-debate/editorials/canada-must-find-ways-to-prevent-postpartum-depression-deaths/article14319424/.

Grigoriadis, S., Wilton, A. S., Kurdyak, P. A., Rhodes, A. E., VonderPorten, E. H., Levitt, A., … Vigod, S. N. (2017). Perinatal suicide in Ontario, Canada: a 15-year population-based study. CMAJ, 189 (34) E1085-E1092; DOI: https://doi.org/10.1503/cmaj.170088.

Knitzer, J., Theberge, S., & Johnson, K. (2008). Reducing Maternal Depression and Its Impact on Young Children. Retrieved from http://www.nccp.org/publications/pdf/text_791.pdf.

Lebel, C., Walton, M., Letourneau, N., Giesbrecht, G., Kaplan, B. and Dewey, D. (2016). Prepartum and Postpartum Maternal Depressive Symptoms Are Related to Children’s Brain Structure in Preschool. Biol Psychiat, 80(11), 859-868.

Letourneau, N. L., Dennis, C. L., Benzies, K., Duffett-Leger, L., Stewart, M., Tryphonopoulos, P. D., ... & Watson, W. (2012). Postpartum depression is a family affair: addressing the impact on mothers, fathers, and children. Issues in mental health nursing, 33(7), 445-457.

Letourneau, N. L., Dennis, C. L., Cosic, N., & Linder, J. (2017). The effect of perinatal depression treatment for mothers on parenting and child development: A systematic review. Depression and anxiety, 34(10), 928-966.

Oates M. (2003). Suicide: The leading cause of maternal death. Br J Psychiat, 183,279-281.

Rahman, A., Surkan, P., Cayetano, C., Rwagatare, P. and Dickson, K. (2013). Grand Challenges: Integrating Maternal Mental Health into Maternal and Child Health Programmes. PLoS Medicine, 10(5), e1001442.

SOGC (2018). Working towards a national Canadian surveillance system to reduce maternal mortality and morbidity. https://sogc.org/files/Maternal%20Mortality%20and%20Morbidity_web.pdf.

Sohr-Preston, S. & Scaramella, L. (2006). Implications of Timing of Maternal Depressive Symptoms for Early Cognitive and Language Development. Clin Child and Fam Psych Rev, 9(1), 65-83.

Stone, K. (2010). How Many Women Get Postpartum Depression? http://www.postpartumprogress.com/how-many-women-get-postpartum-depression-the-statistics-on-ppd

World Health Organization. Improving Maternal Mental Health. Geneva: World Health Organization; 2008.

World Health Organization. Gender and Women's Mental Health Geneva: World Health Organization; 2010. Available from: http://www.who.int/mental_health/prevention/genderwomen/en/.