Ann Rifenberg has focused much of her 10-year career as a midwife learning how to spot and treat women with postpartum depression.
"Most often I see anxiety," she says. "Many women have a great sense of guilt that they aren't being the mother they thought they would be."
In recent years, awareness of postpartum depression as a serious illness has risen in the medical community. But Rifenberg says only a minority of physicians in Madison actually evaluate women for the disease.
And she believes inadequate screening for postpartum depression means many women are left to silently suffer from an illness they are often ashamed to admit they have.
"It's a hidden disease in our culture," says Rifenberg, who works at UW Hospital and Clinics. "It's hidden by the women. The societal expectation is that even when you feel horrible, you deny that there are problems. You put on your makeup."
Making matters worse is that women in the U.S. typically have only about six weeks of recovery time after giving birth, if that. "The prevailing opinion by many is that these women just need to shape up or get over it," says Rifenberg. "So many women are rightfully afraid to self-disclose."
Rifenberg's interest in dealing with depression has come not just from her career, but also from what she experienced after giving birth to her first child 36 years ago.
"It was like a thick, black cloud came over me," she says, drawing her hands over her face. "The joy of my life was smothered."
Screening and treating depressed women is an issue that has gained considerable attention in recent years. In Madison and throughout the country, there are poignant reminders of how mental illness, if left untreated, can lead to tragedy.
This summer Ee Lee, a 23-year-old woman, was arrested on Madison's south side after she purportedly admitted to torturing her 6-week-old daughter to death.
"Those are the kinds of things we are trying to prevent," says Ann Conway, executive director of Wisconsin Perinatal Foundation, in response to Lee's case.
In January of this year, the Perinatal Foundation launched a series of radio novellas in Spanish that tell stories of women suffering from postpartum depression. Conway says the goal is to destigmatize the illness so that Spanish-speaking women will take initiatives to seek treatment, rather than passively waiting to be screened.
The radio program will end in January 2008, but Conway says the Perinatal Foundation will continue focusing resources on postpartum depression.
"We have had a number of opportunities to change direction but we keep coming back to this," she says. "We've done a lot but there's still a lot more to do."
According to Wisconsin's Department of Health and Family Services, postpartum depression affects 10% to 15% of all women who give birth. For women living in poverty, the rate jumps to 28%.
Early screening and management can arrest the symptoms and lessen the severity. But opportunities to detect the disease are often missed.
Rifenberg says a simple questionnaire is often all it takes to coax depressed mothers into revealing their symptoms. But most women do not continue to see their obstetrician-gynecologist after delivery, and the physicians they do see - their child's physician - often don't think to ask.
"The difficulty is that the direct diagnostic tools are not being used," she explains. "Women could fill out these questionnaires while waiting at the pediatrician's office. But there are either time constraints or the provider's comfort level is just not there."
Scrutinizing women for mental health problems is not generally a part of the training infant care providers receive. But Dr. Roseanne Clark, associate professor of psychiatry at the University of Wisconsin School of Medicine and Public Health, thinks it should be.
"It has been found in research that the children of mothers with [postpartum depression] have problems themselves with development," she says. "We need more people who are trained and who have been educated [about postpartum depression]."
Since 2005, Clark has been working with the office of Wisconsin Lt. Gov. Barbara Lawton on a task force created to study women and depression. The group published its results in May 2006, and Clark has since been a part of the effort to find ways to implement the report's recommendations.
Currently, Clark says much of the focus has been on integrating screening into existing health-care programs and procedures. But if these initiatives fail, the group could recommend legislative solutions to ensure that screening programs continue to expand.
"It's important to consider legislation, but we will also go forth with getting programs going," Clark says.
In order for any of the efforts to be effective, Clark says there will need to be a considerable amount of education involving infant health providers. But with the proper support, she believes there will be less resistance to screening among pediatricians.
As she puts it, "They see the suffering."
Dr. Luke Fortney, a family practice doctor with UW Health, admits he did not receive formal training for diagnosing postpartum depression. But he says media attention has put it on the radar. Now he and his medical team are on the lookout with every new patient.
"We don't hand out a formal questionnaire, but we use feeler questions," he says. "[For doctors] in the residency program, now it's a common item on the checklist."
If infant care providers were to include screening in their daily procedures, Dr. Fortney would prefer that the tools come from within the medical community rather than through government legislation.
"I think we do a pretty good job talking with mothers," he says. "But I certainly think that [screening] needs to be included or emphasized in [patient care] guidelines."
Rifenberg, meanwhile, worries about the damage that postpartum depression continues to cause.
"If I could draw an image of postpartum depression," she says, "it would be of a woman just sitting on one side of the room with her child far away on the other side of the room. And there's all this distance between them."