Running Head: POSTPARTUM DEPRESSION
Postpartum Depression
Courtney Masse
University of New Hampshire
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“I don’t know why I feel this way. I have a new baby, and I love my family. I should be
happy! I feel tired, sad, and really don’t have any interest in being with my baby. I just feel
guilty, and I don’t get it! Why am I feeling so down? What’s wrong with me?” These may be
questions that many nurses will face in the clinical setting when dealing with female patients
whom have recently given birth. Although these questions are most likely a sign of the more
frequently identified “baby blues,” which can affect up to 80% of new mothers, the nurse should
always assess for clinical symptoms, which present themselves similarly, but could be indicative
of the more complicated and threatening disorder called postpartum depression.
Postpartum Depression
The event of childbirth can affect a woman both physiologically and psychologically.
Postpartum depression is a mental disorder and major form of depression that is triggered by the
event of childbirth. It is estimated that about 13 percent of new mothers experience this type of
depression (Dennis, 2008). Research suggests that this disorder may surface from factors such as
hormonal changes during and after childbirth, situational risks causing stress, and life stresses
such as work, relationships, and other responsibilities (Mental Health America, 2010). When a
woman is experiencing postpartum depression, she may experience emotional, behavioral, and
physical symptoms such as tearfulness, mood swings, despondency, feelings of inadequacy,
inability to cope with the care of the baby, and increasing guilt about the birth and performance
as a mother (Ugarriza et al. 2007). Most mothers who develop this psychological disorder suffer
in fear, silence, and confusion because of the fact that postpartum depression is not appropriately
recognized and treated worldwide (Beck & Gable, 2000).
Within my personal clinical practice, I have not yet seen a woman with diagnosed
postpartum depression; however, I have seen several women with established baby blues, which
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can later evolve into the more severe postpartum depression. Among the women that I have seen
with this condition, they all present with similar symptoms. They are not interested in holding
their newborn baby, seem to be somewhat sad and set back, rarely offering a word to the
conversation within the room, and express many symptoms of hopelessness. Often times the
physician overlooked these symptoms and reasoned to say that these symptoms are just a normal
reaction from a mother who has just gone through labor and is tired. However, this is not always
the case if these symptoms last for more than a few days. The physician should assess and
address the symptoms to make sure that the woman is not in fact experiencing postpartum
depression, as this could have detrimental effects on both the mother and newborn baby.
Before initiating research I have several thoughts and hypotheses about the information
that I may encounter. I think that most websites, journals, and articles will agree and tell me that
prevention and social support are key. I also think that many doctors will use pharmacological
treatment when a form of psychotherapy and social support are not treating the condition
effectively. In my opinion, I also feel as though doctors can sometimes jump to quickly to
medications, however, which can lead to drug addiction and dependence if not done carefully.
This issue and the issues surrounding the condition are in need of research to identify which
methods are best for prevention and treatment.
Clinical Implications
Preventing postpartum depression is of clinical importance because not only will it
benefit the mother during her postpartum recovery, it will generate the possibility for more
positive long-term outcomes for both the mother and baby. Mother’s who experience PPD are
less likely to seek treatment may neglect self-care. According to and article written by Freeman
et al. (2005) in the Journal of Women’s Health, infants of mothers who have suffered postpartum
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depressive episodes are more likely to develop insecure attachments and behavioral problems. It
also states that mothers with PPD are less likely to engage in preventive health measures for their
babies, such as regular use of a car seats and the covering of electrical outlets. Consequently, the
detection of PPD has extensive consequences for the well-being of children and can be
considered an important concern in the pediatric clinical setting. (Freeman et al. 2005). Several
studies have also reported that the more depressed a new mother is, the greater the delay in the
infant’s development. A new mother’s attention to her newborn is particularly important
immediately following birth because the first year of life is a critical time in cognitive
development (Mental Health America 2010). Research also indicates that women who
experience PPD are less likely than women who do not develop the condition to breastfeed, play
and talk with their newborns and agree with immunizations and well-baby visits (Mclean et al.
2006).
It is important that nurses be educated on the risk factors that may be associated with
higher rates of postpartum depression. According to one research article, identified risk factors
for PPD include a prior history of a mood disorder, especially a previous episode of PPD, a
family history of depression, negative life events, inadequate social supports, and marital discord
(Freeman et al. 2005). One study found that PPD can also be associated with cigarette smoking,
which will increase any person’s risk for developing depression (Freeman et al. 2005).Therefore,
if a woman possesses any of these risk factors she should be provided with extra social support
and should take any and all preventative measures to decrease her chances of developing post
partum depression. In order to take preventative measures nurses also must become educated on
which show the most benefits and which may not be as effective. Current practice focuses on
preventing PPD rather than letting it develop, where it then can be treated with psychotherapy
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and medication. If the condition is prevented, than these types of treatments will not have to be
initiated. This is logical reasoning and is best practice, but discovering the best form of
prevention is the goal of researching this topic. One study that looks at home-based interventions
found that even though 84% of family nurse practitioners have seen at least one postpartum
woman yearly, 42% never screened for PPD in any way. The study says that most family nurse
practitioners follow clinical guidelines, but no guideline exists to address postpartum depression
specifically (Goldsmith 2007). This issue should be addressed, because as stated previously, this
condition is all too often overlooked and it can create long term effects. Whether practice should
be changed or not will be discussed later in the paper, however prevention does seem to be best
practice and does not seem to pose any threats or harm to the patient. Further discussion will
analyze this and prove which methods are most effective.
Clinical Question
After researching the many ways to treat postpartum depression, including both
psychotherapy and pharmacological treatment, it is evident that the best way to treat this
condition is to promote prevention. Preventing the illness from occurring is the first step in
reducing he incidence of this overlooked, and hopefully, in theory, this will promote optimal
outcomes in both the mother and child. Because of this I focused my research on prevention
methods for postpartum depression and decided to ask the following PICO question. In women
who are in any stage of pregnancy, are home-based interventions, maternal education, or the use
of screening tools more effective in preventing and treating postpartum depression? Prevention
can be measured by calculating the percent of incidence of postpartum depression within a
population of new mothers. A decrease in incidence will indicate that the intervention is
effective. With the use of research articles and current studies the answer to this question can be
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found.
Research and Studies
To extensively examine the current research and evidence that can be found in nursing
and medical literature, I conducted my research using several different resources. Firstly, to
decide on my topic to be appraised I researched current issues that could be related to maternal
nursing. I focused my interest on women who have just given birth and complications that can be
associated with the postpartum period. To find general information on maternal issues related to
childbirth I searched the UNH library catalog for books and journals that could be found within
the library. Upon reading several different articles and textbooks, I decided to focus my attention
on postpartum depression, as it seemed to be underrepresented and under treated in the clinical
setting.
The most prominent difficulty that I had related to my search was figuring out the
question I wanted to ask about the clinical relevance and nursing implications associated with
postpartum depression. I knew that I wanted to find current research on the disorder but could
not figure out which direction I wanted to direct my question. However, after reading several
articles and websites I found that there are several different options for health care providers to
prevent and treat PPD. With the discovery of this information I decided to research which
method would be the best so that in future practice, this method can be incorporated to provided
evidence based practice.
To start my search for articles on PPD, I first visited the Diamond Library website where
I found several databases including CINAHL, Cochrane, PubMed, and Medline. The two
databases that I primarily used to find research articles on postpartum depression were CINAHL
and Cochrane. Within these databases I searched key words such as “postpartum depression,”
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“treatment,” “prevention,” and “complications.” After using these key words I looked through
each of the suggested articles given and read the abstract to determine whether or not they were
relevant to my research question. I limited my search to research articles that had linked full text
and tried to exclude any article that were not from at least the year 2000. With the exception of
one article which seemed too relevant to exclude, all of the articles I chose fit this description
and were written after the year 2000. This ensure somewhat current information and attempts to
exclude old information that may no longer be applicable for best evidence based practice. If I
felt that a certain article was applicable, I would then download the PDF or find the article in the
UNH periodicals room to review the entire study. If an article had plausible sources, reasonable
evidence, a strong argument, clinical significance, a well-constructed research methodology,
such as a randomized control trial, and strong reliability and validity, then I felt that it could be
used in my literature review. Articles that were not easily generalized or that did not seem to
have valid sources were excluded from my research. During my search I found twelve articles
that seemed relevant to my research study, however after reading each study, only nine of them
could be referenced within my work. Of the nine articles that I referenced in my paper, five of
them were studies that could be analyzed and summarized as evidence to prove my PICO
question, and the other four were used for general information about PPD.
Evidence Generated From Research
Education, screening, and home-based interventions provided to mothers and soon to be
mothers are the types of preventative measures that health care workers should take to reduce the
mother’s chance of developing postpartum depression. Education can be defined as the health
care team providing information to the mother and her family on all aspects of postpartum
depression. This includes the risk factors that can put a woman in danger for PPD, the types of
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events that cause the condition to manifest, the signs and symptoms to look for, the importance
of seeking treatment, the effects on both the mother and baby if the condition is left untreated,
and if symptoms do occur, the type of treatment options that are available. Home-based
interventions including home visiting, which seems to be the most effective, poses many benefits
since most women who experience postpartum depression fail to seek treatment. Screening refers
to the technique used by the physician to assess whether a woman is at risk for or is currently
experiences post partum depression.
Although home-based interventions during the perinatal period have not been studied
extensively, studies show that intervening during the period of time in the pregnancy can be
beneficial to both the mother and baby. A systematic review performed by Leis et al in 2009,
looked at six studies that focused on treatment for postpartum depression and preventive
measures that are effective. The most significant intervention that was found in Leis’ research
was the use of home-based interventions to deliver care. The first interventions performed in the
patient’s home environment focused on prevention before the onset of the mental disorder.
Among these home-based interventions are education, social support, home-visiting, cognitivebehavioral therapy, and interpersonal psychotherapy, all of which are done to reduce
psychological distress and promote adaptive functioning. Many of these interventions are
intended to identify those mother’s at risk for developing PPD and those that are experiencing
post partum depression, since women with the disorder rarely seek medical attention. With
intervening and providing care such as home visits, these women can be identified and actions
can be taken. (Leis et al. 2009)
One home-based intervention that can be deemed very beneficial is the practice of nondirective counseling. This type of intervention is also commonly called “listening visits” and
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encourages the nurse performing the home visit to aid in the exploration and understanding of
the mothers feelings but not to offer judgment or advice. This intervention, based on the
principles of Rogerian therapy, makes the assumption that talking to a supportive professional
will help people to acquire a more positive view of themselves and their lives. According to the
systematic review of literature performed by Leis in 2009, this intervention was effective in
preventing and treating postpartum depression. Non-directive counseling was given to 55
participants in a study done in Scotland. The counseling was done via home-visits for 8
consecutive weeks. According to the data collected there was a 32% difference in recovery rate
between the groups favoring intervention. Immediately post-intervention women in the
intervention group had a significant reduction in mean scores on the Edinburgh Postnatal
Depression Scale (Leis et al. 2009). In order to add strength to this evidence, a similar study
could be repeated to uncover whether the results would be consistent in other sample
populations. The use of this particular home-based intervention was proven to be effective, but
another study could further support these findings.
This same systematic review of literature states that symbiotically with Rogerian therapy,
the nurse can also implement the use of cognitive behavioral therapy techniques. These
therapeutic techniques focus on addressing negative or dysfunctional thoughts and tactics to
increasing the amount of pleasurable activities and decreasing mood depressing activities.
Promoting activities that send pleasure signals to the brain will increase mood and in theory
prevent the incidence of postpartum depression. (Leis et al. 2009)
It is also important for healthcare workers to be educated and be made aware of
postpartum depression in order to promote it’s prevention. In a recent study 82% of family nurse
practitioners failed to screen for postpartum depression (Goldsmith 2007). The study looked at
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data gathered from 159 questionnaires that were completed by a sample of nurse practitioners in
Illinois and Wisconsin. The questionnaires provided information to the researchers about the
different types of screening methods the practitioners used on there patients to assess for post
partum depression and the barriers that the nurse practitioners encounter when using these
screening tools. Demographics and the amount of practitioners that actually use a screening
method were also looked at. There were 15 questions on the questionnaire, all of which used a
Likert-type scale, multiple choice, or fill in the blank. The researchers concluded that if the
number of NPs who screen for postpartum depression could be increased, many postpartum
patients and families could be positively affected. Advanced practice nursing education should
adequately prepare graduates to screen at-risk patients. Since postpartum depression is often
overlooked, educating healthcare workers on ways to prevent it’s manifestation and the signs and
symptoms to look for, this can decrease it’s occurrence. “The development of graduate curricula
including thorough units on postpartum depression, as well as formulation of clinical practice
guidelines for postpartum depression, could make great strides toward more and better screening,
prompt diagnosis, and treatment” (Goldsmith 2007). In relation to my PICO question, it can be
said that in order to prove whether screening is an effective intervention in the prevention of
postpartum depression, there is a need for increased use of this intervention by healthcare
workers. The study stated that the use of screening could “positively impact new mothers and
families,” therefore it’s use could be beneficial in practice and should be implemented.
Mothers should also be educated on the importance of well-baby visits after giving birth.
These visits will ensure the health of the baby and give the nurse to assess the mother for any
signs of PPD. Even if the sign and symptoms do not present themselves, this is a good
opportunity for the nurse to provide social support, give information on support group, and refer
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the mother to the proper therapeutic treatment provider. During the well-baby visits with the
pediatrician, both the nurse and doctor can use the Edinlurgh Postnatal Depression Scale (EPDS)
to detect and assess the severity of PPD (Cox et al. 1987). This is one of several scales that can
be used but should be taken into consideration by the nurse as it can benefit both the mother and
baby when used properly.
Other preventative methods were also looked at in a study done in Florida in 2007. This
study primarily focused on the sociocultural aspect of nursing and postpartum depression and the
types of social support that are available for women who are pregnant and who have just given
birth. The study assessed for postpartum depression prevention activities in a group of 20
mothers who had given birth within that year and who denied having any signs or symptoms of
postpartum depression. The researchers used an open-ended interviewing method with
qualitative analysis to gather information about the women that participated in the research
study. The only limitation listed in the study states that there were two forms of data collect;
face-to-face interviewing and phone calling. This decreases the level of evidence, however the
information gathered is still very useful. The results showed that these mothers, who were well
educated on the definition of postpartum depression, benefited from protective measures and
rituals, some degree of social seclusion, rest, assistance with tasks, and social recognition of their
new social status as a mother. The study concluded that with this evidence there is a great
importance to social support during the postpartum recovery period for the prevention of
postpartum depression and all members of the health care team should take this into
consideration. These social interactions can be considered as part of the nursing home-based
interventions, with the presentation of resources for social groups and clubs by the nurse. The
home-health visits can also be used as an opportunity to educate not only the mothers, but the
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entire families on the importance and value of the use of social support. (Ugarriza 2007)
With the use of the research articles referenced above there were several strengths and
weakness that can be generalized for all. All of the articles showed positive evidence for
preventative and treatment measures with a wide array of sources of information. They all
included the type of study that was performed, how the study was carried out, and made note of
their limitations. Although all of this is true however, they all seemed to lack extensive research.
The sample sizes used were a bit small and repeated research studies are needed to further
generalize their findings. Most of these studies were done on a considerably small number of
women in one particular location. For example, a sample size of 20 women in one state is not
representative of the entire population of mother in the United States. If these studies were done
on a larger population they could be more easily generalized and applied to women all over the
world. More research could further prove the point of these studies as well as make all
conclusions drawn more legitimate.
Conclusion
After looking at all relevant data, it can be concluded that a combination of home-based
intervention, screening, and education strategies will be beneficial for all mothers in the perinatal
and postpartum phases of pregnancy. Since home-based interventions, screening, and education
can be used symbiotically it would be logical to include all of them into every women’s plan of
care during pregnancy. Including all three interventions can decrease the risk of the woman
developing postpartum depression and will help to easily identify if she does in fact develop the
condition. With that said, there is still a need for more research on this condition, as it is too
frequently overlooked in the health care setting. Researching preventative strategies, treatment
options, and screening plans in more depth will help resolve issues around the occurrence of
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postpartum depression.
With analyzing the research that is available, care for perinatal and postpartum patients
should include screening for risk factors and signs and symptoms of the mental disorder,
maternal education on postpartum depression, and home-based interventions such as non-direct
therapy. Using these tactics in my personal nursing practice will be beneficial to all mothers and
their babies if I decide to enter into maternal nursing. If I do chose to do so, I will also do my
best to inform others within the field of the benefits of these practices and their ability to prevent
and treat postpartum depression.
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References
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psychometric testing. Nursing Research, 49(5), 272–282.
Cox JL, Holden JM, Sagovsky R. (1987). Detection of postnatal depression: Development of the
10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry. 1987: 150.
Dennis, C. (2008). Psychosocial and psychological interventions for treating postpartum
depression. Cochrane Database of Systematic Reviews, (1).
Freeman, M., Wright, R., Watchman, M., Wahl, R., Sisk, D., Fraleigh, L., et al. (2005).
Postpartum depression assessments at well-baby visits: screening feasibility, prevalence,
and risk factors. Journal of Women's Health (15409996), 14(10), 929-935.
Goldsmith, M. (2007). Postpartum depression screening by family nurse practitioners. Journal of
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McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W (2006). The timing of maternal
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