Postpartum Depression

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Postpartum Depression
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Burden

• Approximately 500,000 of the 4 million American
  women giving birth each year experience
  postpartum depression (PPD)
• PPD is under detected and under treated
• Many barriers exist to detection and treatment

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Burden

• In the United States, depression is the leading
  cause of non-obstetric hospitalizations among
  women aged 18-44.
• In the year 2000, 205,000 women aged 18-44 were
  discharged with a diagnosis of depression.
• Seven percent of all hospitalizations among young
  women were for depression.

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Perinatal Psychological Disorders

• The Blues
• Postpartum Depression
• Postpartum Psychosis

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Perinatal Depression Prevalence
Pregnancy Postpartum
Kumar Robeson 1984 13.4 14.9
Watson Elliott 1984 9.4 12.0
OHara et al., 1984 9.0 12.0
Cooper et al. 1988 6.0 8.7
OHara et al., 1990 7.7 10.4
Evans et al., 2001 13.6 9.2
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Postpartum Blues

• Most common, 50-80
• Relatively brief
• Few hours to several days
• Onset usually in first week to 10 days PP
• Typically remit spontaneously
• May represent the initial stages of PPD/PPP

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Typical Blues Symptoms

• Low Mood
• Mood Lability
• Insomnia

• Anxiety
• Crying
• Irritability

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Postpartum Psychosis

• Rare 1/1000 postpartum women
• Hallucinations and/or Delusions
• Risk Factors
• History Bipolar Affective Disorder/Psychosis
• Family history of psychosis
• Having first child
• Aggressive intervention absolutely necessary

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Postpartum Psychosis

• Usually Begins Within 90 Days Postpartum
• Length is Quite Variable
• Prevalence 1/500 to 1/1000
• Family history of bipolar disorder 33/1000
• Family history of postpartum psychosis 22/1000
• Personal history bipolar disorder 1/2
• Sequelae Future Postpartum Psychosis

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Postpartum Depression

• Not as mild or transient as the blues
• Not as severely disorienting as psychosis
• Range of severity
• Often undetected

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Symptoms of Major Depression

• Depressed Mood
• Decreased or increased appetite with or without
  weight changes
• Insomnia or Hypersomnia
• Low energy/fatigue

• Loss of Interest or Pleasure
• Psychomotor agitation or retardation
• Feelings of worthlessness or guilt
• Concentration or problems making decisions
• Suicidal thoughts

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Postpartum Depression Risk Factors

• Lower SES/unemployment
• Past depression or anxiety disorder
• Past history of alcohol abuse
• Stressful life-events
• Poor marital relationship
• Inadequate social support
• Child-care related stressors
• African American ethnicity

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Effects of Perinatal DepressionAn Overview

• Depression negatively effects
• Mothers ability to mother
• Motherinfant relationship
• Emotional and cognitive development of the child

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Postpartum DepressionMaternal Attitudes

• Infants perceived to be more bothersome
• Make harsh judgments of their infants
• Feelings of guilt, resentment, and ambivalence
  toward child
• Loss of affection toward child

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Postpartum DepressionMaternal Behaviors

• Gaze less at their infants
• Take longer to respond to infants utterances
• Show fewer positive facial expressions
• Lack awareness of their infants
• Increased risk for abusing children

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Postpartum DepressionMaternal Interactions

• Flat affect, low activity level, and lack of
  contingent responding
• OR
• Alternating disengagement and intrusiveness

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Effects of Maternal Depression

• Infants- lowered Brazelton scores, frequent
  looking away, fussiness
• Toddlers- poorer cognitive development, insecure
  attachment
• Children- cognitive development of low ses boys
• Adolescents-higher cortisol levels

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What Can Be Done?

• ROUTINE SCREENING
• REFERRAL TO TREATMENT

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Why Screen for Perinatal Depression?

• Which Mother is Depressed?
• You cant tell by looking.
• Perinatal
• Foundation
• Madison, WI
• June 2003

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Why Screen for Perinatal Depression?

• Screening is associated with increased detection
• Georgiopoulos et al., 1999, 2001
• EPDS screening resulted in increased chart-based
  diagnosis of PPD from 3.7 to 10.7 after one
  year of universal screening Rochester, MN

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Barriers to Detection

• Women will present themselves as well as they are
  ashamed and embarrassed to admit that they are
  not feeling happy
• Media images contribute to this phenomena

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Reality for New Mothers

• Tired
• Alone at home
• Lots of care for the baby
• Often there are other young children who need
  care
• No time for self (cant even fit in a shower)
• Complete loss of control over time

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Barriers to Detection (cont)

• Lack of knowledge about range of postpartum
  disorders
• They dont want to be identified with Andrea
  Yeats
• They may also genuinely feel better when you see
  them (they got dressed, out of house, lots of
  attention, not isolated)

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I Was Depressed But Didnt Know It.

• Commonalities in the Experience of Non-depressed
  and Depressed Pregnant and Postpartum Women
• Changes in appetite
• Changes in weight
• Sleep disruption/insomnia
• Fatigue/low energy
• Changes in libido

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My Patient is Poor, Not Depressed!

• Myth
• Not all women with limited economic resources are
  depressed
• Depression can make it difficult for all women to
  cope

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What is Required for Effective Screening?

• A screening tool
• A schedule for screening
• A plan for implementation
• Who does the screening?
• Where is it done?
• How is the primary care health provider informed
  of the results?

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What is Required for Effective Screening?

• What to do with a positive screen?
• Implement or refer for diagnostic assessment
• Arrange for treatment
• Antidepressant medication
• Psychotherapy (individual or group)
• Arrange for follow-up

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Screening

• Who?
• Primary health care professionals
• Physicians/Nurses Obstetrics, Family Practice,
  Pediatrics
• Case Managers/Social Workers

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Screening How?

• Two questions
• Beck Depression Inventory
• Postpartum Depression Assessment Scale
• Inventory to Diagnose Depression
• Edinburgh Postnatal Depression Scale

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What is the Edinburgh Postnatal Depression Scale
(EPDS)?

• John Cox, Jenifer Holden Ruth Sagovsky
• 10 item depression screening tool (reliable and
  valid)
• Simple to complete
• Acceptable to mothers and health workers

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Treatment

• Psychotherapy
• Medication
• Nurse care (based on model of care from the U.K-
  a thinking out-of-the box solution

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Health Visitors in the U.K.

• The most accessible health professionals in the
  community
• Public health nurses providing comprehensive
  family care
• Provide depression screening and counseling to
  new mothers

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Health Visitor Training

• Registered Nurse
• Specialized health visitor training (about 1 year
  full-time)

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Health Visitor Activities

• Home visit
• Infants physical well being
• Infants physical well being
• Depression screening
• Depression treatment for mild to moderate
  depression

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Listening Visits A Treatment Model from the U.K.

• Counseling Stages
• Stage 1 Relationship building
• Stage 2 Exploration
• Stage 3 Action problem solving
• Emphasizes the use of reflective listening

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Do Listening Visits Work?

• Yes! Listening visits are associated with lower
  EPDS scores.
• Elliott, Gerrard, Ashton, Cox (2001)
• Cooper and Murray (1997)
• Wickberg and Hwang (1996)
• Holden Cox Sagovsky (1989)

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Do Listening Visits Work?

• It helped just knowing someone was thereto sort
  of catch me if I fell.
• No one tells you about postnatal depression
  before you have the baby. When it happens you
  feel guilty, you think its somehow your fault.
  You get frightened and think theyll lock you
  away.

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Do Listening Visits Work?

• If someone had told me that a professional could
  come every week and let me talk for half and
  hour, and that I would end up a healed person, I
  wouldnt have believed it. It sounds like
  nonsense, but its true.

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Do Listening Visits Work?

• I wouldnt have told anyone how I felt unless I
  had been asked. Id been bottling it all up like
  a schoolgirl, dont speak until youre spoke to.
  But I could get everything in the open with her,
  and after a few weeks I really felt I was getting
  rid of the depression. It was actually coming
  away from me.

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Nurses Views of Providing Supportive Care
Statewide Survey

• Survey Question
• Nurse delivered counseling with mildly depressed
  women is a good idea (assuming nurses are
  provided with extra time in the current
  workload). (N519)

• Results
• Strongly agree 45.7
• Agree 47.8
• Disagree 3.5
• Strongly disagree .2
• Missing .2

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Womens Views of Nurses Providing Supportive Care

• Survey Question
• If counseling by nurses were available, for
  mildly depressed pregnant or postpartum women,
  would you be willing to see her for treatment?
  (N510)

• Preliminary Results
• Yes 67.5
• Maybe or
• Uncertain 28.6
• No 2.5
• Undetermined 1.4

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Whats Next?

• Healthy Start Project
• Primary Health Care

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