Pacific women in New Zealand have the highest rates of antenatal and postnatal depression, yet low numbers get help. Sela Jane Hopgood asks why.
Warning: This story includes verbal abuse scenes and discusses suicide.
Suliana Katoa is at home in Tāmaki Makaurau with her three children, watching Coco the movie, when she considers suicide.
It is raining hard. Suliana's husband and parents have just headed off to ako hiva (church choir practice).
She grabs a basket full of washing to fold on her bed. She glances at her newborn lying peacefully in his cot and her eldest daughter, who is cuddling a bowl of popcorn.
Suliana spies her two-year-old son sitting on the floor with his milk and cookies.
"Be careful, please don't spill your drink - tokanga'i ho inu na'a mahua," she warns him.
But Michael Glacchino's soundtrack captivates him and he starts to wiggle and hum along to the music. He gets up and begins to dance along to the upbeat rhythm, imitating the scenes of the movie.
Suliana has one eye on the load of washing and one eye on her son as he dances near his glass of milk. She repeats herself, "Watch out, son. Your drink is on the floor." But he carries on moving from one end of the bedroom to the other, eyes glued to the TV screen.
She folds the washing, robotically, as her mind drifts away, thinking of what a difficult week she has had mentally.
"Nobody cares about me. I feel like a failure as a mother. I don't know what I'm doing as a mother. I'm not good enough. Why can't my family and friends be considerate of how hard I'm working? Looking after three kids is so hard," she thinks.
Suliana is a community health worker for Plunket and a part of her recognises that these thoughts might be the result of postnatal depression, but even thinking she might be mentally unwell fills her with shame, so she shakes off the idea.
"I'm afraid of making mistakes and letting other people down. What if I end my life?"
"Mum!" Suliana's son calls out, breaking her train of thought. He has knocked over his glass and milk is seeping into the carpet.
Suliana starts screaming. She is so loud her voice almost drowns out the heavy rain belting against the window.
"What did I tell you?" she yells at him.
She gets down to his level and stares at him. She points her finger in his face and threatens him with a hiding.
He barely recognises Suliana, who is usually cheerful, warm and nurturing. He runs to the corner of the room, lifts his hands over his ears and sobs uncontrollably.
Suliana can't breathe properly. She walks out of the bedroom and heads outside, where the rain continues to fill the dark evening. She can hear her son crying, but she doesn't care. She has no urge to check on him. It's like it's her body, but there is a stranger inside.
Eventually she goes back into the house. Her son has crawled into bed to cuddle up with Suliana's daughter. He's confused and sobbing.
Suliana looks at her son and seeing him so helpless, she feels her heart shatter into a million pieces.
She breaks down and cries. She picks her baby up out of his cot and takes him to the bed, where she sits down and embraces all her children, holding them close to her, while tears run down her face.
Why Pasifika mothers have high rates of perinatal depression
While Suliana may have felt alone that night, antenatal and postnatal depression is common among Pasifika women. In fact, they have higher rates of antenatal (during pregnancy), postnatal (after birth) and perinatal (both) depression than any other ethnic group in New Zealand. Despite that, experts say Pasifika mothers are less likely to seek treatment for their depression.
At Auckland's Lotofale Pacific Mental Health Service, there is framed tapa art on the walls and a chapel off the waiting area. There are also information pamphlets in various Pacific languages. Dr Sara Weeks, a consultant psychiatrist who specialises in maternal mental health, says postnatal depression is more than just feeling stressed.
"It's actually a medical condition where your brain sort of runs out of the chemicals that needs to keep going or runs low on them and so things like sleeping, eating, concentrating and even loving people, just don't work like they would usually do.
"It's not something you just deal with and get through like the stress of a crying baby or a barking dog, who all need feeding - you feed them all, you get on with it and they feel better. With depression, you're likely to crumple into a heap and just not be able to do the task," she says.
The 2019 Growing Up in New Zealand longitudinal study found 23 percent of Pacific women experienced symptoms of perinatal depression, compared with 8 percent of European women and about 14 percent of all other women combined.
Pasifika women who had experienced unfair treatment by a health professional in their lifetime were 66 percent more likely to suffer from postnatal depression, compared with Pacific women who did not report these experiences.
But why do Pacific mothers have such high rates of depression?
Dr Siale 'Alo Foliaki is a child psychiatrist and clinical lead for the child mental health services at Counties Manukau District Health Board. He is also clinical lead for the clinical cultural liaison services at Vaka Tautua, a national "by Pacific, for Pacific" health and social services provider.
The Tongan doctor says historically Pacific cultures respond to the arrival of a newborn baby by being very present and ensuring that the mother does not get fatigued. The way families live near each other, such as in villages, supports this.
"You would have your immediate and extended families keep the mother company, help with the chores, hold the baby so the mother gets rest and it's clearly a very protective means of care," he says.
But migration often leads to the fragmentation of cultural support and the ways family have traditionally offered support can be disrupted, he says.
It's also significant that the number one risk factor for antenatal and postnatal depression is having previously had depression.
Dr Foliaki says research into the migrant Pacific community shows if people have migrated to New Zealand after the age of 18, their mental health statistics are better than the European population as well as Pacific people who are born in New Zealand or migrated to the country before the age of 12.
Another risk factor for perinatal depression is a difficult relationship with a spouse or father of the child, Dr Foliaki explains.
Pacific peoples in New Zealand are twice as likely as non-Pacific people to have committed a serious crime against a family member, according to Pasefika Proud, which is a family violence prevention campaign.
"If there are inter-parental conflict or an unsettled relationship, then that's going to have a significant impact on the wellbeing of the mother," Dr Foliaki says.
Why a broken mind is like a broken arm
If Pasifika mothers have such high rates of perinatal depression, why do experts say they aren't getting help at the same rates as other women?
In general, Pacific peoples access all mental health help at lower rates than others. The New Zealand Health Survey shows Pacific peoples experience very high rates of unmet need for care compared to the total NZ population. Thirty-three percent of Pacific peoples (and 29 percent of the total population) report not seeing their primary care practitioner when needed, with most of this unmet need (20 percent of all Pacific people, 15 percent of the total population) being related to cost.
Dr Foliaki says he's seen many Pasifika mothers who have been diagnosed with antenatal and/or postnatal depression and their families hadn't recognised what was going on and didn't know how serious depression was.
"They're no longer enjoying any of the social interactions, they can't sleep, they can't eat, there's a lot of negative thinking, their self-esteem/confidence drops away, they're not bonding with the child, and actually without talking about it, they're feeling alone.
"Things can get so bad that they don't want to wake up in the morning, and I would argue, how many families, in particular Pacific families, would recognise that cluster of symptoms and say to themselves, hey I think my wife or sister might be depressed?"
Even if depression is recognised, in many Pacific cultures, there is enormous stigma and shame around mental health issues, he says.
"Often the culture interprets depression as a failing on behalf of the family. A young person may have a very caring and organised household (for example mum and dad are still together, grandparents are around to help and there's support for the new mum), but that doesn't necessarily mean that she is going to be protected by mental health issues like depression," Dr Foliaki says.
"From a Pacific point of view, if you get depression, it means the family didn't do what it was meant to do in terms of caring for the family and there's shame in that and that shame translates into poor help seeking behaviours."
But Dr Weeks says it is vital to seek treatment. A mother who has untreated perinatal depression cannot only suffer unnecessarily herself but can have a profound impact on her children right up to adulthood.
"It has extreme effects on the children, leading to both behavioural and cognitive disturbance. For example, they may not be learning that well in school," she says.
"Unfortunately, there is the risk of taking your own life, and there are some people who develop postpartum psychosis, where you can start to believe things that aren't actually true and that can increase the risk of taking your own life or even harming other people including children."
Treatment usually involves medication or therapy (such as counselling) or both. Complimentary therapies, such as exercising, or practicing mindfulness may also be used.
Dr Weeks describes treating postnatal depression using a broken arm analogy.
"Your arm is functioning fine and then something happens, for example you break a bone. It could be that your muscles are not that strong or there was some damage done in childhood or genetically, you have less strong bones, but something happens, and it breaks, so you go get a plaster on it and the bone heals underneath," she says.
"The medication used for broken brains (perinatal depression) helps you function while your own brain heals underneath."
Feeling 'normal' again
Suliana's mum arrives home from ako hiva first and finds her daughter crying, surrounded by her children. Suliana tells her mother how a glass of milk spilled on the floor. But when her husband arrives home, she faces up to what's really been going on.
Suliana's mum looks after the children, while Suliana's husband takes her to see a doctor in Ōtara. She tells the doctor about how distressed she's been and fortunately, a maternal mental health specialist is rostered on and she helps Suliana unpack her thoughts and feelings.
She goes through a questionnaire with Suliana. "Are you suicidal?" it asks and Suliana starts crying again, pouring out how she felt during pregnancy and after the birth of her son.
She was excited and grateful to have another blessing on the way, but she was also overwhelmed, stressed and anxious, more so when she learnt that she was having another boy.
"Bringing up my daughter was relatively easy compared to my second child, my son," she tells the specialist. "He's such an active person and, I think, for me, knowing I was going to have another boy, I couldn't stop thinking about how we were going to manage two active bodies in our busy household.
"It got to a point where I was so tired of feeling hopeless and not knowing what to do, that I wished I could just sleep and never wake up."
She's prescribed an antidepressant medication, Sertraline, but she's not keen. "Nah, I think I should be alright without the medication," she tells the specialist.
After the appointment, Suliana feels strange - disorientated, but also calmer.
She goes home. Suliana's husband nudges her to take the medicine and in the end she does, starting on the lowest dosage. A mental health team begins regular visits to her home, checking how she is.
Soon she starts therapy and realises the depression started when she was pregnant.
Within a few weeks, she begins to feel normal again.
She starts doing other things to help herself. She does a course on mindfulness, and it helps her understand ways to control and navigate her thoughts and feelings and to be present.
Soon after she begins feeling better, Suliana logs into her Facebook account. 'What's on your mind?' appears on her computer screen.
She begins typing: "Please share my story to help our fellow Pacific Island people understand that antenatal and postnatal depression is not a joke".
And then she types out her story. Suliana couldn't speak about her experience while she was lost in darkness. She was scared she'd be viewed as a failure as a mother. But now she wants to reach out to as many Pasifika mothers as she can, to let them know that it is ok to seek help for your mental health.
"If you are feeling the signs that I have shared or have read about the symptoms published by the Ministry of Health, please see your GP straight away or reach out to the mental health support services that are out there," she says.
"There is no shame in admitting that you are mentally not well."
*This story was made possible by the Mental Health Foundation of New Zealand and Frozen Funds Charitable Trust, with support from the Nōku Te Ao Like Minds programme.
Where to get help:
Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
Lifeline: 0800 543 354 or text HELP to 4357
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Depression Helpline: 0800 111 757 (24/7) or text 4202
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email email@example.com
What's Up: online chat (3pm-10pm) or 0800 WHATSUP / 0800 9428 787 helpline (12pm-10pm weekdays, 3pm-11pm weekends)
Kidsline (ages 5-18): 0800 543 754 (24/7)
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
Women's Refuge: (0800 733 843)
It's Not OK (0800 456 450)
Shine: 0508 744 633
Victim Support: 0800 650 654
HELP Call 24/7 (Auckland): 09 623 1700, (Wellington): be 04 801 6655 - 0
The National Network of Family Violence Services NZ has information on specialist family violence agencies.
If it is an emergency and you feel like you or someone else is at risk, call 111.