Tuesday, September 9, 2008

Postpartum Depression in China vs. the United States

Mental health is a universal issue, but in each country, citizens view it differently. The government may address mental illness, but most likely it must first face denial and stigmatization. Postpartum depression is no different. In China, where rapid economic growth has brought new hope for many, it has also raised new mental health issues resulting from urbanization. Of course, depression previously existed, but it is only beginning to be given a name.1 In the United States, there is a longer history of mental health evaluation and treatment,2 but Americans are only beginning to understand postpartum depression.

In America, organizations such as the U.S. National Library of Medicine, the National Institutes of Health and the American Psychological Association perform research on PPD and disseminate the findings to the public. If an American tries to find information about PPD, they can turn to a wealth of resources. They will find that PPD is a serious mental health problem. Mothers may experience a period of prolonged emotional distress after the birth of a child. According to the APA, PPD can have significant consequences for both the new mother and family.3

An estimated 9-16 percent of American women will experience PPD. It becomes extremely difficult for the inflicted to function in their day-to-day lives, due to cognitive impairment and feelings of guilt, anxiety, and fear. They may experience a loss of pleasure in life, insomnia, bouts of crying, and even thoughts of hurting themselves or the child. 4

Even if thoughts of hurting the child are not a symptom, sufferers still have difficulty providing appropriate infant care. Research on American children of mothers with PPD has found that they may display insecure attachment and behavior problems. They are more likely to experience problems in cognitive, emotional and social development, and are at higher risk for anxiety disorders and depression in childhood and adolescence.5 Fathers too are more likely to become depressed if the mother suffers from PPD. 6

There are several biological and situational factors associated with PPD. The dramatic shifts in levels of reproductive hormones, such as estrogen and progesterone, that occur after birth are linked to depression in susceptible women. 7 Other predictors of PPD include a personal or family history of depression, marital dysfunction, young age, acute stress, exposure to toxins, crowding, air pollution, poor diet, low socioeconomic status, and weak social support. The stress of a new child, especially one with a difficult temperament, is also a factor. 8

In America, PPD is not a curse; mothers do not have to resign themselves to their fate. There are successful prevention and treatment tactics. To lessen a mother’s risk, she should seek social support from other mothers, friends and relatives, get enough sleep, and prioritize her responsibilities. To obtain treatment, she should consult a mental health care provider. A variety of effective psychological treatments exist, such as cognitive-behavioral and interpersonal therapy.9

Research has found that the rate of PPD in China is comparable to that of the U.S., but the Chinese do not have the same resources to fight it.10 One study found that approximately one in every ten mothers in Hong Kong falls victim to PPD.11 Another study found similar rates of PPD among Chinese women in other areas, but a significant disparity between women who gave birth to boys and those who gave birth to girls. The study found that PPD is twice as likely to occur in Chinese mothers of girls than Chinese mothers of boys.12 In a sample of women in which 17.3 percent suffered from PPD, the rate of depression in women who gave birth to a female infant was 24. 6 percent while the rate in those women who gave birth to a male was 12.2 percent. The researchers speculated that, because prenatal gender identification had been prohibited in China by this time, prenatal factors were not as important as those that occurred postpartum, such as family member reactions. 13

They speculated that:

The preference for male children may be communicated to the mother and those who deliver females may receive less support and less positive feedback. Social support has widely been found to be a risk factor for PPD. . . . Deteriorating marital/partner relationship after the birth of a girl baby may be another explanation.14

A study published in 2001 in the Chinese Journal of Clinical Psychology backed up the researchers’ speculation.15 This study examined thirty female Chinese patients who had been diagnosed with PPD and found they had less social support than a control group of women with no PPD. 16

To understand why women in China who give birth to girls may be more likely to experience PPD, it is important to understand the public policy and social climate of China. China is the only country where suicides among women outnumber those among men, according to Beijing media quoted through Reuters.17 The ratio of male to female suicides in China is 0.8/1; in the U.S., it is 4.1/1.18 While the global average for suicide rates is 15 per 100,000 people, in China, it is 22. For Chinese women in the countryside, where the majority of Chinese live, it is 30 per 100,000. 19

Michael Phillips, an associate professor of social medicine at Harvard Medical School and head of research at Beijing Hui Long Guan Hospital, studies this discrepancy. He explains Americans assume that virtually everyone who commits suicide has a mental illness. He argues that in China, this is not the case, and the society views suicide as “normal.”20 He suggests “support groups for rural women... and expanded services for mental health” as ways to combat the problem.21

The rural areas are especially dangerous for rural women because they "(u)sually... have lower education or no education," explained He Yanling, the chief doctor at the Shanghai Mental Health Center who worked on a 2004 report about the economic costs of depression.22 He explained that sometimes husbands leave for jobs (and even second families) in the city, leaving their wives on the farm. Those women "have less information and less knowledge about how to seek help," he said.23

Because rural Chinese women lack social support, mental health services and awareness of mental illness, they are not only at risk for suicide, but also for postpartum depression and other mental illnesses. Previous depression, often a predictor of suicide, is also a contributing factor of postpartum depression. A lack of resources to prevent suicide is also a lack of resources to prevent mental illnesses.

Isolation is not only a rural problem. Even in cities, urbanization has led to “social isolation and lack of support from the family,” according to Esther S. Lee Yao, a historian who wrote Chinese Women: Past & Present. She claimed that “the imbalance between a rapidly changing society and the slowly growing progressive attitude of women toward their family role” has meant that “Chinese housewives are . . . confronted with the same kinds of emotional shock experienced by women in other advanced nations.”24 In China, urbanization has weakened traditional familial support networks.25

Both Chinese and American women face the denial and stigmatization of mental illness. The Chinese have traditionally ignored the idea of mental disease, according to He. "Chinese usually think that psychological problems are shameful to mention," she said.26 Psychological problems may not only be shameful to the Chinese, but they may not even be recognized. In fact, in China, no word distinguishes “depression” from “sadness.” 27 Harvard anthropologist Dr. Arthur Kleinman found in the 1980s that many Chinese did not think or talk about mental illness in the same way as Americans.28 They came to “healers” with physical complaints, such as dizziness or headaches, though in many cases in the United States they would be diagnosed as depressed. A World Health Organization survey published in 2004 found that 2.5 percent of Chinese reported a mood disorder in the previous year, compared with 9.6 percent of Americans.29

The United States also has a long history of stigmatization of mental illness, but currently organizations, such as the National Alliance on Mental Illness and Mental Health America, work to combat negative images.30 Mental Health America’s website offers information, other web resources, and even the phone number of a help line.31

Over the years, the Chinese have had political reasons to deny the country's mental health problems. Norman Sartorius, former director of the World Health Organization's mental-health program, pointed out that the Chinese and other Asians have tended to regard depression as something that plagued other places, but not their own countries. "It's a problem of the West," he said of the way the argument is characterized. "The Americans have depression. The English have depression. It's their disease."32 Officials at the Chinese Psychiatrists’ Association say that China has 17,000 certified psychiatrists, one-tenth the number in developed countries, in proportion to the population. 33According, to the CPA, ninety percent of the 30 million people in China suffering from depression fail to get proper treatment due to worries about discrimination and a lack of professional psychiatrists. But for the 10 percent that did receive medical assistance, the results are encouraging. Among depressed Chinese who seek hospitalization, the clinical cure rate was at a new high of 35 percent in 2007.34

While a predisposition to depression explains why some Chinese mothers may be especially susceptible to PPD, it does not explain why one study found giving birth to a girl doubled the risk of postpartum depression. This risk factor is specific to China, because preference for boys over girls is common.

There are several potential factors leading to this phenomenon. This preference is deeply embedded in the culture, dating back to Confucian thought, which dictates that the male rule over the female. There are also many Chinese proverbs which illustrate how unimportant women historically were in Chinese culture. Two examples are “A woman without talent is a woman of virtue” and “It is more profitable to raise geese than daughters.”35

Because China lacks a social security system, parents rely on sons economically when they become old. Traditionally, women lived in their husband’s home after marriage and couldn’t provide much support to their own parents. Patriarchal family names are also considered an source of pride for the family.

While America is also a patriarchal society, families are permitted to have more than one child, so having a girl is not a risk factor for PPD. The Chinese government instituted the “one-child policy” in 1979 to alleviate the social and environmental problems caused by overpopulation. The government uses food coupons and cash rewards to enforce the system. Yao explained that “having no son has been considered one of the three kinds of unfilial behavior, many people have had difficulty complying with governmental policy.” 36

Infanticide with baby girls, though illegal, is not uncommon. According to Yao, it “ can be traced back to early Chinese history.” Dowries would have to be provided for female children at marriage. Yao explained that the practice was “greatly influenced by the philosophy of neo-Confucianism which denied women basic human rights, including the right to live.” She said “In early Chinese history, women were expected to produce as many offspring, preferably male, as possible.” She did conclude that women are better off in present-day China, partly because they are beginning to stay and care for elderly parents.

Still, in 2005, some 118 boys were born in China for every 100 girls. In some regions, the figure has hit 130 boys for every 100 girls; the average for industrialized countries is between 104 and 107 boys for every 100 girls. Infanticide does not necessarily signal PPD, but the high rate of boys to girls does demonstrate a cultural preference for boys. This preference explains why the mother of a girl might be more prone to PPD.

Chinese and U.S. women who suffer from PPD have different available options. If an American woman has PPD, there are several organizations she can contact, including the National Institute of Mental Health, the American Psychological Association, the National Mental Health Association, Postpartum Education for Parents, and Postpartum Support International. Depending on her financial resources, she can choose to undergo counseling, take medication, or even hire a mother’s helper. Women in the United States who suffer from PPD also have a vast array of literature to choose from when addressing their affliction.

While mental illness in America is still stigmatized, there is an increasing awareness of PPD. When Brooke Shields publicly discussed her disease, she let other depressed mothers know that they were not alone. In an editorial composed for the New York Times, published on July 1, 2005, Shields reached out to new mothers everywhere who had, like her, experienced a deep depression after the birth of a child. Shields felt motivated to share her story after a very public disagreement with another celebrity, Tom Cruise, about the need for psychiatric medications. Shields said: Since writing about my experiences with the disease, I have been approached by many women who have told me their stories and thanked me for opening up about a topic that is often not discussed because of fear, shame or lack of support and information. Experts estimate that one in 10 women suffer, usually in silence, with this treatable disease. We are living in an era of so-called family values, yet because almost all of the postnatal focus is on the baby, mothers are overlooked and left behind to endure what can be very dark times. 37

Shields must also have given comfort to mothers when she published her book about her ordeal, Down Came the Rain: My Journey Through Postpartum Depression.

Chinese women do not have a “role model” who has been through PPD. Those who lack a support system may not be aware that other women have experienced it. However, the media has begun to describe postpartum depression to Chinese women. A story on the website of the Chinese Information Center claimed that “close to half of new mothers suffer from postpartum depression.” The story does not cite the testing methods used to determine this figure. But if Chinese women do recognize they have a problem and decide to seek help, they have less resources than American women. The story explains that “depression is often misdiagnosed” and “ a select few maternity hospitals have psychological aid services.”38

Dr. Alan Stone visited Beijing on behalf of the World Psychiatric Association to research the state of psychiatry in China. He found that “ most of the rural population... have no health insurance and for those in the cities who do, there are significant copayments for psychiatric hospitalization.” He also found that “the stigma of mental illness remains an overwhelming fact of life in China and this sociocultural reality creates a barrier to care and makes the specialty of psychiatry less attractive to promising young doctors.” In the United States, psychiatry is a lucrative and competitive profession.39

In both China and America, health insurance is an important factor. According to the 2005 US Census, 15. 9 percent of Americans lacked health insurance.40 In China, 80 percent of rural residents and 40 percent of urbanites did not have medical insurance.41 For those that do, plans vary in their coverage of mental illness. The Chinese government did launch an effort in 2005 to help poor people receive treatment. It established 60 pilot sites in rural areas. According to China Daily, “In every site, 1,000 patients are registered and given free medical treatment.”42

Other hopeful signs are emerging that the Chinese government is becoming willing to take the initiative to expand mental health services. The government launched its first national mental health plan in 2002, with a focus on depression. In October 2004, the State Council (China's Cabinet) announced its mental health policy, spotlighting proposals to target resources at high-risk groups and make it easier for people to get treatment.43 China is also upgrading its training for mental health workers. Until recently, doctors could not easily specialize in psychiatry, He said. "If you worked in a psychiatric hospital, you were a psychiatrist," she said.44 Doctors are now getting specialized training.

The mental health establishment is growing fast, but it has a way to go to catch up with the system in the United States, and the stigma surrounding mental illness in both countries remains. Mental health outreach has only just begun, and has not expanded to specifically target new mothers. Chinese psychologists are engaging more with foreigners and looking for ways to adapt established theories and techniques to Chinese sensibilities, according to The Economist.45

America’s idea of cognitive-behavioral therapy can be adapted to the Chinese culture, but Freudian concepts, with their emphasis on childhood trauma and repressed sexual desires, do not appeal as much. There remains much room for Chinese psychologists to develop their own theories. 46

Of course, the Chinese are not without their own healing methods. China Institute in America, a nonprofit, non-partisan educational and cultural institution that promotes the understanding and appreciation of Chinese culture, addresses the issue of “Acupuncture, Depression, and Fatigue” by explaining that, although, western culture views fatigue as physical and depression as emotional, the Chinese view the two as intertwined.47 Evidence of their connection is achieved through traditional methods of Chinese medicine, such as pulse reading and tongue diagnosis. Acupuncture is one method of treatment for depression/fatigue. 48

Postpartum depression is not fully understood in the United States, but the Chinese are only beginning to researched it, as they have only recently begun advocating for mental health. In both countries, women can greatly benefit from therapy and support. Each country can also benefit from culture-specific solutions. However, before these women will submit to treatment, they must admit that they have a problem. Postpartum depression suffers from intense stigmatization because not only is it a mental disease, but it contrasts with the traditional female role in both cultures. Women have recently begun to question this role, but traditional expectations about child-rearing and motherhood remain. As women’s health issues in general gain legislative funding and public awareness, so will postpartum depression. Women like Brooke Shields who have opened up about their own experiences have helped, but the best social support will be when women feel comfortable opening up to one another.

Shared from : http://wvuerin.blogspot.com/2008/08/postpartum-depression-in-china-vs.html

1 comment:

Kay Bratt said...

Very interesting article. Great job!