A Thief that Steals
Motherhood
-Cheryl Beck
CAAP 6613 Presentation
Carmen Barrack
POSTPARTUM DEPRESSION
According to Statistics Canada (2005) there
were:
•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”,
2010)
•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
POSTPARTUM DEPRESSION
Alone and Adrift...
http://www.youtube.com/watch?v=Sp7eyIR0Dw4&feature=related
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
postpartum
 Lasts longer than 2 weeks
 Feelings are more extreme
Depression during pregnancy & postpartum. (2010). Postpartum Support International. Retrieved from:
http://postpartum.net.gravitatehosting.com/Get-the-Facts/Depression-During-Pregnancy-Postpartum.aspx
-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
http://www.youtube.com/watch?v=odRwFfWLml8&feature=related
Depression during pregnancy & postpartum. (2010). Postpartum Support International. Retrieved from:
http://postpartum.net.gravitatehosting.com/Get-the-Facts/Depression-During-Pregnancy-Postpartum.aspx
1) Past history of depression, PPD (if she has children),
and/or anxiety
-Has she been under a doctors care for same, i.e.
Medication
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
Short-Term
Long-Term
 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,
2010)
 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
PPD?
2. When are the
Assessments being
done?
3. Where are the
Assessments taking
place?
4. What Assessment
procedures and
screening tools are
being used?
 Lack of Standardized
Guidelines in Alberta and
Canada
What role should counsellors/psychologists play in the
screening process?
POSTPARTUM DEPRESSION
Reduce
the Stigma
through
Education
1.
Educate new mothers
about the importance of
their mental health.
Conversational.
Normalizing. (Beck 2006;Vik,
Aass, Britt & Hafting, 2009)
2.
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
resources
4. Provide written
information and contact
details
3.
Procedural Suggestions for Lois Hole Hospital
Counselling Department: Approach &
Thoroughness
Pacific post partum support society. (2010). Retrieved from: http://www.postpartum.org/Wheel%202009.pdf
When?
Where?
 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
positive
predictive
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,
Purchased
2. Available in 2
Languages (Hewitt
2000)
(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.,
2010)
Beck Depression Inventory -II
1. Top 10 Psychological
Test in Terms of Use
(Santor et al., as cited in Anthony & Barlow,
2010)
2. Lends to a clinical
diagnosis
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
PPD
2. Must be
Purchased
3. Available in 2
Languages
(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
http://www.mededppd.org/care_pathways.asp?source=banner
Care pathways. (2009). MediSpin Inc. Retrieved from: www.mededppd.org
Sample Framework
Conclusion
1.
2.
3.
4.
5.
6.
7.
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,
PDSS.
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
diagnosis.
Nonjudgmental, multimodal
assessments that initiate
dialogue and build/strengthen
rapport necessary throughout
the process!
INFORMED CONSENT!
http://www.youtube.com/watch?v=NaVBwp0xHEo
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 &
outcomes
Screening Tool Options: What is your vote?
References
Antony, M. M., & Barlow, D. H. (2010). Handbook of assessment and treatment planning for psychological disorders (2nd ed.). New York:
Guilford Press.
Barnes, D. L. (2006). Postpartum depression: Its impact on couples and marital satisfaction. Journal of Systemic Therapies, 25, 25-42.
Retrieved from http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/jnst.htm&dir=periodicals/per_psych
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory manual (2nd ed.). San Antonio, TX: Psychological
Corporation.
Beck, C. T. (2006). Postpartum depression: It isn’t just the blues. American Journal of Nursing, 106, 40-50. Retrieved from
http://www.nursingcenter.com
Beck, C. T., & Gable, R. (2000). Postpartum depression screening scale: Development and psychometric testing. Nursing Research, 49, 272282. Retrieved from http://journals.lww.com/nursingresearchonline/pages/default.aspx
Beck, C. T., & Gable, R. (2001). Comparative analysis of the performance of postpartum depression screening scale with two other depression
instruments. Nursing Research, 50, 242-249. Retrieved from http://journals.lww.com/nursingresearchonline/pages/default.aspx
Births and total fertility rates by territory and province. Statistics Canada (2005). Retrieved from:
http://www40.statcan.ca/l01/cst01/HLTH85A-eng.htm
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
Chaudron, L. H., Szilagyi, P. G., Tang, W., Anson, E., Talbot, N. L., Wadkins, H. I. M.,...Wisner, L. (2010). Accuracy of depression tools for
identifying postpartum depression among urban mothers. Pediatrics, 125, 609-617. doi: 10.1542/peds.2008-3261
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression
Scale. The British Journal of Psychiatry, 150, 782-786. doi: 10.1192/bjp.150.6.782
Dennis, C.-L. (2004). Can we identify mothers at risk for postpartum depression in the immediate postpartum period using the Edinburgh
postnatal depression scale?. Journal of Affective Disorders, 78, 161-169. doi: 10.1016/S0165-0327(02)00299-9
Gjerdingen, D. K. & Yawn, B. P. (2007). Postpartum depression screening: Importance, methods, barriers, and recommendations for practice.
Journal of the American Boar of Family Medicine, 20, 280-288. doi: 10.3122/jabfm2007.03.060171
Hewitt, C. E., Gilbody, S. M., Mann, R., & Brealey, S. (2010). Instruments to identify post-natal depression: Which methods have been the most
extensively validated, in what setting and in which language?. International Journal of Psychiatry in Clinical Practice, 14, 72-76.
doi: 10.3109/13651500903198020
References
Hood, A. B., & Johnson, R. W. (2007). Assessment in counseling: A guide to the use of psychological assessment procedures (4th ed.).
Alexandria, VA: American Counseling Association.
Lung, F.-W., & Shu, B.-C., Chiang, T.-L., & Lin, S.-J. (2009). Parental mental health, education, age at childbirth and child development
from six to 18 months. Acta Paediatrica, 98, 834-841. doi: 10.1111/j.1651-2227.2008.01166x
McCrae, R. R., Costa, P. T., Ostendorf, F., Angleitner, A., Hrebickova, M., Avia, M. D., . . . Smith, P. B. (2000). Nature over nurture:
Temperament, personality, and life span development. Journal of Personality and Social Psychology, 78, 173-186. doi:
10.1037/0022-3514.78.1.173
Mancini, F., Carlson, C., & Albers, L. (2007). Use of the postpartum depression screening scale in a collaborative obstetrics practice. Journal
of Midwifery and Women’s Health, 52, 429-434. doi: 10.1016/j.jmwh.2007.03.007
Misri, S. & Kendrick, K. (2008). Perinatal depression, fetal bonding, and mother-child attachment: A review of the literature. Current
Pediatric Reviews, 4, 66-70. Retrieved from http://www.benthamscience.com/index.htm
Mitchell, A. J., & Coyne, J. C. (2007). Do ultra-short screening instruments accurately detect depression in primary care?: A pooled analysis
and meta-analysis of 22 studies. British Journal of General Practice, 57, 144-151. Retrieved from
http://www.ingentaconnect.com/content/rcgp/bjgp
Petterson, S. M., & Albers, A. B. (2001). Effects of poverty and maternal depression on early child development. Child Development, 72,
1794-1813. Retrieved from http://www.wiley.com/bw/journal.asp?ref=0009-3920
Stone, S. (2010). Postpartum progress. Retrieved from:
http://www.postpartumprogress.com/weblog/2010/02/how-dsmv-language-on-postpartum-depression-may-affect-insurancecoverage-research-funding.html
US Department of Health and Human Services (2000), Healthy People 2010. With understanding and improving health and objectives for
improving health. Retrieved from http://www.cdc.gov/nchs/data/hp2000/hp2k01.pdf
Vik, K., Aass, I. M., Willumsen, A. B., & Hafting, M. (2009). “It’s about focusing on the mother’s mental health”: Screening for postnatal
depression seen from the health visitors’ perspective – a qualitative study. Scandinavian Journal of Public Health, 37, 239-235.
doi: 10.1177/1403494808100275
References
Evans, G. W., & Kim, P. (2007). Childhood poverty and health. Psychological Science, 18, 953-957. Retrieved from
http://www.psychologicalscience.org/index.php/publications/journals/psychological_science
Hay, D. F., Pawlby, S., Waters, C. S., Perra, O., & Sharp, D. (2010). Mothers’ antenatal depression and their children’s antisocial outcomes. Child
Development, 81, 149-165. Retrieved from http://www.wiley.com/bw/journal.asp?ref=0009-3920