1. Postpartum Depression

2. 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

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

4. Perinatal Psychological Disorders
The Blues
Postpartum Depression
Postpartum Psychosis

5. Perinatal Depression: Prevalence
Pregnancy
Postpartum
Kumar & Robeson 1984
13.4%
14.9%
Watson & Elliott 1984
9.4%
12.0%
O’Hara et al., 1984
9.0%
Cooper et al. 1988
6.0%
8.7%
O’Hara et al., 1990
7.7%
10.4%
Evans et al., 2001
13.6%
9.2%

6. 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

7. Typical Blues Symptoms
Low Mood
Mood Lability
Insomnia
Anxiety
Crying
Irritability

8. 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

9. 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

10. Postpartum Depression
Not as mild or transient as the blues
Not as severely disorienting as psychosis
Range of severity
Often undetected

12. 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

13. 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
Segre, Losch, O’Hara (submitted manuscript)
Being African-American is associated with a 31% increased risk compared to whites of endorsing an item indicating sad mood immediately after childbirth

14. Effects of Perinatal Depression: An Overview
Depression negatively effects:
Mother’s ability to mother
Mother—infant relationship
Emotional and cognitive development of the child

15. Postpartum Depression: Maternal 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

16. Postpartum Depression: Maternal Behaviors
Gaze less at their infants
Take longer to respond to infant’s utterances
Show fewer positive facial expressions
Lack awareness of their infants
Increased risk for abusing children

17. Postpartum Depression: Maternal Interactions
Flat affect, low activity level, and lack of contingent responding OR
Alternating disengagement and intrusiveness

18. 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

19. What Can Be Done?
ROUTINE SCREENING
REFERRAL TO TREATMENT

20. Why Screen for Perinatal Depression?
Which Mother is Depressed?
You can’t tell by looking.
Perinatal
Foundation
Madison, WI
June 2003

21. 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

22. 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

26. 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 (can’t even fit in a shower)
Complete loss of control over time

27. Barriers to Detection (cont)
Lack of knowledge about range of postpartum disorders
They don’t 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)

28. “I Was Depressed But Didn’t 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

29. 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

30. 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?

31. 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

32. Screening Who? Primary health care professionals
Physicians/Nurses: Obstetrics, Family Practice, Pediatrics
Case Managers/Social Workers

33. Screening: How? Two questions Beck Depression Inventory
Postpartum Depression Assessment Scale
Inventory to Diagnose Depression
Edinburgh Postnatal Depression Scale

34. 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

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

36. 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

37. Health Visitor: Training
Registered Nurse
Specialized health visitor training (about 1 year full-time)

38. Health Visitor Activities
Home visit
Infant’s physical well being
Depression screening
Depression treatment for mild to moderate depression

39. 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

40. 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)

41. Do Listening Visits Work?
“It helped just knowing someone was there…to 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 they’ll lock you away.”

42. 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 wouldn’t have believed it. It sounds like nonsense, but it’s true.”

43. Do Listening Visits Work?
“I wouldn’t have told anyone how I felt unless I had been asked. I’d been bottling it all up like a schoolgirl, don’t speak until you’re 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.”

44. 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). (N=519)
Results:
Strongly agree: %
Agree: %
Disagree: %
Strongly disagree .2%
Missing %
One nurse missing

45. Women’s 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? (N=510)
Preliminary Results:
Yes: %
Maybe or
Uncertain: %
No: %
Undetermined: %

46. What’s Next?
Healthy Start Project
Primary Health Care