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Postpartum depression

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Updated April 3, 2019

Transcript

Postpartum

Depression

Precious Oppong

01/04/19

What is postpartum depression?

As a result of pregnancy, childbearing women are at an increased risk for depression (Bicking, 2012). Statistically speaking, following childbirth 1 out of every 10 women endure depressive symptoms such as; emotional and physical exhaustion through stages of pregnancy and postpartum (Biking, 2012). This increased risk can be linked to the Postpartum depression (Biking, 2012). Affecting 15% of child bearing mothers, postpartum depression can be defined as a mental illness brought up during a woman's antepartum stage; prior to birth and or her postpartum stage; following childbirth (Biking, 2012). Commonly, vulnerability of postpartum depression is consistent with the multiple challenges pregnancy influences. Such challenges include; reproductive hormone imbalances, changes in self perception, and difficulties of managing parental roles (Biking, 2012). Although a major impact, allowing for further influences include multiple environmental and physiological factors such as; a history of mental illness, family members affected by a mental illness, insufficient social support, and low socioeconomic status. As a result of of a combination of such, one may experience some of the many symptoms of postpartum depression (Biking, 2012). Symptoms of postpartum depression vary from person to person but most commonly includes, alterations to sleep cycle, mood swings, excessive worrying, severe sadness, and lack of motivation (Biking, 2012).

What makes Postpartum Depression Unique?

Definition and Relevance

Differing from other forms of depression, Postpartum depression consists of distinguishable characteristics that allow for originality. Characteristics of such include; onset, duration and those at risk. looking at onset and duration, It is expected that throughout the first 4 to 6 weeks following labor, symptoms related to postpartum depression should be evident (Couto et al., 2015). With this onset, recovery is expected to be within the time frame of 3 to 6 months post pregnancy (Couto et al., 2015). Although this is most common, onset and recovery varies from person to person. In fact, 12 to 23% of childbearing mothers enduring symptoms throughout pregnancy and 25% endure prolonged duration of associated symptoms for as long as 12 months (Smith, 2012). With this it can be averaged that Postpartum depression begins during pregnancy with symptoms that can last up to 12 months (Smith, 2012). Next, those affected by postpartum depression allow for further differences. Differing from other depression types in which vulnerability lays within all, Postpartum depression solely puts child bearing mothers at risk (Biking, 2012). With this, reason, although not diagnosed, because newborns are heavily dependent on their mother following birth, affected by the diagnosis of a childbearing women is her newborn baby (Biking, 2012).

Corrêa, H. (2015). Postpartum depression: A systematic review of the genetics involved. World journal of psychiatry, 5(1), 103–111. doi:10.5498/wjp.v5.i1.103

Smith, J. (2012). Depression in Pregnancy and Postpartum. Retrieved from http://www.heretohelp.bc.ca/visions/having-a-baby-vol7/depression-in-pregnancy-and-postpartum

Biking, C. (2012). Maternal Perinatal Depression in the Neonatal Intensive Care Unit: The Role of the Neonatal Nurse. NeoNatal Network. 5(30), 295-304.

Bicking, C. (2012). Maternal Perinatal Depression in the Neonatal Intensive Care Unit: The Role of the Neonatal Nurse. Neonatal Network, 5(31), 295-304.

Importance of Postpartum Depression

Although Postpartum depression is an expected outcome of pregnancy, it can ultimately be alarming to both the child bearing mother and her newborn as associated symptoms allow for complications with health (Ghaedrahmati et al., 2018). Looking at one of the most common symptoms of postpartum depression; hopelessness, threats to quality of life of a mother and her newborn can be identified (Biking, 2012).

Feelings of hopeless commonly occur within childbearing women due to high expectations of what pregnancy and parenting ought to be (Javadififar, Majlesi, Nikbakht, Nedjat & Montazeri, 2019). Pregnancy and parenting are often depicted with constant expressions of joy and excitement (Javadififar et al., 2019). Although a possible outcome, this perspective is often overemphasized with an underemphasis of the challenges associated with new roles and responsibilities (Javadififar et al., 2019). As these images of what parenting resembles are constantly portrayed, preconjurned thoughts of the benefits are likely to be solely present upon conception (Javadififar et al., 2019). When entering parenthood the multiple changes it can bring on such as financial struggles can ultimately result in a lack of hope within a mother as her ability to care for her child did not meet her expectations (Javadififar et al., 2019).

As a characteristic of hopelessness includes the inability to find meaning, self care practices needed for growth and well being may be lacked (Javadififar et al., 2019). One practices for example that may be overlooked is food consumption (Virtrual Medical Centre, 2018). Maximizing health, food provides a childbearing mother and her newborn with necessary nutrients that aid growth and development (Virtrual Medical Centre, 2018). If absent a childbearing mother and her newborn will be impacted greatly.

To begin, if a mother is undernourished with a BMI of 18.5 or less she is likely to remain that way through pregnancy (Virtrual Medical Centre, 2018). As food is going both to the mother and her child weight gain may be hard to achieve (Virtrual Medical Centre, 2018). With this, a undernourished mother may not be able to adhere to the multiple demands of her baby such as; food demands, this increases the risk of premature death as a mother's body will be overworked more than she can handle (Virtrual Medical Centre, 2018).

Moving on to complications with a newborn, during pregnancy a mother is encouraged to increase her folic acid, calcium, protein and iron intake (Marangoni et al.,, 2016) . These nutrients provide benefits for proper development and growth of a newborn (Marangoni et al., 2016). Folic acid reduces the risk of spinal cord and brain defects, iron increases the amount of oxygen that is delivered to the baby, calcium insures proper bone development and protein promotes proper organ development (Marangoni et al, 2016). Due to the fact that food consumed by a mother is also consumed by her child in the womb, if a mother is not eating her child will not receive these nutrients and as a result birth defects will be likely to occur (Marangoni et al, 2016). A common birth defect that can result is a low birth weight. Allowing for long term disadvantages a low birth weight is associated with respiratory diseases and chromosomal abnormalities (Marangoni et al, 2016).

With this, the importance of Postpartum depression can be seen to be associated with the multiple risk factors that can lead to a diminished quality of life. With this, awareness of the following is important; those who are risk, assessment techniques, and interventions so health care providers are able to understand a person's individual situation in order to to reduce the risk of morbidity and promote optimal health for a mother and her newborn.

Importance

Ghaedrahmati, M., Kazemi, A., Kheirabadi, G., Ebrahimi, A., & Bahrami, M. (2017). Postpartum depression risk factors: A narrative review. Journal of education and health promotion, 6, 60. doi:10.4103/jehp.jehp_9_16

Javadifar, N., Majlesi, F., Nikbakht, A., Nedjat, S., & Montazeri, A. (2016). Journey to Motherhood in the First Year After Child Birth. Journal of family & reproductive health, 10(3), 146–153.

Virtual Medical Centre. (2018). Under-Nutrition Before and During Pregnancy. Retrieved from https://www.myvmc.com/pregnancy/under-nutrition-before-and-during-pregnancy/

Marangoni, F., Cetin, I., Verduci, E., Canzone, G., Giovannini, M., Scollo, P., … Poli, A. (2016). Maternal Diet and Nutrient Requirements in Pregnancy and Breastfeeding. An Italian Consensus Document. Nutrients, 8(10), 629. doi:10.3390/nu8100629

Risk Factors

#1 socioeconomic status

Women who present with a low socioeconomic status are at an increased risk for Postpartum depression (Goyal, Gay & Lee, 2010). Socioeconomic status is associated with two factors; finance and education (Goyal et al., 2010). With this being said, having a low socioeconomic status would deem one to have a low income and low education level. Those with a low socioeconomic status are at a 4% higher risk of obtaining postpartum depression when compared to individuals of higher classes (Goyal et al., 2010). Increasing the the risk of postpartum depression diagnosis, low money and education inhibit one to increase control over their lives.

To begin, regarding finances, vulnerability of obtaining Postpartum depression can be associated to the stresses that an inadequate income influences. As money is limited, one may be torn in regards to spending (Goyal et al., 2010). Facing multiple dilemmas, items of equal importance may be sacrificed due to insufficient funds. As a result of continually having to make such complex decisions, one will be prone to a chronic level of high stress (Goyal et al., 2010). As a result of high stress, when facing stressess of similar levels such as the ones influenced by challenges of pregnancy and parenthood, due to a high arousal one will be triggered easier (Goyal et al., 2010)

Next, lower levels of education increase the risk of postpartum depression (Raven, 2019). Enrollment within an educational institution for a prolonged duration allows for fillings of knowledge gaps revolving postpartum depression through teaching (Raven, 2019). As one progresses through school, they are exposed to a variety of topics through available courses (Raven, 2019). Among, such courses is one specific to parenting. With this course, a variety of topics are presented to students. Allowing for Postpartum depression teachings, complications within a women postpartum stage are discussed (Raven, 2019). Allowing for for a decreased chance of postpartum depression, taught within the course are interventions that can can be used to lower one’s risk of postpartum depression (Raven, 2019). With this increased awareness, when planning to conceive, because taught, one can lower their risk of a postpartum diagnosis with use of interventions (Raven, 2019).

Risk Factors

Goyal, D., Gay, C., & Lee, K. A. (2010). How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers?. Women's health issues : official publication of the Jacobs Institute of Women's Health, 20(2), 96–104. doi:10.1016/j.whi.2009.11.003

Raven, R. (2019). Benefits of Parenting Classes in High School. Retrieved from https://teens.lovetoknow.com/Benefits_of_Parenting_Classes_in_High_School

Risk Factors

##2 Previous diagnosis of depression

Those with a prior depression diagnosis are at a risk for postpartum depression. In fact, those who've had depression within their lifetime are 80% more likely to undergo another mental illness (Shallcross et al., 2015). Recurrence of depression is termed a depression relapse. Disrupting ones recovery process, depression relapse occurs while one is within the stage of remission in regards to recovery. Remission, is a short period of time that one has been symptomless (Moller, Riedel & Seemuller, 2019). Most commonly, the remission stage of recovery persists from four to six months before allowing one to reach recovery. Throughout this duration one can be seen to be vulnerable for a depression relapse (Legg, 2017). This is a result of triggers; visuals, or smells associated with the cause of onset of ones previous depressive state (Shallcross et al., 2015). If one is within the remission stage in respect to recovery, this is a crucial time where helped should be seeked (Shallcross et al., 2015). As one is not fully recovered, due to a associans triggers responsible for previous causes of depression onset, encounter with such again can allow for a depression relapse during or following pregnancy. Thus, resulting in postpartum depression (Shallcross et al., 2015).

#3 Family members with Postpartum depression

Next, if a mental illness has been acquired by a family member, one is put a an increased risk for a postpartum depression diagnosis. A study conducted by Elizabeth Corwin, Ruth Kohen, Monica Jarret & Brian Stafford (2010) provided evidence for this as they consider the role of monoamine oxidase A in regards to mood regulation. Monoamine oxidase A. is a enzyme that is passed on through genes within chromosomes. Monoamine oxidase A being partially responsible for mood regulation plays a part in the prevalence of postpartum depression as it allows for the metabolism of the following monoamines; norepinephrine (Sacher et al., 2014). Norepinephrine is a hormone produced by the adrenal medulla and acts as a neurotransmitter (Sacher et al., 2014). Allowing for mood regulation, norepinephrine stimulates impulses in aims to bring the brain to a state of arousal resulting in happiness (Sacher et al., 2014). As a result of a deficient amount of estrogen following birth, monoamine oxidase-A density is increased (Corwin, Kohen & Jarrett, 2010).With this, norepinephrine is seen to increase (Corwin et al., 2010) Allowing for an increase in of the neurotransmitter results symptoms including anxiety and stress are evident, With postpartum depression being partially influenced by stressors this increase in norepinephrine is likely to bring on postpartum depression during and or following pregnancy. Considering Monoamine oxidase A is passed on through chromosomes, depending on the amount inherited, risk varies (Corwin, et al., 2010).

#4 Childbearing mother

At risk for Postpartum Depression is a child bearing mother. A risk is evident due the fact that experienced following childbirth are fluctuations of reproductive hormones (Hotze Health & Wellness Centre, 2018). A reproductive hormone that contributes to such includes Progesterone (Hotze Health & Wellness Centre, 2018). During pregnancy, progesterone is present at high levels. Following birth an decrease occurs of the reproductive hormone as the need during pregnancy which was to regulate the placenta; a temporary organ that provides nourishment to a fetus is no longer needed (Hotze Health & Wellness Centre, 2018). As progesterone has a role to act on GABA receptors in order to allow the body to achieve a relaxed state, a deficiency will result in the inability to do so (Arelin, 2015). As a result, irritability of an individual will result allowing for increased stress on the brain (Arelin, 2015). This increased amount of stress increases the risk for postpartum depression as it is a stressor related illness (Hotze Health & Wellness Centre, 2018).

Risk Factors Continued

Arélin, K., Mueller, K., Barth, C., Rekkas, P. V., Kratzsch, J., Burmann, I., … Sacher, J. (2015). Progesterone mediates brain functional connectivity changes during the menstrual cycle-a pilot resting state MRI study. Frontiers in neuroscience, 9, 44.

Sacher, J., Rekkas, P. V., Wilson, A. A., Houle, S., Romano, L., Hamidi, J., … Meyer, J. H. (2014). Relationship of monoamine oxidase-A distribution volume to postpartum depression and postpartum crying. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 40(2), 429–435. doi:10.1038/npp.2014.190

Corwin, E. J., Kohen, R., Jarrett, M., & Stafford, B. (2010). The heritability of postpartum depression. Biological research for nursing, 12(1), 73–83. doi:10.1177/1099800410362112

Shallcross, A. J., Gross, J. J., Visvanathan, P. D., Kumar, N., Palfrey, A., Ford, B. Q., … Mauss, I. B. (2015). Relapse prevention in major depressive disorder: Mindfulness-based cognitive therapy versus an active control condition. Journal of consulting and clinical psychology, 83(5), 964–975. doi:10.1037/ccp0000050

Hotze Health & Wellness Centre. (2018). How Childbirth Affects Hormones, Estrogen Dominance, Postpartum Thyroiditis & Adrenal Health. Retreived from https://www.hotzehwc.com/2018/02/how-childbirth-affects-hormones-estrogen-dominan/

Moller, H., Riedel, M., Seemuller, F. (2019). Relapse or recurrence in depression: why has the cutoff been set at 6 months? Retrieved from https://www.medicographia.com/2011/10/relapse-or-recurrence-in-depression-why-has-the-cutoff-been-set-at-6-months/

Legg, T. J. (2017). What are the early signs of a depression relapse? Retrieved from https://www.medicalnewstoday.com/articles/320269.php

Jean Watson's Human Caring Theory

To deepen my understanding of a postpartum depressive patients concerns I will utilize caritas number 5 of Jean Watson's human caring theory. Stated is the action of being “present to, and supportive of the expression of positive and negative feelings” (Watson Caring Science Institute, 2010, p. 2 ). As Jean Watson’s theory is based on providing a transpersonal approach to care, the use of this caritas will be beneficial (Watson Caring Science Institute, 2010). As a transpersonal approach to care can be defined as “reaching beyond the personal realm or transcending the singular, personal state of being” (Clark, 2016, p. 2), it will enable me to go beyond my ego-self in order to understand one's lived experience. I understand the importance to a trans-personal aspect of care, as it encourages seeing a patient as a whole person instead of a source of illness (Watson Caring Science Institute, 2010). Looking at an absence of trans-personal care, the importance of use is further understood as the opposite could easily discourage a postpartum depressive patient; as they endure many symptoms that require constant validation such as, hopelessness, loss of interest and loss of motivation (Watson Caring Science Institute, 2010). With this, potentially restricting formation of a connection, hindered would be my understanding as one is less likely to share information if perceived of no importance (Watson Caring Science Institute, 2010). In order to to fulfill this caritas I plan to utilize communication strategies of empathy, unconditional positive regard and active listening.

Caritas Praxis

Watson Caring Science Institute. (2010) Core Concepts of Jean Watson’s Theory of Human Caring/Caring Science. Retrieved from https://www.watsoncaringscience.org/files/PDF/watsons-theory-of-human-caring-core-concepts-and-evolution-to-caritas-processes-handout.pdf

Caritas Praxis

Empathy

In order to be present to, and supportive of the expression of positive and negative feelings portrayed by an individual with postpartum depression, I will utilize the emotional response of empathy. Empathy can be defined as the ability to understand one's situation, perspective, and feelings without losing sight of one's own (Mercer & Reynolds, 2002). Due to mood swings associated with postpartum depression utilizing empathy will benefit a patient with postpartum depression. As a result of mood swings, one day one can be engaging in normal conversation and anticipating recovery and the next, discussing brutal situations such as suicide and or murder. Utilizing empathy will be ideal to deal with such (Yang, Zhao, Wang, Liu, Zhang, Li & Cui, 2015). Allowing me to be both positive and supportive to a patient's negative feelings, empathy will provide me with two benefits; inhibiting assumptions and promoting non judgemental behavior (Mercer & Reynolds, 2002). As practice that has a empathy basis allows a healthcare professional to understand the whole of a situation from a patient's perspective, the risk of assumptions is decreased (Mercer & Reynolds, 2002). This is beneficial as assumptions can ultimately impede on the nurse-client therapeutic relationship. As assumptions are made based on personal thought and rational, personal reasoning may have little association with a patient. As a result of this, association of such may ultimately offend a patient with postpartum depression ( Mercer & Reynolds, 2002). Next, promoting non judgemental behavior, empathy continues to provide benefits. As one understands the whole of another's situation, criticism is lacked as they understand what has brought them to said situation (Mercer & Reynolds, 2002). Allowing for support and being present to a patient, when in contact with a patient, it will allow for a clear mind when communicating allowing one to adhere to their patient (Mercer & Reynolds, 2002). 25% of those diagnosed by postpartum depression restrain getting help with a fear of of being judged (Pearson, 2014). With non judgemental behavior, trust will be built, ultimately enhancing the client nurse relationship further.

Empathy

Examples of use:

1. "I know how you feel"

2. "It must be hard going to work feeling this way"

3. "It is never easy getting use to something that appears so suddenly"

Mercer, S. W., & Reynolds, W. J. (2002). Empathy and quality of care. The British journal of general practice : the journal of the Royal College of General Practitioners, 52 Suppl(Suppl), S9–S12.

Pearson, C. (2014). Why So Many Women Don't Seek Help For Postpartum Depression. Retrieved from https://www.huffingtonpost.ca/2014/11/18/untreated-postpartum-depression_n_6172742.html

Yang, L., Zhao, Y., Wang, Y., Liu, L., Zhang, X., Li, B., & Cui, R. (2015). The Effects of Psychological Stress on Depression. Current neuropharmacology, 13(4), 494–504. doi:10.2174/1570159X1304150831150507

Caritas Praxis

Unconditional Positive Regard

Next, Utilizing unconditional positive regard will help me be supportive of both negative and positive feelings portrayed by a patient diagnosed with postpartum depression. Unconditional positive regard involves attending to a situation with optimism; the belief that within any positive or negative situation a positive outcome will result (Conversano, Lensi, Della Vista & Arpone, 2010). With this, in regards to dealing with a patient diagnosed with postpartum depression, it will allow one me to be supportive and present through a means of motivation. Unconditional positive regard will help me be present with my patient as it will be prompt to to listen to one’s situation in order to provide motivation in the form of positivity. Next allowing for motivation, unconditional positive regard will allow one to be both supportive to negative and positive feelings as it will provide one with validation that there is hope regardless of personal feelings of doubt (Conversano et., 2010).

Unconditional positive regard/ Active Listening

Active Listening

Lastly, active listening will allow me to be present to my patients negative and positive feelings as active listening promotes effective communication (Jahromi, Tabatabaee, Abdar & Rajabi, 2016). For effective communication to occur, both the sender; the person sending messages through speech and the receiver being the intended audience of the speaker, are expected to be in a mutual understanding of the information proposed (Jahromi et al., 2016). Active listening promotes effective communication as it allows one to remain focus and it allows for validation to the speaker through nonverbal communication (Jahromi et al., 2016). With this, active listening will allow being present to negative and positive thoughts of a patient with postpartum depression as it allows one to obtain the whole of a story (Jaromi et al., 2016). In regards to being present, because active listening requires minimal distractions, it allows one to actual be present with an individual. In regards to being supportive, as received is the whole of a patient's situation allowed will be support through patient specific interventions.

Conversano, C., Rotondo, A., Lensi, E., Della Vista, O., Arpone, F., & Reda, M. A. (2010). Optimism and its impact on mental and physical well-being. Clinical practice and epidemiology in mental health : CP & EMH, 6, 25–29. doi:10.2174/1745017901006010025

Jahromi, V. K., Tabatabaee, S. S., Abdar, Z. E., & Rajabi, M. (2016). Active listening: The key of successful communication in hospital managers. Electronic physician, 8(3), 2123–2128. doi:10.19082/2123

Family Centered Care

Family centred interventions are ideal when considering methods to promote recovery of a postpartum depressive patient. Family-centered interventions involves centring care around a patient and their family members (Backman, Chartrand, Dingwall & Shea, 2017). Family centred care interventions are beneficial for a individual with postpartum depression as it reduces stressors at home in order to create an environment that promotes healing (Backman et al., 2017). When deciding upon appropriate family-centred care interventions for a mother with postpartum depression, I will utilize the social determinants of health to help assist. The social determinants of health are a range of the main social, environmental and personal factors that contribute to health. The social determinants of health can be seen to be made up of the following factors; Income and social status, Employment and working conditions, Education and literacy, Childhood experiences, Physical environments, Social supports and coping skills, Healthy behaviours, Access to health services, Biology and genetic endowment, Gender, and Culture (Braveman & Gottlieb, 2014). Simply, if a family is to have negative and or deficient associations with any one of these factors, stress levels will increase (Braveman & Gottlieb, 2014).. Thus altering a women's transitions to recovery as stressors endured at home may continue one’s depressed mood. With this being said, family centred care interventions in regards of a family's social determinants of health are necessary for a women enduring postpartum depression.

Relevance: With pregnancy, three social determinants of health that commonly individuals struggle with include income, social support and education.

Family Centered Care

Backman, C., Chartrand, J., Dingwall, O., & Shea, B. (2017). Effectiveness of person- and family-centered care transition interventions: a systematic review protocol. Systematic reviews, 6(1), 158. doi:10.1186/s13643-017-0554-z

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it's time to consider the causes of the causes. Public health reports (Washington, D.C. : 1974), 129 Suppl 2(Suppl 2), 19–31. doi:10.1177/00333549141291S206

Family Centered Care Interventions

Income:

Relevance: Pregnancy often cost a lot financially. With the average cost of caring for a baby being around $12, 000 for the first year alone, supplying this may be a challenge (Harris, 2019). With this if a family with individual who is diagnosed with postpartum depression is struggling financially, accommodations should be made in order to help. Importance with this lays with the fact that stressors related to complications of insufficient funds can cause additional stressors for a mother with postpartum depression, which ultimately puts her at risk of worsening symptoms (Blair & Raver, 2016). If one diagnosed with postpartum depression is constantly enduring such stress that dilemmas cause for, recovery is likely to be delayed (Blair & Raver, 2016).

Solution: To help support with such, introducing the thought of involvement within social assistance will be beneficial. Social assistance refers to a variety of programs, funded by the government that allow those who are eligible to receive financial and employment assistance. (Ministry of Children, Community, and Social services, 2019) Reducing stressors it provides a family with funds for basic necessities needed for everyday life, such as; clothing, shelter and food. Allowing for long-term stability, stressors associated with an insufficient fund are likely to be reduce as employment aid is provided (Ministry of Children, Community, and Social services, 2019).

Social support:

Relevance: Those who are teen parents and those with unexpected births, which account for 44% of the world wide population are at a risk of lack of social support during postpartum depression (Bearak, 2018)

Solution: If a couple is has little to no social support during enduring postpartum depression, involvement in postpartum depression support groups will be ideal. Support groups involve a group of people who endure similar situations (Reblin & Uchino, 2006). Postpartum depression support groups will be ideal for a couple who have low social support networks throughout their postpartum stage as it will increase the level of social support they receive and it it will allow them to converse and obtain advice and information from those going through postpartum depression as well (Reblin & Uchino, 2006).

Education

Relevance: Couples who are immigrants and teenage couples are at risk for lack of education on Postpartum depression. This is alarming as since unaware about the illness, these individuals are unlikely able to take precautions such as; exercise and meditation to reduce the risk of a severe case postpartum depression

Solution: Couples who persist with low levels of education will be provided private health teaching classes. Allowing for filling of knowledge gap, health teaching classes provide information to a couple about postpartum depression(Ghaedrahmati, Kazemi, Kheirabadi, Ebrahimi, & Bahrami, 2017). With this, what to expect, what precautions to take, and associated risk factors will be received and sad individuals can act accordingly in order to promote their health (Ghaedrahmati et al., 2017). As it is it understood in regards to intelligence, variations are present among populations, the benefit of health teaching classes being private allows for a couple to acquire information at a pace necessary to facilitate their learning (Ghaedrahmati et al., 2017). In respects to one's culture, benefits continue as health teaching classes can be provided in language of choice to facilitate learning (Ghaedrahmati et al., 2017).

Interventions

Ministry of Children, Community, and Social services. (2019). About social assistance in ontario. Retrieved from https://www.mcss.gov.on.ca/en/MCSS/programs/social/index.aspx

Lee, J. (2016). Benefits of couples counseling. Retrieved from https://www.wellsanfrancisco.com/four-benefits-of-couples-counseling/

Blair, C., & Raver, C. C. (2016). Poverty, Stress, and Brain Development: New Directions for Prevention and Intervention. Academic pediatrics, 16(3 Suppl), S30–S36. doi:10.1016/j.acap.2016.01.010

Bearak, J., Popinchalk, A., Alkema, L., Gilda, S. (2018). Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. The Lancent Updates, 6(4), 380-389.

Reblin, M., & Uchino, B. N. (2008). Social and emotional support and its implication for health. Current opinion in psychiatry, 21(2), 201–205. doi:10.1097/YCO.0b013e3282f3ad89

Assessment Tools

When an individual is suspected of acquiring postpartum depression, to confirm a diagnosis, assessment tools are necessary for use (Registered Nurses Association of Ontario, 2019). Recommend by the the Registered Nurses Association of Ontario (Registered Nurses Association of Ontario, 2019) routinely screening postpartum depression is necessary up to one year in all child bearing mothers within there postpartum stage (Registered Nurses Association of Ontario, 2019). The importance of use of assessment tools with a individual suspected to have postpartum depression is related to assessment tools being responsible for the detection of nearly 50% of those with a postpartum depression diagnosis (Registered Nurses Association of Ontario, 2019). Further need for the importance is due to the fact assessment tools allow for early detection of an illness (Registered Nurses Association of Ontario, 2019). With this, it allows for interventions to take place to reduce severity of Postpartum Depression (Registered Nurses Association of Ontario, 2019).

Benefits: Benefits of assessment tools continue as they also promote accurate diagnosis. Postpartum Depression can be seen to coexist with other mental illnesses such as; dementia (Li et al., 2011). Both dementia and postpartum depression can be seen to have similar symptoms (Li et al., 2011). These symptoms include; self-esteem and confidence, tearfulness and appetite, concentration and memory problems (Li et al., 2011).

Two assessment tools that allow for the detection of Postpartum depression include; The Edinburgh Postnatal Depression scale and The Patient Health Questionnaire.

Assessment tools

Registered Nurses AssosiatAssociationion of Ontario. (2019). Assessment and Interventions for Perinatal Depression. Retrieved from https://rnao.ca/bpg/guidelines/assessment-and-interventions-perinatal-depression

Li, G., Wang, L. Y., Shofer, J. B., Thompson, M. L., Peskind, E. R., McCormick, W., … Larson, E. B. (2011). Temporal relationship between depression and dementia: findings from a large community-based 15-year follow-up study. Archives of general psychiatry, 68(9), 970–977. doi:10.1001/archgenpsychiatry.2011.86

Assessment Tools

Assessment tools continued

The Edinburgh Postnatal Depression Scale is among assessment tools geared specifically for Postpartum depression (Registered Nurses Association of Ontario, 2019). The Edinburgh Postnatal Depression Scale is a questionnaire that provides one with a ten questions that aim to determine if one has symptoms of postpartum depression (Provincial Health Services Authority, 2019) Questions provided range from one's personal perception of emotions to the presence of any harmful motives such as suicide (Provincial Health Services Authority, 2019). The Edinburgh Postnatal Depression Scale is put in place to assess one's state within the previous seven days. (Provincial Health Services Authority, 2019). The significance of a prior seven day time frame allows for accurate diagnosis of postpartum depression (Provincial Health Services Authority, 2019). Due to the fact that for postpartum depression to be confirmed symptoms must be present for at least 2 weeks this is necessary (The American College of Obstetricians and Gynecologist, 2013). While answering each question, points are accumulated. When finished, the total of points accumulated indicates the risk for postpartum depression. If one scores less that 8 points, then postpartum depression is not likely, points of nine to eleven indicate a high possibility of postpartum depression, and if a score results higher than 14 then postpartum depression is possible (Provincial Health Services Authority, 2019).

Suicide detection: The The Edinburgh Postnatal Depression Scale not only determines the presence of postpartum depression, but also the presence of suicidal thoughts (Provincial Health Services Authority, 2019). If the first three questions of the The Edinburgh Postnatal Depression Scale obtained a positive score than an individual would be at a risk for suicide (Provincial Health Services Authority, 2019) .

Benefits: The benefit of the Edinburgh Postnatal depression scale includes sensitivity as it has an 81% accuracy in detecting depression (Ing, Fellmeth, White, Stein, Simpson & McGready, 2017).

Ing, H., Fellmeth, G., White, J., Stein, A., Simpson, J. A., & McGready, R. (2017). Validation of the Edinburgh Postnatal Depression Scale (EPDS) on the Thai-Myanmar border. Tropical doctor, 47(4), 339–347. doi:10.1177/0049475517717635

Provincial Health Services Authority. (2019). The Edinburgh Postnatal Depression Scale. Retrieved from http://www.perinatalservicesbc.ca/health-professionals/professional-resources/health-promo/edinburgh-postnatal-depression-scale-(epds)

The American College of Obstetricians and Gynecologist. (2013). Postpartum Depression. Retrieved from https://www.acog.org/Patients/FAQs/Postpartum-Depression?IsMobileSet=false

Assessment Tools Continued

The Patient Health Questionnaire (PHQ-9)

The Patient Health Questionnaire (PHQ-9) is another assessment tool that can be used to assess a patient with postpartum depression (Hinz, Mehnert, Kocalevent, Brähler, Forkmann, Singer, & Schulte, 2016). Differing from the Edinburgh Postnatal Depression scale, the The Patient Health Questionnaire is a two part questionnaire that is made use of on those with a confirmed case of depression and measures to the extent of how sevre one has acquired the illness (Hinz et al., 2016). The first part of the The Patient Health Questionnaire (PHQ-9) presents with a total of nine questions (Hinz et al., 2016). In order to assess severity of Postpartum depression that one has acquired, questions asks one to reflect on the past two week. Similar to the The Edinburgh Postnatal Depression Scale, while completing points are accumulated (Hinz et al., 2016). With a possibility of 27 points, the amount of points that one has achieved determines severity (Hinz et al., 2016). A score of 0 to 4 indicates postpartum depression as being absent in an individual and interventions at this point should consist of monitoring the patient, a score of 5 to 9 indicates postpartum depression is mildly acquired and the use of clinical judgement will be needed in order to diagnose, a score of 10-14 indicates postpartum depression being moderate, a score of 15-19 indicates a moderately severe case that should be attended to with psychotherapy and if points acquired are anywhere from 20 to 27 said individual has a severe case of postpartum depression (Hinz et al., 2016). The second part of the The Patient Health Questionnaire (PHQ-9) does not apply to all. Only does who have achieved the maximum points possible should next have completed the second portion (Hinz et al., 2016). The second portion provides one with four questions inquiring about suicide (Hinz et al., 2016).

Assessment Tools Continued

Hinz, A., Mehnert, A., Kocalevent, R. D., Brähler, E., Forkmann, T., Singer, S., & Schulte, T. (2016). Assessment of depression severity with the PHQ-9 in cancer patients and in the general population. BMC psychiatry, 16, 22. doi:10.1186/s12888-016-0728-6Registered Nurses Assosiation of Ontario. (2019). Assessment and Interventions for Perinatal Depression. Retrieved from https://rnao.ca/bpg/guidelines/assessment-and-interventions-perinatal-depression

Interventions

Screening tool: In order to promote optimal health for a mother with a Postpartum depression diagnosis, interventions should be put in placed. The first intervervention that should be put in place for a patient with postpartum depression is a screening tool (Registered Nurses Association of Ontario, 2019). Allowing for early detection, use of screening tools make evident one’s associated risk with of postpartum depression and if acquired, the severity (Registered Nurses Association of Ontario, 2018). In regards to a Patient with postpartum depression, A screening tool that will assist with further direction of additional interventions to incorporate within assessment is the use the Edinburgh Postnatal Depression Scale (EPDS) (Registered Nurses Association of Ontario, 2018). The Edinburgh Postnatal Depression Scale confirms if an individual has postpartum depression or not (Registered Nurses Association of Ontario, 2018). Depending on the results, if one scores for a high risk for Postpartum depression the following interventions are necessary; a comprehensive assessment, formulating a collaborative care plan, promoting self care strategies, and utilization of psychotherapy (Registered Nurses Association of Ontario, 2018). On the contrary, for a result indicating a low risk of postpartum depression ideal for such individual would be health teaching (Paterick et al., 2017).

Edinburgh postnatal depression scale

Interventions

Benefits: Benefits with the use of the Edinburgh Postnatal Depression Scale (EPDS) not only lie with the allowances of timely interventions, but as a section of questions are dedicated to identify the presence of existing suicide plans, it can ultimately reduce the risk of premature death among postpartum depressive patients (Registered Nurses Association of Ontario, 2018). This is necessary as a numerous amount of suicides are the result of a mental illnesses. In fact alongside substance use disorders, depression is the most prevalent diagnosis among suicide victims, accounting for a total of 1.4% of deaths worldwide (Bradvik, 2018).

Registered Nurses Assosiation of Ontario. (2019). Assessment and Interventions for Perinatal Depression. Retrieved from https://rnao.ca/bpg/guidelines/assessment-and-interventions-perinatal-depression

Brådvik L. (2018). Suicide Risk and Mental Disorders. International journal of environmental research and public health, 15(9), 2028. doi:10.3390/ijerph15092028

Paterick, T. E., Patel, N., Tajik, A. J., & Chandrasekaran, K. (2017). Improving health outcomes through patient education and partnerships with patients. Proceedings (Baylor University. Medical Center), 30(1), 112–113.

Registered Nurses Association of Ontario. (2019). Assessment and Interventions for Perinatal Depression

Interventions continued

After analyzing the results of the Edinburgh Postnatal Depression Scale (EPDS), if an a mother were to have a score ranging from zero to seven, indicating a low risk for Postpartum depression interventions necessary for said individual would include health teaching.

Health teaching: Health teaching provides information to an individual on a health related topic (Paterick, Patel, Tajik & Chandrasekaran, 2017). Health teaching can be done in the form of counselling, classes, and support groups.

Benefits: Health teaching will be ideal for a patient with a low risk of Postpartum depression as it will educate one on what to expect if a Postpartum depressive episode were to occur. (Paterick et al., 2017) Potentiating health, an individual would then have a high sensitivity of indicating such symptoms which would increase the risk of necessary interventions being able to be taken place within a timely manner if symptoms were to be detected (Paterick et al., 2017).

Importance: The importance of health teaching for a mother who presents with a low risk for postpartum depression, lies with the fact that postpartum depression has an onset that ranges from birth up to one year following (RNAO, 2018). With that being said, if not present during time of screening, which is encouraged 2 weeks following childbirth, one is still able to develop postpartum depression at a later time (Rnao, 2018).

Low Risk Intervention

Registered Nurses Association of Ontario. (2019). Assessment and Interventions for Perinatal Depression

Interventions continued

If the results from the use of the Edinburgh Postnatal Depression Scale present a score of 14 and up, indicating a high possibility of postpartum depression, a comprehensive assessment, collaborated care plan and psychotherapy should be issued to a mother with postpartum depression (Registered Nurses Association of Ontario, 2019).

Comprehensive Assessment: A comprehensive assessment consists of a health history and a physical examination (RNAO, 2019) When comparing both similarities arise between a health history and a physical assessment as the aid to acquire information on a patient (Jiang & Li, 2016) . Differing from one another, a health history inquires information on social, cultural, familial, and economic aspects of the patient's life through questioning and a physical assessment receive information about one's physical makeup by palpation and percussion; through touch, Auscultating; though listening and inspection (Jiang & Li, 2016).

Benefits: A comprehensive assessment provides possible links to Postpartum depression by considering a patients whole situation (RNAO, 2019). With this, further interventions can be made in specific to an individual's situation (Jiang & Li, 2016).

Collaborative care plan: A collaborative care plan being; a document of how care should be directed in respect of a patient and the interpersonal team, allows for many benefits for postpartum depression management (Rnao, 2019). A care plan assists with postpartum depression management as it as it allows for guidance in an organized way on how to improve and promote optimal health (Grote, Katon, Russo, Lohr, Curran, Galvin & Carson, 2015).

Benefits: A care plan being collaborative is necessary for an individual with a high risk for postpartum depression as it allows for two important benefits; patient centred care and efficient interventions. To begin, With a care plan being made alongside the patient, it allows for patient centred care . With a collaborative care plan being made in respect of the patient, values, preferences and beliefs of the patient will be gathered and taken into consideration when deciding upon further interventions (Grote et al., 2015). With this, benefits arise as care is specific to accommodate one’s needs. Next, as the symptoms of postpartum depression can cause a number of complications, cooperation of different professions may be necessary in order to promote recovery. Looking at common symptoms of postpartum depression one will benefit from a collaborative care as they may require counselling from a therapist to deal with lack of motivation and stress, a psychiatrist to deal with anxiety, and a doctor or nurse to provide necessary treatments and medications (Grote et al., 2015).

Psychotherapy: Psychotherapy promotes recovery as it allows one to self identify problems in order to facilitate change (Registered Nurses Association of Ontario, 2019). The most common type of psychotherapy that allows for this result is Cognitive behavioral therapy (camh, 2019). Cognitive behavioural therapy is a type of psychotherapy that is associated with improvements with depression and other mental illnesses (camh, 2019). Challenging negative feelings and thoughts influenced by mental illness, cognitive behavioral therapy promotes healing by allowing individual to the self-identify barriers inhibiting change (camh, 2019).

Benefits: The benefits of cognitive behavioural therapy is that it is is timely with an expected duration of 5 to 10 minutes and it allows for patient autonomy, allowing the patient to self identify a problem instead of being told (camh, 2019).

High Risk Interventions

Jiang, S., & Li, P. (2016). Current Development in Elderly Comprehensive Assessment and Research Methods. BioMed research international, 2016, 2-10.

Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative Care for Perinatal Depression in Socioeconomically Disadvantaged Women: a Randomized Trial. Depression and anxiety, 32(11), 821–834. doi:10.1002/da.22405

Cahm. (2019). Cognitive-behavioural therapy. Retrieved from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/cognitive-behavioural-therapy

Registered Nurses Association of Ontario. (2019). Assessment and Interventions for Perinatal Depression

Interventions continued

Following a screen that indicates a high risk for for postpartum depression, introduced should be self-care interventions (Registered Nurses Association of Ontario, 2019). Self care interventions such interventions including; time for self, exercise, and relaxation promotes health as it allows for a holistic healing; healing of the mind body and spirit (Registered Nurses Association of Canada, 2019).

1. Time for self: Encouraging a mother with postpartum depression to allow time for herself is important (Registered Nurses Association of Ontario, 2019). Due to the multiple needs a newborn requires, a mother may spend constant time with a child to ensure needs are met (Roskam, Raes, & Mikolajczak, 2017). This can often leave the a mother lack time for their own personal needs (Roskam et al., 2017). Being detrimental to a mother suffering from postpartum depression as the main cause of onset revolves around parenting If one is never relieved from their duty, due to constant reminders stress may stay persistent (Roskam et al., 2017). With this being said, allowing time for self gives a mother a break from the constant stressors faced through parenting.

Ways this will can be done: Encouraged will be to going on walks, hanging out with friends, partaking in hobbies, and physical activity (Roskam et al., 2017).

2. Exercise: Next, a postpartum patient should partake in exercise (Registered Nurses Association of Ontario, 2019). Specifically speaking, aerobic exercises that include; jogging, swimming, dancing and walking improve one's mental health as they allow for an increased production of serotonin in the brain (Childs & de Wi, 2014). As serotonin aids in mood regulation allowing for optimistic emotions, with increased exercising depressive symptoms will be overpowered (Childs & de Wi, 2014).

Ways this will be done: Mothers 18 and older affected by postpartum will be encouraged to follow the recommended exercise duration of 2 hours and 30 minutes and mothers affected by postpartum depression who are 17 and under will be encouraged to partake in the recommended duration of 30 minutes of exercise (Health Canada, 2011)

Relaxation: Relaxation is another intervention ideal for a patient with postpartum depression (Registered Nurses Association of Ontario, 2019). Relaxation can be done in a variety of ways and aims to reduce tension and anxiety holistically; of the mind body and spirit Norelli, (Krepps & 2019).

Ways this will be done: Encouraged will be a variety of activities that allow for relaxation such as; deep breathing, meditation, yoga, getting a massage, and listening to music

High risk interventions continued

Childs, E., & de Wit, H. (2014). Regular exercise is associated with emotional resilience to acute stress in healthy adults. Frontiers in physiology, 5, 161. doi:10.3389/fphys.2014.00161

Health Canada. (2011). Canada’s Food Guide. Retrieved from https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide-aliment/print_eatwell_bienmang-eng.pdf

Laneri, D., Schuster, V., Dietsche, B., Jansen, A., Ott, U., & Sommer, J. (2016). Effects of Long-Term Mindfulness Meditation on Brain's White Matter Microstructure and its Aging. Frontiers in aging neuroscience, 7, 254. doi:10.3389/fnagi.2015.00254

Norelli SK, Krepps JM. Relaxation Techniques. [Updated 2019 Jan 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513238/

Registered Nurses Association of Ontario. (2019). Assessment and Interventions for Perinatal Depression

Roskam, I., Raes, M. E., & Mikolajczak, M. (2017). Exhausted Parents: Development and Preliminary Validation of the Parental Burnout Inventory. Frontiers in psychology, 8, 163. doi:10.3389/fpsyg.2017.00163

How will I know my interventions were effective?

To assess if interventions provided to a mother with postpartum depression were effective an assessment tool should be re administered and visual inspection should be utilized. To begin, effectiveness of interventions can be measured by re administering the Edinburgh Postnatal Depression Scale. Comparing results from from a prior screening will allow the indication of improvements Following re-administering the Edinburgh Postnatal Depression Scale if presented is a lower score, indicating a lower score for postpartum depression interventions should be concluded as effective. Next, through visual inspection of a mother with postpartum depression, effectiveness of interventions can be gathered. Symptoms of postpartum depression are noticeably defining with expressions of sadness, lack of motivation and hopelessness. With this, if an individual is presenting with contrasting expressions with a clear presence of happiness interventions can be seen as effective. To encourage further recovery I will continue said interventions of; encouraging self care practices, and social support to allow for a full recovery if not yet reached.

Effectiveness of interventions

Change in facial expression

Edinburgh postnatal scale

How has evidence based research changed my practice?

After analyzing a various of evidence based research, my ability to provide skillful care to a mother with postpartum depression has improved. As prior to my research I had multiple knowledge gaps on how to go on about assessment and what interventions that would promote health for a mother with postpartum depression, Evidence based research has equipped me with the skills necessary and will allow me in the future to insure I make use of them in my practice. I know understand to go about assessments I should, utilize screening tools, conduct a comprehensive assessment, create a collaborative care plan, engage using psychotherapy and promote self care (Registered Nurses Association of Ontario, 2019). Conducting research that I had has also allowed me to understand the uniqueness of each mothers diagnosis as I now understand that Postpartum depression varies greatly from onset, symptoms, severity and recovery process. With this, during my practice when dealing with one who has postpartum depression I will ensure to gather subjective information from the patient of how they perceive the illness. With this, I will be able to alter interventions specific to my patients to aid with recovery.

Conclusion

Registered Nurses Association of Ontario. (2019). Assessment and Interventions for Perinatal Depression. Retrieved from https://rnao.ca/bpg/guidelines/assessment-and-interventions-perinatal-depression

References