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Abstract: In the western world, most women deliver their infants in a hospital setting. The purposes of this article are to provide guidelines and suggest best practices related to hospital-based care for postpartum depression by perinatal nurses; with this information, policies, procedures, and educational programs can be implemented to improve nursing care of new mothers. Hospital-based perinatal nurses need to "launch" new mothers from the hospital into the community so that the new mothers are prepared for self-monitoring for symptoms of depression, and know what steps to take if they do experience depressive symptoms.
Postpartum depression (PPD) is a common experience for approximately 13% of new mothers internationally (Gavin et al., 2005). The symptoms are usually experienced by women by 4 to 6 weeks postpartum (American Psychological Association [APA], 2000). Risk factors for PPD include stress, low socioeconomic status, low levels of social support, a previous history of depression, and unexpected birth outcomes (Beck, 2001; Logsdon & Davis, 2003; Vigod, Villegas, Dennis, & Ross, 2010). PPD has an adverse and long-lasting impact on the woman's relationships, functioning, development, and her ability to mother her infant (Beck, 1998; Logsdon, Wisner, & Hanusa, 2009).
In the western world, most women deliver their infants in a hospital setting. Hospital-based perinatal nurses have extended contact with new mothers for 2 to 3 days. This provides a unique opportunity to identify new mothers with risk factors for PPD, link them with available healthcare services, and provide them with tools and resources needed if PPD does occur. Few studies have provided evidence related to nursing care for PPD that women receive while hospitalized including identification of depression risk factors, depression screening, patient education, and referrals. In terms of patient education, pamphlets about PPD may be included in educational packets sent home (Garg, Morton, & Heneghan, 2005), but little attention is paid to the preferred learning style of new mothers (Summers & Logsdon, 2005; Wisner, Logsdon, & Shanahan, 2008). Hospital maternity nurses may not feel confident to actively teach mothers about PPD (Logsdon, Pinto Foltz, Scheetz, & Myers, 2010) as few have received formal education related to care of women with PPD. The purposes of this article are to provide guidelines and suggest best practices related to hospital-based care for PPD by hospital-based perinatal nurses; with this information, policies, procedures, and nursing staff educational programs can be implemented to improve nursing care of new mothers. We begin with a discussion of PPD risk factors, provide an overview of depression screening tools and related disorders that may be confused with PPD during screening, outline key points in patient education, and conclude with recommendations for policy and procedures and an example of a family teaching plan.
Risk factors for PPD include stress, low socioeconomic status, low levels of social support, a previous history of depression, and birth complications such as preterm birth that results in separation of mother and baby (Beck, 2001; Logsdon & Davis, 2003; Vigod et al., 2010). Before symptoms are readily identifiable by healthcare professionals, beginning signs of PPD may be present in mothers early in the postpartum period. Screening is the most widely used method for early detection. However, it should be noted that a positive screening result does not always equate to possessing the targeted condition, as screening procedures are not diagnostic. In addition, the value of a nurse's intuition that "something is just not right" cannot be overemphasized.
Research has consistently demonstrated maternal mood in the immediate postpartum period (e.g., first 2 weeks postpartum) is a significant predictor of PPD (Beck, 2001) and confirms the need for heightened awareness in the early postnatal period. In a meta-analysis of 85 studies (Beck, 2002a), "maternity blues" was a significant predictive factor of PPD, further confirming these preceding studies that depressive symptoms in the immediate postpartum period are important.
There is growing evidence to suggest that a single screen for PPD in the early postpartum period has a high false-positive rate (Dennis et al., 2009), indicating that a two-stage process is required to increase screening accuracy. For example, any women who scores positive for depressive symptomatology in the first few days after birth should be screened again to confirm the depressive symptomatology. Although there is no research suggesting the best time to perform the second screen, waiting 2 weeks would be consistent with diagnostic criteria, which suggests the presence of depressive symptoms almost every day for at least a 2-week period. This second screen can be performed over the telephone to decrease resource implications or in community agencies to which the postpartum woman is referred.
The Postpartum Depression Predictors Inventory-Revised (PDPI-R) consists of 13 risk factors related to PPD. The first 10 items are risk factors that can be assessed during pregnancy and comprise the Prenatal Version of the PDPI-R: marital status, socioeconomic status, prenatal depression, prenatal anxiety, unplanned/unwanted pregnancy, history of depression, social support, marital/partner satisfaction, and life stress. After a woman gives birth, the last three predictors (child care stress, infant temperament, and maternity blues) can be assessed. The PDPI-R can be administered via an interview conducted by a clinician (Beck, 2002b) or as a self-report inventory (Beck, Records, & Rice, 2006).
The Postpartum Depression Screening Scale (PDSS) is a 35-item self-report instrument (Beck & Gable, 2005). The scale indicates the severity of PPD symptoms and whether a mother needs to be referred for a diagnostic evaluation. The PDSS consists of seven dimensions or subscales: Sleeping/Eating, Disturbance, Anxiety/Insecurity, Emotional Lability, Mental Confusion, Loss of Self, Guilt/Shame, and Suicidal Thoughts. These individual dimension scores help clinicians to know which symptoms of PPD a mother is struggling with. With a cutoff score of 80, the PDSS achieved a sensitivity = .94 and specificity = .98 for major depression criteria.
One of the most widely used instrument to assess for postpartum depressive symptomatology is the Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-report scale specifically designed to screen for PPD in community samples (Cox, Holden, & Sagovsky, 1987). The items include questions related to maternal feelings during the past 7 days and refer to depressed mood, anhedonia, guilt, anxiety, and suicidal ideation. One advantage of this scale is that it does not include common somatic symptoms such as insomnia and appetite changes, which may occur naturally in postpartum women. Although a 12/13 cutoff is suggestive of major depressive symptomatology, a lower threshold of 9/10 has been recommended for community screening to ensure all potential cases of PPD are identified (Murray & Carothers, 1990). Importantly, researchers have consistently found the EPDS to be (1) convenient to administer (requires little time or special training and can even be done via telephone), (2) inoffensive to women (high acceptability in diverse cultures), (3) readily incorporated into everyday clinical practice, and (4) widely available at no cost.
Since the Andrea Yates' tragedy, PPD has received increased attention from clinicians, researchers, and legislators. PPD, however, is not the only mental disorder that can plague new mothers. It is important to differentiate PPD from these other postpartum disorders so that mothers will not be misdiagnosed and receive inappropriate treatment. Symptoms of the disorders discussed below should result in immediate psychiatric consultation.
Postpartum psychosis can have grave consequences for a mother and her infant, including suicide and infanticide. Symptoms can include hallucinations, delusions, confusion, extreme agitation, rapid mood swings, and inability to sleep or eat. The delusions and hallucinations are perceived as consistent with the mother's reality. She is not distressed by thoughts of harming her infant and can act on these thoughts (Wenzel, 2011). Psychotic mothers frequently believe they need to harm their baby so that the baby can be saved.
This disorder has been called the PPD imposter (Beck & Driscoll, 2006). Hypomanic episodes are key components of this disorder. A hypomanic episode is defined as a distinct period of "persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days" that occurs within 4 weeks after birth (APA, 2000). Common symptoms can include decreased sleep, increased self-esteem, increased talkativeness, and increased goal orientation.
A panic attack is the cardinal symptom of this postpartum anxiety disorder. Panic attacks are distinct periods of intense fear, which may involve symptoms such as sweating, heart palpitations, shortness of breath, chest pain, numbness, dizziness, sense of impending doom, fear of going crazy, and losing control.
In this anxiety disorder mothers experience obsessive thoughts and/or compulsive behaviors. Obsessions are recurrent thoughts or images that are intrusive, such as harming their infant, and can result in distress. Mothers try to remove or stop these images and thoughts but to no avail. Compulsions are repetitive thoughts or actions that mothers perform in response to an obsession to decrease distress or stop a horrible event from occurring (APA, 2000). In obsessive-compulsive disorder (OCD) these intrusive thoughts a mother can have of harming her baby are not consistent with her reality (Wenzel, 2011). She is horrified that she can even have such thoughts and does not want to share them with others. A mother with OCD does realize that her obsessions and/or compulsions are not reasonable. Unlike psychotic mothers, OCD mothers are unlikely to act on these thoughts.
Traumatic childbirth is "an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to the mother or her infant." The birthing woman experiences "intense fear, helplessness, loss of control, and horror" (Beck, 2004, p. 28). Posttraumatic stress disorder (PTSD) is composed of three symptom clusters: (1) reexperiencing the traumatic event through flashbacks and nightmares; (2) avoidance of triggers of the trauma, and (3) hyperarousal, which can include exaggerated startle response, anger, or sleep disturbance (APA, 2000).
A major maternal help-seeking facilitator is education about PPD (Dennis & Chung-Lee, 2006). Further, women feel that any open discussion about PPD may help reduce the stigma associated with this condition and promote help-seeking (Mauthner, 1997).
Some women prefer to obtain health information from Web sites rather than to read printed handouts. Summers and Logsdon (2005) reviewed 34 Web sites on PPD for content, ease of use of technology, and readability. The information was only complete and accurate in 14.7% of the Web sites. All Web sites had reading levels of 8th grade or higher, instead of the recommended reading level of 5th grade or lower to be appropriate for all populations of new mothers (Logsdon & Hutti, 2006). Hospital-based perinatal nurses should recommend Web sites that have been evaluated for accurate content and appropriate reading level (e.g., http://www.MedEdPPD.org). Hospitals with rich information technology resources may want to consider developing an educational program that includes Facebook, text messages, and their own Web site.
Many women with PPD are not identified and do not receive depression treatment. Barriers to treatment can be categorized into personal, family, healthcare provider, healthcare system (Sobey, 2002; Wisner, Parry, & Piontek, 2002), and society/community barriers (Sealy, Fraser, Simpson, Evans, & Hartford, 2009). In their assessment, nurses should identify the barriers that are specific to each woman (e.g., risk factors for PPD, depression screening results, and family and professional barriers in specific community and individualize the teaching plan to overcome these barriers). Discharge education on PPD has been effective in reducing depressive symptoms in at least one research study (Ho et al., 2009).
Women from diverse cultures do not proactively seek help for PPD (Dennis & Chung-Lee, 2006). Many women have difficulty understanding the problems they are experiencing, often assuming their struggles are a normal part of motherhood and reasonable response to adversity (Edge, Baker, & Rogers, 2004). For women who recognize that they are experiencing PPD, many are unwilling or unable to disclose their feelings to partners, family members, friends, and healthcare professionals (Amankwaa, 2003; Mauthner, 1997; Nahas & Amasheh, 1999). Many mothers report not knowing where to obtain assistance or being unaware of treatment possibilities (Dennis & Chung-Lee, 2006). Some mothers consider professional or medical assistance as inappropriate for treating emotional problems (Thome, 2003) and that the role of healthcare professionals is to provide physical care (Parvin, Jones, & Hull, 2004).
The fear of losing one's baby is a major help-seeking barrier (Mauthner, 1999; Shakespeare, Blake, & Garcia, 2003; Templeton, Velleman, Persaud, & Milner, 2003). Shame, stigma, and the fear of being labeled mentally ill are also significant factors in whether women decided to seek or accept help (Dennis & Chung-Lee, 2006). Some depressed mothers refuse to seek treatment due to perceived insufficient time and the inconvenience of attending appointments. In some cultures, depression is a sign of internal weakness and not a legitimate illness. The importance of fulfilling traditional gender roles is also found among some cultures resulting in women not informing anyone about their emotional problems for fear of failing to perform their role as a woman and mother (Parvin et al., 2004). Clinical practice guidelines are available to address PPD education plans in culturally diverse women (Callister, Beckstrand, & Colbert, 2010).
Research suggests that family members are often unable to provide assistance or promote help-seeking due to a lack of understanding about PPD. However, in some cultures family members may actively discourage women from obtaining help, as it is unacceptable to admit to depressive symptoms or discuss such difficulties external to the family context (Dennis & Chung-Lee, 2006). For example, among Arabic women the family is the reference for assistance and mediates between the mother and the outside world (Nahas & Amasheh, 1999). In the Korean culture, having and raising children is a key family function; accordingly, any concern about the mother rapidly mobilizes resources as the whole family works together to resolve the crisis. An attempt should be made to include family in teaching about PPD if appropriate.
Healthcare professionals play a salient role in either promoting help-seeking behaviors or hindering the obtainment of treatment since research suggests that depressed mothers may be high utilizers of health services (Dennis, 2004). Significant PPD treatment barriers include inappropriate assessments paralleled with an insufficient knowledge about PPD (Mauthner, 1997; Thome, 2003). Access to healthcare is a barrier for some women (Amankwaa, 2003). Several qualitative studies suggest that healthcare professionals had a tendency to normalize depressive symptoms and to dismiss them as self-limiting (Mauthner, 1997), while other studies reported that women felt their depressive symptoms were given only cursory attention (Amankwaa, 2003). Not surprisingly, when healthcare professionals minimized a mother's feelings and symptoms she became reluctant to pursue treatment (Edge et al., 2004). A U.S. qualitative study found that after depressed mothers made the decision to seek professional help, they felt disappointment, frustration, humiliation, and anger due to their interactions with healthcare professionals (Beck, 1993). In another qualitative study, Australian mothers felt that their physicians displayed disinterest and "patronizing attitudes," which increased their feelings of worthlessness and guilt in their inability to cope. They also described dissatisfaction with their hospital doctors and family physicians claiming they had limited time for counseling and preferred to prescribe medication that alleviated symptoms but reinforced feelings of inadequacy.
Comparably, women in the United Kingdom (UK) complained that (a) there was insufficient time in their consultations with their general practitioner, (b) their problems were not taken seriously, (c) they were not examined properly, and (d) they were not referred to secondary services as necessary (Parvin et al., 2004). Lack of language support services further contributed to some of these women not seeking help. Language barriers were also an obstacle for UK women in Black and minority ethnic communities (Templeton et al., 2003).
Women need individualized care from healthcare providers that is nurturing, identifies their risk factors for PPD, and gives them the tools and resources to obtain healthcare that they need after hospital discharge. Hospital-based perinatal nurses are the key members of the healthcare team to fulfill these roles and to prepare women to overcome barriers that they will likely encounter.
Women should be encouraged to take care of themselves by eating well-balanced diets, drinking a lot of water, and resting as much as possible. Fatigue has been found to exacerbate PPD (Bozoky & Corwin, 2002). National groups such as Postpartum Support International and LaLeche League are invaluable sources of accurate information and support. For women with PPD, a clinical disorder, this support will not be sufficient and they will need to seek treatment.
Hospital-based perinatal nurses should be knowledgeable about the mental healthcare that is available in the community for women with PPD. Case managers and social workers frequently can provide this information. Antidepressant therapy and counseling are generally effective for treatment of PPD, but not all mental health providers can offer both. For example, clinical psychologists and psychiatric social workers generally are unable to prescribe medications. Psychiatrists and advanced practice nurses may prescribe and monitor medications but may not offer counseling.
Each community will differ in terms of healthcare providers who have expertise and are available to treat women for PPD. In the United States, the rules for referral to specialty practices (mental health) vary by the source of reimbursement. Some insurance plans require that primary care providers must refer woman to mental health providers. Other plans allow women to self-select into mental health providers within the network system. For low-income women without healthcare insurance, a Medicaid application for mental health services is required. In some communities, programs for low-income women such as Healthy Start provide mental health services in the woman's home or neighborhood as part of overall services provided. Table 1 provides an example of a PPD policy and Table 2 is a teaching plan.
Hospital-based perinatal nurses need to launch new mothers from the hospital into the community. With education new mothers will be prepared for self-monitoring for symptoms of depression and know what actions to take if they experience depressive symptoms. Some hospital-based nurses may decide to go further to promote the mental health of new mothers. In some communities, hospital nurses have been involved with community-wide task forces to educate healthcare providers about PPD, to help identify women who might be affected by PPD, and to develop interventions to help women to adjust to the role of mother (Straub et al., 1998; Wroblewski & Tallon, 2004). Internationally, nurses screen women for PPD and offer counseling to those with high scores (Cowley, Caan, Dowling, & Weir, 2007), and women in the United States find screening and counseling by nurses to be acceptable (Segre, O'Hara, Arndt, & Beck, 2010). Perinatal nurses who do not feel comfortable with identifying risk factors for depression, conducting depression screening, or preparing the new mother for depression care in the community should seek professional development opportunities. Although the Registered Nurses' Association of Ontario (2005) previously published a best practices guideline entitled Interventions for Postpartum Depression, the practice recommendations did not focus on the first few days postpartum or nursing care while the woman was hospitalized. Thus, our recommendations for nursing practice of hospital-based perinatal nurses go beyond previous published guidelines.
Summary of latest evidence, tools, resources and for consumers and providers
Postpartum Support International Web site
Charitable trust in New Zealand whose mission is to provide support to mothers who have suffered through traumatic childbirth and to educate healthcare professionals and the lay public on PTSD due to traumatic childbirth
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