A Thief that Steals
-Cheryl Beck
CAAP 6613 Presentation
Carmen Barrack
According to Statistics Canada (2005) there
•447, 485 pregnant women in Canada
•54, 646 pregnant women in Alberta
Boyd, Le and Somberg (2005) state
researchers use the rate of 13% to calculate
the number of women who suffer with
postpartum depression. This equates to:
•58,173 women in Canada
•7,103 women in Alberta
50% of those who experience postpartum
depression will go undiagnosed and
needlessly suffer alone (“Healthy People”,
•Close to 30,000 women in Canada
•Over 3,500 women in Alberta
1. Lois Hole Hospital for Women Case Study
-Move Toward Early Universal Screening
2. What is Postpartum Depression?
-Baby Blues or Postpartum Depression?
-Risk Factors
-Short and Long Term Consequences
3. Current Assessment Issues in Screening for PPD
- DSM-IV-TR Diagnosis Complications
-Lack of Rigorous Guidelines – who, what, where, when???
4. Suggested Assessment Framework for PPD Screening
-Reduce the Stigma through Education
-Multi-modal Understanding of PPD
-Formal Assessment Options
-Integrative Approach
-Conclusion: Working Together for a New Mother’s Well-Being
5. Questions and Discussion
Alone and Adrift...
What is Postpartum Depression?
The Baby Blues are:
 A Normal Biological Response
 Early Onset, usually days after
giving birth
 Lasts approximately 2 weeks
 Feeling overwhelmed, tired and
sad due to the demands of their
new role of being a mother
PPD is:
 A Mood Disorder
 Onset can be first year
 Lasts longer than 2 weeks
 Feelings are more extreme
Depression during pregnancy & postpartum. (2010). Postpartum Support International. Retrieved from:
-Change in Appetite
-Anger, frustration, irritability
-Can’t concentrate
-Excessive crying
-Feeling like they can’t cope
-Loss of interest in activities
-Loss of energy
-Negative thoughts about baby or over concern
-Feeling like they could harm baby or oneself
Depression during pregnancy & postpartum. (2010). Postpartum Support International. Retrieved from:
1) Past history of depression, PPD (if she has children),
and/or anxiety
-Has she been under a doctors care for same, i.e.
2) Presence of an identifiable support system. Single
mothers are twice as likely to develop PPD.
3) Was the birth "traumatic" versus very difficult (as is
often viewed by new moms)
4) Were there any previous pregnancy losses
D. Boddington (personal communication, July 4, 2011)
1) Socioeconomic Status – women in poverty are exposed to
additional social and physical stressors increasing the
likelihood, intensity and length of PPD (Evans & Kim, 2007; Petterson &
Albers, 2001)
2) Maternal age and education (Lung, Shu, Chiang and Lin, 2009)
3) Breastfeeding (Mancini, Carlson & Albers, 2007)
4) Life Stresses – financial, marital, losses
5) Pre-existing Medical Conditions – thyroid, diabetes
6) Infertility Issues or Multiples (“Depression during pregnancy”, 2010)
7) Sick or Difficult Baby (McCrae et al., 2000)
Potential Consequences of PPD
 Insecure attachment and
 Developmental Impairments:
altered brain development in
baby (Dawson et al., 1999; Misri &
Emotional, Cognitive and
Behavioural (Evans & Kim, 2007; Hay,
Kendrick, 2008)
Pawlby, Perra & Sharp, 2010; Petterson &
Albers, 2001)
 Mother’s quality of life and
well-being are diminished
 Strain on support network
(Barnes, 2006)
Turning our
Attention to Current
Assessment Issues
1. Postpartum Depression is
classified as 296.90 –
Mood Disorder Not
Otherwise Specified
2. There is a postpartum
onset specifier with some
common symptoms
listed, but...
3. Must be within 4 weeks
of delivery
4. DSM-V may increase
onset to 6 months (Stone,
 No Differential Diagnosis for
Postpartum Depression in
DSM-IV-TR (2000).
Does this affect assessment procedures? Diagnosis? Will the
time change help? Is a differential diagnosis needed?
Image Retrieved from: http://www.bing.com/images/search?q=DSM-IV-TR+(2000)+picture&view=detail&id=B3AA85599D9C9E944ECF664C3F0FFCA93888474E&first=0&qpvt=DSM-IVTR+(2000)+picture&FORM=IDFRIR
Turning our
Attention to Current
Assessment Issues
1. Who is Assessing for
2. When are the
Assessments being
3. Where are the
Assessments taking
4. What Assessment
procedures and
screening tools are
being used?
 Lack of Standardized
Guidelines in Alberta and
What role should counsellors/psychologists play in the
screening process?
the Stigma
Educate new mothers
about the importance of
their mental health.
Normalizing. (Beck 2006;Vik,
Aass, Britt & Hafting, 2009)
Informal multimodal
assessment to determine
risk and take preventive
action. In private (Cox,
Holden & Sagovsky, 1987)
Educate mother and
supporters about PPD:
prevalence, symptoms,
onset, community
4. Provide written
information and contact
Procedural Suggestions for Lois Hole Hospital
Counselling Department: Approach &
Pacific post partum support society. (2010). Retrieved from: http://www.postpartum.org/Wheel%202009.pdf
 For mothers informally
determined to be at risk,
follow-up screening
appointments should be
made with the hospital
counselling center
within 2-4 weeks of a
baby’s birth at which
time a formal assessment
is conducted.
Assess Early!!!
By Who?
 To screen as many
mothers as possible,
formal assessment tools
could be administered
during routine
postpartum visits
(doctor, nurse?) or at
baby vaccination visits.
Assess Every Mother!!!
Which option is better?
Consider training, time and referral
system to increase compliance &
outcomes (Gjerdingen & Yawn, 2007; Mansini,
Carlson & Albers, 2007;Vik, Aass, Britt & Hafting, 2009)
What Formal Screening Tools Are Available? Most Suitable?
1. Most Validated
Screening Tool -53
studies, during
pregnancy, for fathers
(Hewitt, Gilbody, Mann and Brealey, 2010)
2. Available in 20
Languages (Hewitt et al., 2010)
3. Free, Downloadable
4. Short Screening Tool
(Mitchell & Coyne, 2007)
5. Easy to Administer,
Score (Cox et al., 1987)
6. Readability (Dennis, 2004)
1. Cut-Off Scores
(Chaudron et al., 2010)
2. No Irritability
Measure (Beck &
Gable, 2000)
3. Greatest range
in sensitivity,
specificity and
value (Boyd et al., 2005)
Postpartum Depression Screening Scale
1. Overall sensitivity,
1. Must be
specificity & PPV
greatest (Boyd et al., 2005)
2. New: only test to
include cardinal
symptoms of
irritability, anxiety,
insomnia, agitation,
confusion (Beck & Gable, 2001)
3. Easy to Administer,
Score (Beck & Gable, 2000)
4. Readability (Beck & Gable,
2. Available in 2
Languages (Hewitt
(Beck & Gable, 2000)
Published by: Western Psychological Services
Retrieved from: http://portal.wpspublish.com/
et al., 2010)
3. 35 Questions
4. Not greatly
studied (Hewitt et al.,
Beck Depression Inventory -II
1. Top 10 Psychological
Test in Terms of Use
(Santor et al., as cited in Anthony & Barlow,
2. Lends to a clinical
3. Strongest Specificity
(Boyd et al., 2005)
4. Easy to Administer,
Score (Beck et al., 1996)
5. Readability (Beck et al., 1996)
6. Can be used with
clients as young as 13
yrs (Beck et al., 1996)
1. Not specific to
2. Must be
3. Available in 2
(Hewitt et al., 2010)
Comparing Psychometrics
To select a formal screening tool for a
universal program, one should consider
accuracy, clinical-effectiveness, cost and
acceptability (Hewitt et al., 2010).
All three tools can successfully (AUC
> 0.8) detect women with postpartum
depression; no significant difference
in test accuracy (Chaudron et al., 2010).
What is your vote?
Boyd, R. C., Le, H. N., & Somberg, R. (2005). Review of screening instruments for postpartum depression. Archives of Women’s Mental Health, 8, 141-153. doi: 10.1007/s00737-005-0096-6
Combining Professional Judgement & a Formal Testing Tool to Screen
for PPD
Care pathways. (2009). MediSpin Inc. Retrieved from: www.mededppd.org
Sample Framework
Mental health professional
perform universal informal
assessment (questions) with
every new mom in the hospital.
Formal assessment screening
tool(s) administered early by
counselling professionals for
those deemed at-risk. If clinical
diagnosis needed, BDI-II. If not,
Formal assessment screening
tool administered by a nurse at
either public health clinic or
doctor’s office for general
population. EPDS suggested.
Referral system in place to send
mothers with possible PDD later onset or previously missed.
Screening is not diagnosis.
SCID is required for a final
Nonjudgmental, multimodal
assessments that initiate
dialogue and build/strengthen
rapport necessary throughout
the process!
Questions to Discuss
DSM-IV-TR (2000) Issue:
Does this affect assessment procedures? Diagnosis? Will the time change
help? Is a differential diagnosis needed?
Lack of Guidelines Issue:
What role should counsellors/psychologists play in the screening process?
Thoughts about Initial Informal In-Hospital Assessment Procedure:
Procedural Suggestions for Lois Hole Hospital Counselling Department:
Approach & Thoroughness
Doctors Office or Public Health Clinic: Which option is better?
Consider training, time and referral system to increase compliance &
Screening Tool Options: What is your vote?
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Postpartum depression: The Thief that Steals