Postpartum depression, or depression after childbirth, is a widespread and potentially devastating condition. Symptoms range in severity, but typically include standard difficulties associated with depression, with the addition of a disinterest in and/or thoughts of harming the new baby (Dennis, 2013). An inquiry into the LVPG (Lehigh Valley Practice Group) OBGYN and Pediatric offices within the LVHN (Lehigh Valley Health Network) determined that each practice has about four mothers per month (with one possible exception of 20-30 per month) who develop postpartum depression, but there is a limited amount of support available to these patients. A review into the current research base suggests that providing emotional support within the primary care setting and utilizing nontraditional formats (i.e. online and telephone) to provide evidence-based treatment would effectively support mothers struggling with postpartum depression while minimizing the number of referrals needed to outside psychiatric providers.
The birth of a new child is, for most, expected to be a joyous, exciting experience. Unfortunately, this is not the case for the large number of women who develop a perinatal mood disorder, such as postpartum depression (PPD). This condition affects women across all ages, socioeconomic status, and levels of parenting experience (Yawn et al., 2012). While there are variances in reported prevalence rates depending on the time and type of screening used, a recent Cochrane Review found a 19.2% prevalence rate of postpartum depression within the first 12 weeks following birth, with a 7.1% period prevalence of major depression (Dennis, 2013).
The exact etiology of postpartum depression remains unclear. However, there are quite a few known risk factors. Mothers who have a history of psychopathology (especially of anxiety or depression), have been abused, or are young are at a higher risk for developing postpartum depression (Dennis, 2013). Stressful life events, such as marital conflict, occurring concurrently with the already stressful process of adjusting to life with a new baby, also increase a mother’s risk. A lack of social support further compounds this increased risk (Dennis, 2013).
The severity and duration of symptoms vary widely, from mild baby blues which generally last less than two weeks, to severe postpartum psychosis, which is very rare and extreme. Common symptoms include dysphoria, sleep disturbances, changes in appetite, guilt, confusion, disinterest in the baby, and thoughts of harming oneself and/or the child; if left untreated these symptoms can develop into severe clinical depression (Dennis, 2013).
The effects of postpartum depression are not limited to the woman suffering, but also have direct impacts on the wellbeing of the infant. Depressed mothers have been shown to interact differently with their infants when compared to their non-depressed counterparts. For example, they tend to do use less infant-directed speech, have less synchrony in their interactions with their infants, spend less time touching their infants and do so in a proportionally more negative manner, and perform fewer enrichment activities such as reading, playing games, and singing songs (Field, 2010). As the child ages, depressed mothers also discipline less consistently and tend to use less positive reinforcement (Dennis, 2013). The risk of the use of harsh punishment, such as spanking, hitting, or slapping, is increased with depressed mothers (Field, 2010). The quality of caregiving practices also suffers when depression comes into play. Mothers suffering from depression are less likely to continue breastfeeding or to keep up with appropriate well-visits and vaccinations for the child, and tend to have more acute care visits, such as trips to an emergency room (Field, 2010).
All of these differences have negative impact on the children. Children of depressed mothers have been shown to be more fussy, more likely to have an insecure attachment with the mother, perform more negatively on measures of cognitive and motor development, and show slower development of self-regulatory strategies (Dennis, 2013). Later, children whose mothers were depressed during infancy use less expressive language, and perform more poorly on measures of cognitive-linguistic functioning (Field, 2010). These effects can follow the child throughout their life, potentially negatively impacting their future relationships and overall life satisfaction.
From this information, it is clear that there is a need for a comprehensive model of care for patients of our network who need emotional support after delivery. The researcher’s goal was to discern the current care being given to moms who need emotional support after delivery, gaps in our process, and to explore possibilities for improvement in the care we provide to the mothers and families who come through our system.
The first goal was to determine the need for postpartum emotional support within our network, and the current process of care for those mothers who require support. Emails were sent to College Heights OBGYN, OBGYN Associates of the Lehigh Valley, ABC Pediatrics, and the Center for Women’s Medicine, and a discussion was had with a provider from 402-CARE. Topics covered included the number of mothers from each area needing emotional support after delivery and the current process of providing support to these women.
With this information in mind, the next step was to explore the current research base to find some evidence-based treatment options for improving care within our system. Research was conducted on the efficacy of traditional models of care (i.e. support groups, individual therapy, screening, etc.) as well as more progressive options, such as telephone and online support. All options explored originated in published, peer-reviewed journal articles.
Additionally, the internet was explored in an attempt to identify outside resources available to our hospital and patients. All websites were reputable, national sources including Postpartum Support International and the CDC.
The first objective of this research was to uncover a clearer image of the current process of care for patients needing emotional support after delivery. In order to become more fully aware of the need for postpartum emotional support, I asked College Heights OBGYN, OBGYN Associates of the Lehigh Valley (OBGA), the Center for Women’s Medicine, and 402-CARE about the number of women they hear from each month needing emotional support after delivery. 402-CARE is getting about one call per month, OBGA reports having less than four postpartum depression patients per month, ABC Pediatrics has up to 5 positive screens for PPD per location per month, and the Center of Women’s Medicine is providing support to 40 per year. College Heights OBGYN reports receiving 20 – 30 moms per month who need referrals for postpartum depression. This number is significantly higher than those of the other providers. The reason for this disparity is unclear, but should be examined in order to ensure accuracy.
I also attempted to discover what is currently being done for these patients. At College Heights OBGYN, nurses attempt to refer these calls to appropriate psychiatric services based on insurance, but mentioned that occasionally they reach the end of their list without successfully finding a provider currently accepting new patients, at which time the patient is told to call their insurance provider for further assistance. Darla Moyer at 402-CARE sends an informational packet to each mom who calls seeking support, makes personalized phone calls, and refers them to the postpartum support group. This support group, called “Understanding Emotions After Delivery,” had previously been successful and is positively reviewed by those who attend, but has been declining in popularity and is now scarcely attended.
The second objective of this researcher was to examine the current research base to identify evidence-based options for improved postpartum emotional support. The beginning of any care process involves detection of the condition requiring attention. Currently, ABC Pediatrics is screening mothers using the Edinburgh Postnatal Depression Scale (EPDS) at the baby’s one-month well visit. The use of this scale is appropriate, and is recommended by several sources due to its non-clinical questions and ability to pick up on stress and anxiety as well as depression (Chaudron et al., 2010). However, screening only at one month postpartum may be inadequate for detecting many cases of PPD. There is an elevated risk for the development of depression during the first three months postpartum, and PPD can develop throughout the first year after birth (Wisner et al., 2010). Therefore, at least one more screening at a later time postpartum, such as at 12 weeks, is recommended (Wisner et al., 2010; Chaudron et al., 2010).
However, screening alone does not lead to improved patient outcomes or increased levels of treatment (Yawn et al. 2012, Patel et al., 2010). Once a case of postpartum depression is identified, there must be effective treatment options available to the patient. A meta-analysis of screening, diagnosis, and management programs over a 10-year period found that successful programs were self-contained within primary care and had specific, detailed follow-up, management, and therapy procedures in place (Yawn et al., 2012). A stepped-care model provides a framework for developing such a program. The model works as follows (Miller et al., 2010):
Screen all patients
Diagnostic on-site evaluation for scores above a certain cutoff
Identification of women to treat on site based on severity and complexity
Referral to mental health care if response to treatment is inadequate
This model of care allows the majority of patients to receive care within the primary care setting, thereby reducing the strain on the limited number of psychiatric care providers (Miller et al., 2010). It also reflects the preferences of moms, as a study recently found that 69.4% of moms with perinatal depression preferred to receive treatment at their OB office, either from an OB practitioner or on-site mental health professional, rather than be referred to a psychiatric care setting (Goodman, 2009).
Another option would be to incorporate evidence-based methods into non-traditional formats, such as through telephone and online support. Both of these formats eliminate the need for mothers to travel outside of their homes, would allow them to seek treatment at times that work within their schedule, and would allow them to keep their need for treatment confidential. All of these benefits would combat the top three reported barriers to treatment: lack of time, stigma, and an inability to find someone to take over childcare while they attend appointments (Goodman, 2009).
Screening with the EPDS, peer support, and interpersonal therapy (IPT) have all been effectively incorporated into telephone settings and have favorable results on the reduction of PPD symptomology and/or incidence (Dennis, 2013). While there are no online programs currently offered for the treatment of PPD, there is one in trial stages (entitled MomMoodBooster) that has achieved favorable results (Danaher et al., 2012). In addition, there are a large number of outside resources, such as Postpartum Support International, that offer online support through chat rooms and forums, as well as telephone support.
This evidence-based information can be incorporated into an updated, more comprehensive model of care for within our network. Screening using the EPDS should be conducted at two points postpartum, with the additional screening being at a later time postpartum, such as between 10 and 12 weeks. The screening is available online and can be administered over the phone, so if it cannot be worked into a routine at a provider’s office, it could be administered in one of these alternative formats.
The largest challenge facing providers has been the lack of mental health professionals available for referrals. Therefore, referrals should be limited to those patients for whom intensive, one-on-one therapy with a professional is a necessity. This could be accomplished by implementing a stepped-care model with a social worker located at either the OB or pediatrician offices. With this model in place, patients could discuss screening results and receive baseline support in a familiar setting. Only patients with severe PPD or who did not respond to this baseline support would need to be referred outside the primary care office.
Alternative formats of care, such as telephone and web support, should also be considered as a method for reducing the burden on the network’s providers while increasing the amount of support available to patients. Outside resources should be promoted to patients as an additional method of finding support and gaining education. For example, Postpartum Support International (postpartum.net) offers a “Chat with an Expert” program which provides telephone support guided by a trained professional several times per month, as well as a vast amount of information and links to additional resources.
These changes would increase the number of patients receiving the care necessary to effectively manage difficult emotions during the postpartum period, and increase the overall quality of care provided by the network to its patients and the community.
Chaudron, L. H., Logsdon, C., Turkin, S., White, J. (2010, June 4). Perinatal depression: Detection and screening. The Pittsburgh Training Program for Perinatal Depression Screening. Lecture conducted from University of Pittsburgh, Pittsburgh, PA. Accessed online at http://mededppd.org/pitt_overview.asp.
Danaher, B., Milgrom, J., Seeley, J., Stuart, S., Schembri, C., Tyler, M., et al. MomMoodBooster Web-Based Intervention for Postpartum Depression: Feasibility Trial Results. Journal of Medical Internet Research, e242.
Dennis C. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews [serial online]. January 11, 2013; (2) Available from: Cochrane Database of Systematic Reviews, Ipswich, MA. Accessed June 23, 2014.
Field, T. (2010). Postpartum depression effects on early interactions, parenting, and safety practices: A review. Infant Behavioral Devlopment 33(1), 1. http://dx.doi.org/10.1016/j.infbeh.2009.10.005
Goodman, J. H. (2009), Women’s Attitudes, Preferences, and Perceived Barriers to Treatment for Perinatal Depression. Birth, 36: 60–69. doi: 10.1111/j.1523-536X.2008.00296.x
Miller, L. J., Hughes, C., Swartz, H., Wisner, K. (2010, June 4). Iterative steps in a comprehensive program model: Treatment overview. The Pittsburgh Training Program for Perinatal Depression Screening. Lecture conducted from University of Pittsburgh, Pittsburgh, PA. Accessed online at http://mededppd.org/pitt_overview.asp.
Patel, S. R., Barkin, J. L., McShea, M., Stein, B. (2010, June 4). Improved Outcomes for Perinatal Depression. The Pittsburgh Training Program for Perinatal Depressio
Published In/Presented At
Perhamus, G., (2014, July, 25) Improving Care for Postpartum Depression. Poster presented at LVHN Research Scholar Program Poster Session, Lehigh Valley Health Network, Allentown, PA.
Research Scholars, Research Scholars - Posters