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JOGNN Evidence-Based Recommendations for Depressive Symptoms in Postpartum Women Karen McQueen1, Phyllis Montgomery2, Stephanie Lappan-Gracon3, Marilyn Evans4, and Joanne Hunter5

ABSTRACT Correspondence Karen McQueen, RN, MA(N), School of Nursing, Lakehead University, 955 Oliver Road, Thunder Bay, Ontario, Canada, P7B 5E1. [email protected]

Postpartum depression is a serious health issue affecting 13% of women from diverse cultures. Despite the welldocumented consequences of postpartum depression, it remains difficult to identify, and diverse practices relate to its prevention and treatment. Evidence-based interventions are essential to improve both maternal and infant health outcomes associated with pregnancy. This article describes the development process of an evidence-based practice guideline for postpartum depression and highlights the practice recommendations related to the confirmation, prevention, and treatment of depressive symptoms in postpartum mothers.

JOGNN, 37, 127-136; 2008. DOI: 10.1111/j.1552-6909.2008.00215.x Keywords postpartum depression best practice guidelines recommendations evidence nurses

Accepted October 2007

P

ostpartum depression is a serious condition that af-

To partially address this issue, the Registered Nurses’

fects approximately 13% of new mothers (O’Hara &

Association of Ontario (RNAO, 2005) developed a best

Swain, 1996) most frequently within the first 12 weeks

practice guideline (BPG) entitled Interventions for Post-

after delivery (Gaynes et al., 2005; Goodman, 2004). The

partum Depression to promote evidence-based prac-

consequences of postpartum depression are well docu-

tice in the confirmation, prevention, and treatment of

PhD, associate professor, School of Nursing, Laurentian University, Sudbury, Canada

mented for mothers and infants (Austin & Priest, 2005;

postpartum depression. Its rigorous development in-

Mayberry & Affonso, 1993; Murray & Cooper, 1997). In

volved a systematic appraisal of scientific evidence for

particular, the presence of maternal depression influ-

the purpose of assisting nurses with clinical decision

3RN,

ences a mother’s ability to emotionally and cognitively

making to achieve effective client outcomes. The pur-

interact with her infant and family especially when the

pose of this article was to outline the 10 clinical postpar-

depression is prolonged and untreated. Additionally,

tum recommendations with their supporting evidence.

1RN,

MA(N), assistant professor, School of Nursing, Lakehead University, Thunder Bay, Ontario, Canada 2RN,

MN, manager, Clinical Genetics & Metabolics, The Hospital for Sick Children, former Best Practice Guidelines Coordinator, Registered Nurses’ Association of Ontario 4RN,

PhD, assistant professor, School of Nursing, University of Western Ontario, London, Canada 5RN,

MN, primary care nurse practitioner, University Health Centre, Toronto, Canada

http://jognn.awhonn.org

women who have suffered from postpartum depression are twice as likely to experience another depressive episode within a 5-year period (Cooper & Murray, 1995).

Methods

Despite the negative outcomes associated with postpar-

The RNAO BPG development is a provincial effort that was

tum depression, it often remains undetected, as many

initiated in 1999 to improve the quality of nursing care by

mothers are reluctant to disclose symptoms of depres-

promoting interventions with the best available empirical

sion and seek treatment even when they are in frequent

support. In 2004, a panel of researchers, clinicians, con-

contact with health professionals (Dennis & Chung-Lee,

sumers, and administrators with expertise in the area of

2006). In particular, a study of 60 primiparous mothers in

postpartum depression was established by the RNAO to

the U.K. found that only 25% of the mothers sought pro-

review existing evidence for the purpose of developing

fessional assistance for depressive symptoms (McIn-

practice, education, and policy recommendations. Through

tosh, 1993). As such, postpartum depression remains an

a process of consensus and discussion, the panel deter-

undetected condition of maternal morbidity, and no sys-

mined from the outset that the scope of the guideline was

tematic approach to its detection, prevention, or treat-

the confirmation, prevention, and treatment of postpartum

ment has been established in nursing practice.

depression during the first postpartum year.

© 2008, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

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Depressive Symptoms in Postpartum Women

assigned a level of evidence, according to the hierarchy

No systematic approach for the detection, prevention, or treatment of postpartum depression has been established in nursing practice.

of evidence presented in Table 1. The next step involved review and revision of each drafted recommendation by the guideline panel. The

Three clinical questions guided the identification of relevant research literature: (a) how can nurses confirm depressive symptoms in postpartum women, (b) what effective prevention interventions can nurses implement in practice, and (c) what effective treatment interventions can nurses implement in practice? Databases (Medline, CINAHL, PsychInfo, Cochrane Registry of Controlled Trails, Cochrane Pregnancy and Childbirth Group Trails Register, and EMBASE) were searched to identify peer-

draft guideline was then sent to a total of 46 stakeholders representing diverse perspectives including women who experienced postpartum depression for review and feedback. A final step was the integration of the stakeholders’ feedback. The completed RNAO guideline includes 10 specific practice, 1 educational, and 3 organizational/policy recommendations. For a more detailed explanation of the method, the guideline is available at www.rnao.org.

reviewed research and guidelines published in English

An updated literature search using the same keywords,

between 1985 and 2004. This yielded approximately 106

databases, and clinical questions was conducted for the

articles and two guidelines (British Columbia Reproduc-

years 2005 to August 2007 to ensure that the current re-

tive Care Program, 2003; Scottish Intercollegiate Guide-

search evidence supports the practice recommendations.

lines Network, 2002) related to the research questions for

A total of 12 articles were identified and included.

review. Both guidelines were critically appraised using the Appraisal for Guidelines and Evaluation Instrument (AGREE Collaboration, 2001). The appraisal instrument assesses six domains including scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence.

Findings and Recommendations In total, 10 specific practice recommendations were developed (Table 2), including 2 prevention recommendations, 6 recommendations related to the confirmation of

However, the panel determined that the two guidelines

depressive symptoms, and 2 that addressed treatment

did not comprehensively address the scope identified by

of postpartum depression. For each recommendation,

the RNAO panel. Next, a master’s prepared nurse with

its supporting research is discussed in addition to the

expertise in critical appraisal conducted a quality ap-

identification of its level of evidence.

praisal of the studies using the Effective Public Health

Prevention Recommendations.

Practice Project (2003) Quality Assessment Tool for Quantitative Studies. The tool is divided into several sections

Recommendation 1. Nurses provide individualized,

including selection and allocation bias, confounders,

flexible postpartum care based on the identification

blinding, data collection methods, withdrawals and drop-

of depressive symptoms and maternal preference

outs, analysis, and intervention integrity. Using the scoring

(Level of Evidence = Ia).

algorithm, an overall qualitative rating of weak, moderate, or strong is assigned. The quality appraisal was then reviewed by the members of the three subgroups addressing each of the clinical questions. Draft recommendations were developed and with assistance from the team leader,

Systematic reviews of randomized control trials examining the effects of preventive psychosocial or psychological interventions for reducing the risk of developing postnatal depression suggest that intensive, professionally based support may prevent women from developing postnatal depression. In this body of research, the re-

Table 1: Levels of Evidence

viewers indicate that the preventive approaches were di-

Ia

Evidence obtained from meta-analysis or systematic review of randomized controlled trials.

verse: antenatal and postnatal classes, lay home visits, or

Ib

Evidence obtained from at least one well-designed randomized controlled trial.

2005; Chabrol & Callahan, 2007; Dennis, 2005). Support-

IIa

Evidence obtained from at least one well-designed study without randomization.

ive home visits made postnatally were identified as being

IIb

Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization.

particularly effective when the population included vul-

III

Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies.

IV

Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

Note. Registered Nurses’ Association of Ontario (2005).

early postpartum follow-up (Boath, Bradley, & Henshaw,

nerable mothers and when the visits were individualized. MacArthur et al. (2002), in a randomized controlled trial of 2,064 women, assessed community-based postpartum care in the U.K. The intervention was designed to be flexible and meet the individual needs of the new mother. Individual maternal needs were determined by

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McQueen, K., Montgomery, P., Lappan-Gracon, S., Evans, M., and Hunter, J.

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Table 2: Practice Recommendations Level of Evidence

Recommendation Prevention

1. Nurses provide individualized, flexible postpartum care based on the identification of depressive symptoms and maternal preference.

Ia

2. Nurses initiate preventive strategies in the early postpartum period.

Ia

Confirming depressive symptoms

3. The Edinburgh Postnatal Depression Scale (EPDS) is the recommended self-report tool to confirm depressive symptoms in postpartum mothers.

III

4. The EPDS can be administered anytime throughout the postpartum period (birth to 12 months) to confirm depressive symptoms.

III

5. Nurses encourage postpartum mothers to complete the EPDS by themselves in privacy.

III

6. An EPDS cutoff score of greater than 12 may be used to determine depressive symptoms among English-speaking women in the postpartum period. This cutoff criterion should be interpreted cautiously with mothers who: (a) are non-English speaking, (b) use English as a second language, and/or (c) are from diverse cultures.

III

7. The EPDS must be interpreted in combination with clinical judgment to confirm postpartum mothers with depressive symptoms.

III

8. Nurses should provide immediate assessment for self-harm ideation/behavior when a mother scores positive (e.g., from 1 to 3) on the EPDS self-harm item number 10.

IV

9. Nurses provide supportive weekly interactions and ongoing assessment focusing on mental health needs of postpartum mothers experiencing depressive symptoms.

1b

Treatment

10. Nurses facilitate opportunities for the provision of peer support for postpartum mothers with depressive symptoms.

IIb

Note. Registered Nurses’ Association of Ontario (2005).

midwives using a symptom checklist and assessment.

Researchers evaluating the effect of intervention onset re-

Women in the control group received standard care of

port that interventions initiated in the antenatal period fail to

midwifery home visits with follow-up from health visitors

reduce the risk of women developing postpartum depres-

and general practitioners. Significant group differences

sion in comparison to interventions delivered only in the

were found in favor of the intervention group with 14.4%

postnatal period (Dennis, 2005; Shaw, Levitt, Wong,

of mothers scoring above 12 on the Edinburgh Postna-

Kaczorowski, & The McMaster University Postpartum Re-

tal Depression Scale (EPDS) in comparison to 21.3% of

search Group, 2006). For example, Matthey, Kavanagh,

mothers in the control group suggesting that the deliv-

Howie, Barnett, and Charles (2004), in a study of 268 pre-

ery of flexible and mother-centered care may improve

natal primiparous mothers, found no differences in depres-

women’s mental health outcomes.

sive symptoms at 6 months postpartum between mothers

Armstrong, Fraser, Dadds, and Morris (1999) conducted a trial of “at-risk” families. The subjects included mothers living in circumstances such as violence, financial stress, unstable housing, ambivalent about pregnancy, and having had limited antenatal care. Mothers in the intervention group (n = 90) received nursing home visits weekly to 6

who received additional psychosocial intervention and those who received routine care or baby play information sessions. By way of caution, much of the antenatal prevention studies have significant methodological limitations such as heterogeneous samples, diverse screening measures for depression, and high attrition rates.

weeks postpartum, then every 2 weeks to 12 weeks post-

Maternal mood in the immediate postpartum period (or

partum, and then monthly to 24 weeks postpartum. Moth-

up to 2 weeks postpartum) is a significant predictor of

ers in the control group (n = 91) were given instructions

postpartum depression (Beck, 2002; Dennis, 2005).

on how to access existing community child health ser-

Mothers who scored high on the EPDS at 7 days post-

vices. At 6 weeks postpartum, intensive nursing home

partum were more likely to have depressive symptoms

visits resulted in significantly lower mothers’ EPDS scores

at 1 and 2 months postpartum (Dennis, 2005). Similar

compared to those in the control group. These differ-

findings have been found in other studies of mothers

ences, however, were not maintained at the 16-week

with diverse ethnic orientations (Yamashita, Yoshida,

postpartum follow-up. Armstrong et al. hypothesize that

Nakano, & Tashiro, 2000). Beck’s metasynthesis of qual-

continuation of biweekly visits might enable the initial pre-

itative research suggests that mothers who talk about

ventive effect to be maintained to 24 weeks postpartum.

postpartum blues as overwhelming also describe experiences of postpartum depression. Such findings

Recommendation 2. Nurses initiate preventive strat-

support the importance of early interventions such as

egies in the early postpartum period (Level of Evi-

referral or support in order to minimize the impact of

dence = Ia).

symptoms for the mother and her family.

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Table 3: Potential Research Questions Prevention

Depressive Symptoms in Postpartum Women

further independent psychometric testing is required before any recommendations can be made regarding its use (Boyd et al.; RNAO, 2005). Comparatively,

1. Can health providers reliably identify women at risk for postpartum depression?

Gaynes et al.’s (2005) systematic review of 10 studies

2. Are supportive preventive interventions more effective when provided by peers or health professionals?

assessed the accuracy of different screening tools for

Confirmation 1. Is any one tool superior in confirming depressive symptoms in postpartum women? 2. What are the effects of false-negative and false-positive postpartum depression scores? 3. Does the repeated administration of tools to assess depressive symptoms alter the validity, sensitivity, or specificity of the tool?

detecting depression and did not identify any one particular tool as superior. They found that the estimates of sensitivity and specificity appeared equivalent and they were unable to combine the results of different studies for meta-analysis due to the different tools and cutoffs used. They concluded that there are various screening

Treatment 1. What interventions do mothers perceive as beneficial in the treatment of postpartum depression?

instruments (including the EPDS) that can be used to

2. Are any treatment interventions more effective than others?

depression.

3. What are the long-term treatment effects (medication and nonmedication) for postpartum depression on mothers and infants?

It is noteworthy that both systematic reviews identified

4. Are multifaceted interventions more effective than single interventions?

that many included studies suffered from small sample

identify perinatal depression, most accurately major

size. Overall, identifying that the evidence base is quite limited, more research is required including larger samConfirming Depressive Symptom Among Postpartum

ples that are representative of the population, diverse

Women.

racial and ethnic mix, and other demographic variables. See Table 3 for future potential research studies. Addi-

Recommendation 3. The EPDS is the recommended self-report tool to confirm depressive symptoms in postpartum mothers (Level of Evidence = III). Various tools such as the Beck Depression Inventory, the Postpartum Depression Screening Scale (PDSS), the Hospital Depression and Anxiety Scale, and the Hamilton Rating Scale for Depression have been clinically used to screen for depressive symptoms in postpartum mothers. The panel recommends the EPDS in

tionally, the systematic reviews had different inclusion/ exclusion criteria, thus the difference in number of studies included (Gaynes, 10; Boyd, 36). The main difference was Gaynes et al.’s (2005) inclusion criteria that specified a clinical assessment or structured clinical interview to confirm depressive symptoms. Boyd et al. (2005) and RNAO (2005) did not require a clinical interview and therefore included studies with self-reported depressive symptoms.

clinical practice (RNAO, 2005). It has demonstrated

Recommendation 4. The EPDS can be administered

reliability, sensitivity (or proportion of mothers correctly

anytime throughout the postpartum period (birth to

identified as having depressive symptoms), specificity

12 months) to confirm depressive symptoms (Level

(proportion of mothers correctly identified as not having

of Evidence = III).

depressive symptoms), and positive predictive value (proportion of mothers who were diagnosed with postpartum depression) (Boyce, Stubbs, & Todd, 1993; Cox, Holden, & Sagovsky, 1987; Harris, Huckle, Thomas, Johns, & Fung, 1989; Thompson, Harris, Lazarus, & Richards, 1998). Ease of administration, acceptability by different cultures, international recognition, and availability at no cost were identified as supportive for the clinical applicability of the EPDS (Dennis, 2003a).

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For the majority of women, the onset of depression usually occurs within the first few weeks or months after delivery (Cooper, Campbell, Day, Kennerley, & Bond, 1988; Goodman, 2004; McIntosh, 1993; Small, Brown, Lumley, & Astbury, 1994). However, for some mothers, the inception of depressive symptoms occurred after 12 weeks (Small et al., 1994) and others much later between 6 and 12 months (Cooper et al., 1988).

Since the development of this recommendation, two

A systematic review of 30 studies evaluating the preva-

systematic reviews have been conducted to evaluate

lence and incidence of postpartum depression found

screening tools for postpartum depression in the post-

that the prevalence of major and minor depressions

natal period (Boyd, Le, & Somberg, 2005; Gaynes et al.,

began to rise following delivery with the highest

2005). Boyd et al. reviewed 36 studies evaluating eight

increase of 12.9% at 3 months, declining slightly in the

self-report measures used to assess for depressive

4th through 7th month (9.9%-10.6%), and declining

symptoms in the postpartum period. Their findings con-

even further (approximately 6.6%) from the 8th to 12th

curred with the RNAO’s recommendation that the EPDS

month (Gaynes et al., 2005). As such, the presence of

is the most extensively studied postpartum assessment

depressive symptoms remains fairly high for the first 6

tool with moderate psychometric soundness. Although

months postpartum before it starts to decrease. It is

the PDSS also demonstrates promise as a valid tool,

noteworthy that research has not specified an “optimal”

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clinical time to employ the EPDS or the implications of

The EPDS may be used as part of a comprehensive assessment to identify depressive symptoms early so that referral and treatment may be initiated.

repeatedly applying the EPDS to assist with assessment. The validity, sensitivity, and specificity of repeated use with a postpartum mother are unknown. Recommendation 5. Nurses encourage postpartum mothers to complete the EPDS tool by themselves in privacy (Level of Evidence = III). Current research suggests that EPDS scores are more reliable when mothers complete the EPDS alone, without others present (Cox & Holden, 2003). Researchers report that mothers are often reluctant to disclose emotional problems (Beck, 2002; Brown & Lumley, 2000) or

pressive symptoms at 7 days postpartum (Ghubash, Abou-Saleh, & Daradkeh, 1997). A cutoff score of 9/10 was considered most appropriate at 6 weeks postpartum for mothers of Chinese descent (Lee et al., 1998). These research findings highlight the social and cultural expectations and context of motherhood and reinforce the importance of clinical judgment when interpreting the EPDS score for all mothers regardless of language.

to obtain professional assistance (Small, Johnston, &

While the systematic review by Gaynes et al., (2005)

Orr, 1997). Furthermore, the EPDS can be effectively

did not recommend any specific cutoff value, they

administered during a phone conversation with a mother

emphasized that the relative cost, or value, of errors in

(Dennis, 2003b; Zelkowitz & Milet, 1995). The RNAO

screening tests is of utmost importance in setting cutoff

Best Practice Guideline (2005) provides sample lead-in

scores. For example, a false-negative result may lead to

questions and administration protocol.

a prolonged and untreated depression, whereas a falsepositive result may lead to unnecessary treatment or

Recommendation 6. An EPDS cutoff score greater than 12 may be used to determine depressive symptoms among English-speaking women in the

stress associated with an incorrect screen. Thus, the screening test should try to maximize the most effective cutoff.

postpartum period. This cutoff criterion should be interpreted cautiously with mothers who (a) are non-

Recommendation 7. The EPDS must be interpreted

English speaking, (b) use English as a second lan-

in combination with clinical judgment to confirm

guage, and/or (c) are from diverse cultures (Level of

postpartum mothers with depressive symptoms

Evidence = III).

(Level of Evidence = III).

Research has demonstrated that the EPDS is most effective in the confirmation of depressive symptoms (sensitivity and specificity) when the recommended cutoff score of greater than 12 is used in the postpartum period among English-speaking mothers in the U.K. (Cox et al., 1987), Canada (Zelkowitz & Milet, 1995), and Australia (Boyce et al., 1993). An EPDS score greater than 12 does not mean a mother has postpartum depression, nor does a score translate into the severity of depressive symptoms (Cox & Holden, 2003). Conversely, a score of 11 does not indicate that the mother is not experiencing emotional distress particularly when the health professional has identified concerns. Rather, an EPDS score indicates the mother’s perception of her mood. In addition, different cutoff scores may be required for

The clinical use of the EPDS is not intended to replace health professionals’ comprehensive assessment of a mother/family during the postpartum period. Instead, the guideline recommends that the EPDS be used as an adjunct to clinical evaluation. Elliott and Leverton (2000) emphasize that when used alone, “the EPDS is just a piece of paper, a checklist” (p. 305). When combined with knowledge in prevention, identification, and treatment of postpartum depression, however, the EPDS can facilitate discussion about needs, family and role transitions, and supports (Cox & Holden, 2003; Lundh & Gyllang, 1993). Additionally, the EPDS may be used as a means of identifying improving or worsening symptoms and to assist decision making regarding engaging support systems, providing postpartum depression information, and referring and securing treatment.

non-English versions of the EPDS (Dennis, 2003b). For example, with Japanese subjects, using a 12/13 cutoff

Recommendation 8. Nurses should provide immedi-

score, no mothers obtained an EPDS score of 13 or

ate assessment for self-harm ideation/behavior

higher (Okano et al., 1998; Yoshida, Yamashita, Ueda, &

when a mother scores positive (e.g., from 1 to 3) on

Tashiro, 2001). Researchers suggest that, due to cul-

the EPDS self-harm item number 10 (Level of Evi-

tural expectations, Japanese mothers may be reluctant

dence = IV).

to disclose depressive symptoms and, therefore, a lower cutoff of 8/9 may be more suitable for this popula-

Question number 10 on the EPDS assesses any

tion (Okano et al., 1998). When used with Arabic women,

thoughts specific to self-harm ideation. In a Canadian

a threshold score of 11/12 was adopted to confirm de-

population of 594 mothers, 4.5% (n = 27) expressed

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Table 4: Assessment of Self-Harm

Depressive Symptoms in Postpartum Women

purposeful listening in order to promote a safe space for the exploration of the woman’s reality (RNAO, 2005).

1. How often do you have thoughts of harming yourself? 2. How severe are these feelings? How much have they been bothering you?

Additional support for the effectiveness of nondirective

3. Have you had these kinds of feelings before? If so, what happened? How did you cope with them?

counseling comes from qualitative literature of mothers’

4. Have you made any previous suicide/self-harm attempts?

with a compassionate listener (Ritter, Hobfoll, Lavin,

5. Have you thought about how you would harm yourself?

Cameron, & Hulsizer, 2000; Small et al., 1994). With

6. What support do you have at home?

training, this interactive approach can be used by a va-

7. (If she has a partner) Have you talked about your feelings with him/her?

riety of health care providers with women with mild-to-

8. Are you close to your parents/other family members? Do they know how you have been feeling?

moderate depression (Holden et al., 1989; Wickberg &

9. Can you count on your partner and/or family members to give you emotional support? 10. Is there anyone else in your life whose support you can count on? 11. Have you told this person or anyone else about your feelings? 12. Could you phone this person and would he/she come if you felt the needed support? Note. Based on Holden (1994) and Registered Nurses’ Association of Ontario (2005).

expressed needs to disclose their emotional concerns

Hwang, 1996). For women experiencing severe depression, other treatments are often required. The degree of depression alone is not the sole indicator of a specific intervention (such as medication, cognitive behavioral therapy, or interpersonal psychotherapy); rather, treatment based on maternal needs and preferences is the guiding principle (Holden, 1996). Health providers (nurses and home visitors) working with mothers with

suicidal thoughts at 1 week, with a similar amount at

postpartum depression require access to support from

4.3% (n = 23) at 4 weeks, which increased slightly to

physicians, psychiatrists, psychologists, or community

6.3% (n = 32) at 8 weeks (Dennis, 2004a). Additional

psychiatric nurses so that referrals can be made in a

researchers have identified similar percentages of sui-

timely fashion (Holden, 1996).

cidal ideation (Morris-Rush, Freda, & Bernstein, 2003). Depression is a major risk factor for suicide, and any positive score (1-3) related to suicidal ideation or selfharm must be further assessed in a timely manner. Although various suicide assessment scales are available for use in practice, the developers of the EPDS recommend additional questions for assessment (see Table 4). Agency policies and procedures must be in place to assist health providers with decision making in the plan of care for mothers who score positive on self-harm (Cox & Holden, 2003). Treatment Recommendations.

More recent findings also provide additional support for the effectiveness of diverse treatments for postpartum depression. In particular, British Medical Journal ’s Clinical Evidence search and appraisal identified cognitive behavioral therapy, interpersonal therapy, and nondirective counseling as likely to be effective nondrug treatments for postpartum depression (Howard, 2006). Similarly, Bledsoe and Grote’s (2006) preliminary metaanalysis found diverse interventions to be effective for treating nonpsychotic major depression during pregnancy and postpartum. Their research involved 16 treatment trials with 922 participants, which assessed treatment effects during pregnancy (3 trials) and the postpartum period (13 trials). However, their findings

Recommendation 9. Nurses provide supportive

combined both the antenatal and the postnatal studies

weekly interactions and ongoing assessment focus-

and therefore cannot be generalizable to this postpar-

ing on maternal mental health needs of postpartum

tum treatment recommendation. Finally, a literature re-

mothers experiencing depressive symptoms (Level

view by Chabrol and Callahan (2007) suggests

of Evidence = Ib).

equivalent effectiveness among the psychological inter-

Diverse psychological/psychosocial interventions delivered on a weekly basis have been identified as effective in the treatment of postpartum depression. These in-

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ventions (nondirective counseling, cognitive behavioral therapy, and interpersonal therapy) with no one intervention identified as being optimal.

clude interpersonal psychotherapy (Klier, Muzik, Rosen-

There are also some preliminary findings that suggest

blum, & Lenz, 2001), cognitive behavioral therapy

that additional therapies such as group interpersonal

(Honey, Bennett, & Morgan, 2002), and nondirective

therapy (Reay et al., 2006), telecare support (Ugarriza

counseling (Cooper, Murray, Wilson, & Romaniuk, 2003;

& Schmidt, 2006), and exercise (Daley, Macarthur, &

Holden, Sagovsky, & Cox, 1989; Wickberg & Hwang,

Winter, 2007) may potentially have therapeutic effects

1996). While all the interventions evaluated were effec-

on depressive symptoms. However, these findings are

tive, nondirective counseling may be of particular inter-

preliminary and based on pilot work, and more research

est as nurses can implement it into their practice.

is required before any recommendations can be made

Nondirective counseling involves the art of presencing

regarding their use as an adjunct or primary treatment

(i.e., being there), displaying nonjudgment as well as

for postpartum depression.

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Recommendation 10. Nurses facilitate opportunities for the provision of peer support for postpartum mothers with depressive symptoms (Level of Evidence = IIb).

The degree of depression alone should not dictate the type of intervention; rather, treatment should be based on maternal needs, preferences, and severity of symptoms.

Many studies identified a lack of support as a strong risk factor in the development of postpartum depression

2000). Therefore, health care providers need to be

(Dennis, 2003b, 2004b). Presence of a trustworthy,

aware of the potential significance of depressive symp-

available, and understanding listener and/or belonging

toms in the early postpartum period and valid measure-

to a group of similar others may be effective in reducing

ments to confirm the presence of depressive symptoms

the potential severity of depressive symptoms particu-

in postpartum mothers.

larly when women describe postpartum depression in

However, numerous barriers have been documented re-

terms of isolation, as being misunderstood and as being

lated to the identification of women with postpartum de-

alone (Brugha et al., 1998; Eberhard-Gran, Eskild,

pression. These include culture (Okano et al., 1998),

Tambs, Schei, & Opjordsmoen, 2001). Limited research,

reluctance to seek professional help (Small et al., 1997),

however, has been conducted specifically evaluating

reluctance to disclose emotional problems (Brown &

the efficacy of social support and postpartum depres-

Lumley, 2000), and lack of knowledge related to postpar-

sion, and the research that has been conducted has

tum depression (Edge, Baker, & Rogers, 2004). As such,

been inconclusive (Chen, Tseng, Chou, & Wang, 2000;

the use of a tool, such as the EPDS for the confirmation

Dennis, 2003b, 2004a; Fleming, Klein, & Corter, 1992;

of mothers with depressive symptoms, may assist to ad-

Morgan, Matthey, Barnett, & Richardson, 1997).

dress some of the barriers related to identification. While a large systematic review identified that several

Summary Although several well-designed studies have been conducted evaluating diverse interventions for the prevention of postpartum depression, no one intervention has been identified as effective. When considering the multifactorial etiolology of postpartum depression, this may not be surprising. Overall, promising findings regarding prevention indicate that interventions that are flexible,

tools may be effective for assessing postpartum depressive symptoms (Gaynes et al., 2005), the panel has recommended the EPDS as a valid self-report tool for the identification of depressive symptoms in postpartum mothers (RNAO, 2005), as it has been psychometrically tested in diverse populations, translated into 23 languages, and demonstrated high sensitivity, specificity, and predictive power (Dennis, 2004a).

are individually based, target “at-risk women,” and are

Additionally, it has been identified as the most exten-

delivered postnatally are more likely to be effective in

sively evaluated tool for the assessment of depressive

the prevention of postpartum depression (Dennis, 2005;

symptoms in postpartum women (Boyd et al., 2005).

Dennis & Creedy, 2004).

When used as a screening tool to identify depressive

Additionally, much of the research on prevention has concentrated on the primary prevention (activities that will help prevent a certain condition) of postpartum depression. However, secondary prevention strategies (activities targeted toward specific subgroups expected to be at higher risk for a problem, with the aim to slow or interrupt the progress of the condition through early detection and treatment; RNAO, 2005) are also very important. Current evidence supports the significance of postpartum depressions screening for early detection and treatment of symptoms (Boyd et al., 2005; Freeman et al., 2005; Horowitz & Cousins, 2006). Therefore, training health professionals to identify women with depres-

symptoms, the EPDS provides a relatively rapid measure of emotional distress, which is easily interpreted by clinicians (Mosack & Shore, 2006; Sharp & Lipsky, 2002), and it is easy to administer, requiring little time and training (Cox & Holden, 2003). However, its usefulness is partly dependent on the clinician’s understanding of its specific purpose and limitations. Thus, the EPDS is neither a diagnostic instrument nor a substitute for a diagnostic assessment. Instead, the EPDS is intended to provide severity of symptoms information and should be used as an adjunct to a thorough assessment of the emotional needs of the new postpartum mother.

sive symptoms and make appropriate referral may hold

The use of the EPDS for the confirmation of depressive

the most promise for reducing negative outcomes asso-

symptoms in mothers requires knowledge specific to

ciated with prolonged and untreated postpartum de-

the administration and interpretation of the EPDS,

pression (Austin & Priest, 2005; Gjerdingen & Yawn,

including cutoff scores, use in diverse populations,

2007). Additionally, research supports the need for

assessment for any positive response to the self-harm

structured or validated tools for assessment rather than

item, and avoidance of overreliance on EPDS scores.

unstructured interviews (Evins, Theofrastous, & Galvin,

Furthermore, when health professionals are assessing

JOGNN 2008; Vol. 37, Issue 2

133

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Depressive Symptoms in Postpartum Women

mothers for the presence of depressive symptoms,

The BPG Interventions for Postpartum Depression is

there must be policies and procedures in place to en-

one resource to support evidence-based decision mak-

sure that women who are identified as having depres-

ing in nursing practice. The implementation of evidence-

sive symptoms have access to treatment. In particular,

based care specific to mothers with postpartum

evidence from experts supports the implementation of

depression has the potential to improve outcomes for

harm reduction methods especially with regard to a

mothers, infants, and families through early identifica-

woman’s expression of self-harm ideation. Regardless

tion of depressive symptoms, with referral and treatment

of the EPDS score, if a clinician is concerned about a

sensitive to individual mothers’ needs. However, the

women’s safety, it is more direct to inquire about her sui-

magnitude of the outcomes associated with evidence-

cidal risk in a sensitive and respectful manner (Cardone,

based guidelines is often inconsistent and dependent

Kim, Gordon, Gordon, & Silver, 2006). Through a fo-

on several variables including the quality of the evi-

cused risk assessment, a skilled clinician can deter-

dence, the method of guideline development, and the

mine if the presenting behavior reflects psychopathology,

strategies used to disseminate and implement the

contextual stressors, or a combination of both.

guideline recommendations into practice (Rycroft-

Finally, a potential criticism of the EPDS-related recommendations may be the timing or intervals of EPDS administration, as no one best time to screen has been identified. As a result, it is challenging for clinicians or decision makers to specify an optimal time for administration. However, this should not be considered a serious limitation of the EPDS as the timing of administration question exists with any tool used to assess for postpartum depressive symptoms.

Malone, 2004). Therefore, describing the rigorous process used to develop the guideline and actively promoting the dissemination of the recommendations in a concise, easy to use, and accessible manner such as this article may have the potential to increase the uptake of evidence-based care and ultimately improve outcomes for mothers with postpartum depression. Finally, the guideline while conceptualized within the scope of nursing practice can be used by various health care providers caring for postpartum mothers.

While diverse treatments are identified as effective in the care of mothers with postpartum depression, treatment should be initiated based on maternal need (severity of

Acknowledgments

symptoms), preference of treatment options, and avail-

The authors thank Dr. Cindy-Lee Dennis and the panel

ability of services. Women with mild-to-moderate depres-

members.

sive symptoms may benefit from interventions provided by nurses, within their scope of practice, including nondirective counseling, weekly supportive interactions, and/ or facilitation or referral to support groups. Women with

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