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Postpartum Depression

Postpartum Depression. 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. Burden.

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Postpartum Depression

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  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 18-44. • In the year 2000, 205,000 women aged 18-44 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

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

  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

  11. 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 Symptoms of Major Depression

  12. 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

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

  14. 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

  15. 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

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

  17. 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

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

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

  20. 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

  21. 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

  22. 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

  23. 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)

  24. “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

  25. 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

  26. 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?

  27. 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

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

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

  30. 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

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

  32. 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

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

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

  35. 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

  36. 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)

  37. 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.”

  38. 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.”

  39. 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.”

  40. 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: 45.7% Agree: 47.8% Disagree: 3.5% Strongly disagree .2% Missing .2% Nurses’ Views of Providing Supportive Care: Statewide Survey

  41. 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: 67.5% Maybe or Uncertain: 28.6% No: 2.5% Undetermined: 1.4% Women’s Views of Nurses’ Providing Supportive Care

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

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