Not again.

That was the dread that hit 18-year-old Bianca Lewis when she learned she was pregnant with her second child, less than a year after her daughter was born.

The depression that had troubled the single mother during her first pregnancy intensified after the birth of her second child.

Lewis, of Sun Prairie, frequently cried.

She fell into fits of screaming rage.

She abused alcohol.

She even broke ceramic plates over the head of the father of her children.

More than 65 percent of depressed mothers don’t get adequate treatment for depression, according to a nationwide study released this fall by the UW-Madison School of Medicine and Public Health. The study of 2,130 women found that black, Hispanic and other minority mothers were among the least likely to be helped. Women with health insurance were more than three times as likely to receive adequate care compared to uninsured mothers, the study found.

“Expanding health insurance coverage to mothers with depression is a critical step in

helping them get the care they need,” said lead author Whitney Witt, assistant professor of population health sciences at UW-Madison.

Nationally, depression that develops during the pregnancy and up to a year after giving birth afflicts up to 15 percent of women, a condition that can cause long-lasting problems in children. Although women of all income levels and backgrounds can suffer from perinatal depression, for women living in poverty, it’s twice as likely to strike, according to the Wisconsin Association for Perinatal Care.

Solutions to the problem of perinatal depression in Wisconsin remain elusive.

Consider that:

• Few health care professionals specialize in perinatal depression, meaning not many women are screened for it, physicians may overlook depressive symptoms and there are few places for treatment if they’re diagnosed.

• Women living in poverty are especially vulnerable because they are often already under excessive stress.

• Some women may avoid treatment because of the stigma of feeling depressed at a time that’s supposed to be among the most joyful in their lives.

• Some who qualify for state-sponsored health insurance while pregnant may lose the coverage after the baby is born because of more-restrictive income requirements for women who aren’t pregnant.

Some symptoms of perinatal depression include feelings that persist for two or more weeks — being overwhelmed, a lack of energy, sleep disturbances, difficulty attaching to the child, loss of concentration and, in severe cases, a desire to hurt themselves or their baby. Postpartum depression can make a woman unable to pick up her child when it needs her or respond appropriately to other cues.

“The attachment that can very quickly rupture when a mother has postpartum depression is potentially devastating,” said Jenny Grether, program coordinator of the Early Childhood Initiative of Dane County, a local home visitation and employment program.

The majority of women suffering from perinatal depression will suffer in silence, and the harm to their children can be profound, experts say, including delays in the child’s cognitive and language development, behavioral problems or other psychological issues.

Mothers and children can also be at physical risk. The most extreme form of perinatal depression, perinatal psychosis, may cause a mother to hate her unborn baby or infant, have thoughts of suicide or of harming the child. While this type of perinatal depression is extremely rare, several cases have made national headlines. In 2008, Alisa Lorraine Evans of Milwaukee was found not guilty by reason of mental disease after she killed one of her twin infant sons and injured another after she was diagnosed with perinatal psychosis.

Insurance limits are tight

On top of the natural stress of being a new mother, poor women struggle, often alone, with how to feed their children, a lack of adequate transportation, child care, employment and health insurance.

The Early Childhood Initiative works in the low-income neighborhoods of Allied Drive, Russet Road and Wexford in Madison, as well as the town of Sun Prairie. Women who are pregnant or have a child under 1 year old can participate in the program.

While its main mission is help children and create self-sufficient families, the program has become one of the primary screening tools for perinatal depression in low-income areas of Dane County. The program finds that just over half of the new mothers and pregnant women screened in low-income areas of Dane County had depressive symptoms at levels warranting further evaluation.

For many low-income women, a lack of adequate health insurance remains a significant roadblock to getting help. For those who do have state-sponsored insurance, finding therapists who charge on a sliding scale, or who accept patients receiving Medicaid, is difficult, said Birdie Meyer, president of Postpartum Support International.

BadgerCare Plus, the state’s health insurance program for low-income residents, has a special eligibility standard for pregnant women, offering state-subsidized coverage, for example, to a family of four making up to $66,144 a year.

Following the birth, the mother will still be covered for at least 60 days and the child is still eligible for BadgerCare Plus, but the income eligibility for his or her mother tightens to $44,100 a year to qualify for BadgerCare Plus.

Sixty days after the birth, women who don’t meet the income-level requirements are dropped, according to the Wisconsin Department of Health Services. Some cases of postpartum depression don’t show up in the first two months, meaning a woman could be dropped from coverage before the condition is identified or treated.

“I am stable now”

For Bianca Lewis, the path toward wellness has been rough.

Lewis moved from Houston to Dane County to live with her baby’s father in 2006. But things didn’t work out, Lewis said, because he was involved with two other women, and he’d already fathered two children with one of the women. A few months after the birth of her first child, Lewis found herself alone with her baby daughter at a homeless shelter.

She’d just had her gall bladder removed and was preparing her seven-month-old daughter for surgery to repair a congenital defect when she found out she was pregnant again.

She felt miserable, overwhelmed — and depressed.

“So here I go all over again,” Lewis said. “Not knowing if he’s going to be there or not. And I’m going to be sitting here with two kids … “

Lewis got help from the Early Childhood Initiative, where she was referred by her landlord after her first child was born. She’s been seeing a therapist, has been on and off medication and has developed a support network to help her through episodes of depression. Throughout her apartment are handwritten reminders to “Take your meds!”

Since she qualified for state-subsidized health insurance and was connected to treatment by the Early Childhood Initiative, Lewis didn’t have to worry about access to care. Even without this stress, however, Lewis felt burdened with other problems that make it hard to cope with depression.

“Mentally, I am stable now, but I still have three bodies to worry about,” Lewis said. “I have to make sure that we have enough food at the house and that everyone gets to their doctors’ appointments … I just want everything to be like the classic normal family — have a perfect home, the kids can have a father-figure, a picket fence house, all of that.”

Access improves, yet stigma persists

Access to treatment for women in Wisconsin suffering from perinatal depression has improved over the past 10 years, said Ann Conway, executive director of the Wisconsin Association for Perinatal Care. Women and health care providers are more aware of the problem, which has boosted the number of women getting screened for perinatal depression. And a growing amount of research has focused on the effects maternal depression on infants, children and families, she said.

Still, many women with perinatal depression aren’t getting help, Conway said.

“Some of the things that have remained the same include the stigma associated with a mental illness; the fear of prescribing selected antidepressant medications for pregnant and breastfeeding women; and a lack of mental health providers, ” Conway said.

Jennifer Doering, assistant professor of nursing at the University of Wisconsin-Milwaukee, agreed a stigma persists.

“In society, there is the idea that you can’t be a good mom and have a mental disorder,” she said. ” The two, for whatever reason, wrongly seem to be on the opposite ends of the spectrum.”

The depression itself can be a significant barrier to getting help, Doering said.

“Simply making the phone call when you are depressed to seek help is, for many women, a severe and almost insurmountable burden, ” she said.

Should screening be required?

Rebecca Cohen, a mental health program analyst for the state Department of Health Services, believes all pregnant women and new mothers should be screened for depression. She said identifying women suffering from perinatal depression would help knock down some of the barriers to getting help. The Wisconsin Association for Perinatal Care recommends women be checked for depression twice during pregnancy and twice after the child is born, once at six weeks after birth and another time before the child is 1 year old.

Some states have passed legislation dealing with perinatal depression, including New Jersey, which requires health care providers to screen all new mothers for the condition. Earlier this year, a bill was introduced in the U.S. House of Representatives that would ensure new mothers are screened and treated for postpartum depression. The bill also calls for increased funding for research on postpartum depression.

Still, most women like Lewis who do find treatment do so by accident, said Lisa Hebgen, Wisconsin state co-coordinator of Postpartum Support International. She said there are few support groups in Wisconsin aimed at women with perinatal depression, who may feel alienated in regular new-mother groups.

Hebgen, who suffered from postpartum depression after the birth of her son, found Dane County had few health care providers versed in the problem. Nowhere in her birthing classes or doctor visits did she hear about perinatal depression. Hebgen said when she began experiencing symptoms of depression, her concerns were ignored.

Said Conway of the Wisconsin Association for Perinatal Care: “The most common lament we hear … is the lack of services for mental illness, especially for pregnant women with mental illness.”

What is perinatal depression?

A majority of new mothers may experience the ‘baby blues’ where they feel tired, have no energy and are overwhelmed by both joyful and depressive emotions. The postpartum blues may last up to 10 days and normally go away naturally.

But symptoms of perinatal depression, which afflicts pregnant women or new mothers, are more serious and last longer than the ‘baby blues.’ Some of the symptoms include depressed mood, lack of interest in activities, an inability to sleep, decreased concentration, a lack of energy to respond to the baby’s needs, emotional detachment from the child, feelings of guilt about that detachment and thoughts of harming oneself or the child.

Researchers have long thought that perinatal depression is caused by hormonal imbalances. However, many recent studies have found that other risk factors may have a stronger impact on perinatal depression. Those include recent stressful events like a job loss, financial difficulty, relationship problems or divorce or a general lack of social support.

The Centers for Disease Control and Prevention has found that reports of postpartum depression are high among teenage mothers, victims of physical abuse, low-income patients, smokers and mothers with less than 12 years of education.

The most serious and rare form of perinatal depression is perinatal psychosis. Women with this disorder can have delusions, paranoia and hallucinations, including hearing voices and having thoughts of harming their babies or themselves. Women with these symptoms should seek medical help immediately.

Women with perinatal depression can experience anxiety disorders such as panic disorder or obsessive-compulsive disorder in addition to their depression. Postpartum obsessive-compulsive disorder can cause a mother to have persistent thoughts about harm to her baby, causing her to excessively protect her child.

Perinatal depression can last several months to a year or longer if left untreated. Extended maternal depression can damage a mother’s relationship with her child but also result in delays in the child’s cognitive and language development, behavioral problems and other psychological issues. Some of the treatment options include therapy and medication.

Key facts about perinatal depression

• Few health care professionals specialize in perinatal depression, meaning not many women are screened for it, physicians may overlook depressive symptoms and there are few places for treatment if they’re diagnosed.
• Women living in poverty are especially vulnerable because they are often already under excessive stress.
• Some women may avoid treatment because of the stigma of feeling depressed at a time that’s supposed to be among the most joyful in their lives.
• Some who qualify for state-sponsored health insurance while pregnant may lose the coverage after the baby is born because of more-restrictive income requirements for women who aren’t pregnant.

If you need help

• UW-Madison Postpartum Depression Treatment Program, 608-263-5000
• Postpartum Support International, Lisa Hebgen, Wisconsin state co-coordinator, 608-929-7629, http://postpartum.net/
• Maternal and Child Health Hotline in Wisconsin, 800-722-2295, www.mch-hotlines.org