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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. kmcqueen@lakeheadu.ca Postpartum depression is a serious health issue affecting 13% of women from diverse cultures. Despite the welldocumented consequences of postpartum depression, it remains difcult 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 conrmation, prevention, and treatment of depressive symptoms in postpartum mothers.

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Keywords postpartum depression best practice guidelines recommendations evidence nurses

Accepted October 2007

MA(N), assistant professor, School of Nursing, Lakehead University, Thunder Bay, Ontario, Canada PhD, associate professor, School of Nursing, Laurentian University, Sudbury, Canada MN, manager, Clinical Genetics & Metabolics, The Hospital for Sick Children, former Best Practice Guidelines Coordinator, Registered Nurses Association of Ontario PhD, assistant professor, School of Nursing, University of Western Ontario, London, Canada MN, primary care nurse practitioner, University Health Centre, Toronto, Canada
5RN, 4RN, 3RN, 2RN,

1RN,

ostpartum depression is a serious condition that affects approximately 13% of new mothers (OHara &

To partially address this issue, the Registered Nurses Association of Ontario (RNAO, 2005) developed a best practice guideline (BPG) entitled Interventions for Postpartum Depression to promote evidence-based practice in the conrmation, prevention, and treatment of postpartum depression. Its rigorous development involved a systematic appraisal of scientic evidence for the purpose of assisting nurses with clinical decision making to achieve effective client outcomes. The purpose of this article was to outline the 10 clinical postpartum recommendations with their supporting evidence.

Swain, 1996) most frequently within the rst 12 weeks after delivery (Gaynes et al., 2005; Goodman, 2004). The consequences of postpartum depression are well documented for mothers and infants (Austin & Priest, 2005; Mayberry & Affonso, 1993; Murray & Cooper, 1997). In particular, the presence of maternal depression inuences a mothers ability to emotionally and cognitively interact with her infant and family especially when the depression is prolonged and untreated. Additionally, women who have suffered from postpartum depression are twice as likely to experience another depressive episode within a 5-year period (Cooper & Murray, 1995). Despite the negative outcomes associated with postpartum depression, it often remains undetected, as many mothers are reluctant to disclose symptoms of depression and seek treatment even when they are in frequent contact with health professionals (Dennis & Chung-Lee, 2006). In particular, a study of 60 primiparous mothers in the U.K. found that only 25% of the mothers sought professional assistance for depressive symptoms (McIntosh, 1993). As such, postpartum depression remains an undetected condition of maternal morbidity, and no systematic approach to its detection, prevention, or treatment has been established in nursing practice.

Methods
The RNAO BPG development is a provincial effort that was initiated in 1999 to improve the quality of nursing care by promoting interventions with the best available empirical support. In 2004, a panel of researchers, clinicians, consumers, and administrators with expertise in the area of postpartum depression was established by the RNAO to review existing evidence for the purpose of developing practice, education, and policy recommendations. Through a process of consensus and discussion, the panel determined from the outset that the scope of the guideline was the conrmation, prevention, and treatment of postpartum depression during the rst postpartum year.

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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.
Three clinical questions guided the identication of relevant research literature: (a) how can nurses conrm 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 peerreviewed research and guidelines published in English between 1985 and 2004. This yielded approximately 106 articles and two guidelines (British Columbia Reproductive Care Program, 2003; Scottish Intercollegiate Guidelines Network, 2002) related to the research questions for 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. However, the panel determined that the two guidelines did not comprehensively address the scope identied by the RNAO panel. Next, a masters prepared nurse with expertise in critical appraisal conducted a quality appraisal of the studies using the Effective Public Health Practice Project (2003) Quality Assessment Tool for Quantitative Studies. The tool is divided into several sections including selection and allocation bias, confounders, blinding, data collection methods, withdrawals and dropouts, analysis, and intervention integrity. Using the scoring 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,

of evidence presented in Table 1. The next step involved review and revision of each drafted recommendation by the guideline panel. The 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 nal step was the integration of the stakeholders feedback. The completed RNAO guideline includes 10 specic practice, 1 educational, and 3 organizational/policy recommendations. For a more detailed explanation of the method, the guideline is available at www.rnao.org. An updated literature search using the same keywords, databases, and clinical questions was conducted for the years 2005 to August 2007 to ensure that the current research evidence supports the practice recommendations. A total of 12 articles were identied and included.

Findings and Recommendations

In total, 10 specic practice recommendations were developed (Table 2), including 2 prevention recommendations, 6 recommendations related to the conrmation of depressive symptoms, and 2 that addressed treatment of postpartum depression. For each recommendation, its supporting research is discussed in addition to the identication of its level of evidence. Prevention Recommendations. Recommendation 1. Nurses provide individualized, exible postpartum care based on the identication of depressive symptoms and maternal preference (Level of Evidence = Ia). 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

Ia Ib IIa IIb III IV Evidence obtained from meta-analysis or systematic review of randomized controlled trials. Evidence obtained from at least one well-designed randomized controlled trial. Evidence obtained from at least one well-designed study without randomization. Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization. Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies. Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

viewers indicate that the preventive approaches were diverse: antenatal and postnatal classes, lay home visits, or early postpartum follow-up (Boath, Bradley, & Henshaw, 2005; Chabrol & Callahan, 2007; Dennis, 2005). Supportive home visits made postnatally were identied as being particularly effective when the population included vulnerable 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 exible and meet the individual needs of the new mother. Individual maternal needs were determined by

Note. Registered Nurses Association of Ontario (2005).

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Table 2: Practice Recommendations

Recommendation Prevention 1. Nurses provide individualized, exible postpartum care based on the identication of depressive symptoms and maternal preference. 2. Nurses initiate preventive strategies in the early postpartum period. Conrming depressive symptoms 3. The Edinburgh Postnatal Depression Scale (EPDS) is the recommended self-report tool to conrm depressive symptoms in postpartum mothers. 4. The EPDS can be administered anytime throughout the postpartum period (birth to 12 months) to conrm depressive symptoms. 5. Nurses encourage postpartum mothers to complete the EPDS by themselves in privacy. 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. 7. The EPDS must be interpreted in combination with clinical judgment to conrm postpartum mothers with depressive symptoms. 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. Treatment 9. Nurses provide supportive weekly interactions and ongoing assessment focusing on mental health needs of postpartum mothers experiencing depressive symptoms. 10. Nurses facilitate opportunities for the provision of peer support for postpartum mothers with depressive symptoms.
Note. Registered Nurses Association of Ontario (2005).

Level of Evidence Ia Ia III III III III

III IV 1b IIb

midwives using a symptom checklist and assessment. Women in the control group received standard care of midwifery home visits with follow-up from health visitors and general practitioners. Signicant group differences were found in favor of the intervention group with 14.4% of mothers scoring above 12 on the Edinburgh Postnatal Depression Scale (EPDS) in comparison to 21.3% of mothers in the control group suggesting that the delivery of exible and mother-centered care may improve womens mental health outcomes. Armstrong, Fraser, Dadds, and Morris (1999) conducted a trial of at-risk families. The subjects included mothers living in circumstances such as violence, nancial 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 weeks postpartum, then every 2 weeks to 12 weeks postpartum, and then monthly to 24 weeks postpartum. Mothers in the control group (n = 91) were given instructions on how to access existing community child health services. At 6 weeks postpartum, intensive nursing home visits resulted in signicantly lower mothers EPDS scores compared to those in the control group. These differences, however, were not maintained at the 16-week postpartum follow-up. Armstrong et al. hypothesize that continuation of biweekly visits might enable the initial preventive effect to be maintained to 24 weeks postpartum. Recommendation 2. Nurses initiate preventive strategies in the early postpartum period (Level of Evidence = Ia).

Researchers evaluating the effect of intervention onset report that interventions initiated in the antenatal period fail to reduce the risk of women developing postpartum depression in comparison to interventions delivered only in the postnatal period (Dennis, 2005; Shaw, Levitt, Wong, Kaczorowski, & The McMaster University Postpartum Research Group, 2006). For example, Matthey, Kavanagh, Howie, Barnett, and Charles (2004), in a study of 268 prenatal primiparous mothers, found no differences in depressive symptoms at 6 months postpartum between mothers 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 signicant methodological limitations such as heterogeneous samples, diverse screening measures for depression, and high attrition rates. Maternal mood in the immediate postpartum period (or up to 2 weeks postpartum) is a signicant predictor of postpartum depression (Beck, 2002; Dennis, 2005). Mothers who scored high on the EPDS at 7 days postpartum were more likely to have depressive symptoms at 1 and 2 months postpartum (Dennis, 2005). Similar ndings have been found in other studies of mothers with diverse ethnic orientations (Yamashita, Yoshida, Nakano, & Tashiro, 2000). Becks metasynthesis of qualitative research suggests that mothers who talk about postpartum blues as overwhelming also describe experiences of postpartum depression. Such ndings support the importance of early interventions such as referral or support in order to minimize the impact of symptoms for the mother and her family.

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Table 3: Potential Research Questions

Prevention 1. Can health providers reliably identify women at risk for postpartum depression? 2. Are supportive preventive interventions more effective when provided by peers or health professionals? Conrmation 1. Is any one tool superior in conrming 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 specicity of the tool? Treatment 1. What interventions do mothers perceive as benecial in the treatment of postpartum depression? 2. Are any treatment interventions more effective than others? 3. What are the long-term treatment effects (medication and nonmedication) for postpartum depression on mothers and infants? 4. Are multifaceted interventions more effective than single interventions?

further independent psychometric testing is required before any recommendations can be made regarding its use (Boyd et al.; RNAO, 2005). Comparatively, Gaynes et al.s (2005) systematic review of 10 studies assessed the accuracy of different screening tools for detecting depression and did not identify any one particular tool as superior. They found that the estimates of sensitivity and specicity 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 instruments (including the EPDS) that can be used to identify perinatal depression, most accurately major depression. It is noteworthy that both systematic reviews identied that many included studies suffered from small sample size. Overall, identifying that the evidence base is quite limited, more research is required including larger sam-

Conrming Depressive Symptom Among Postpartum Women. Recommendation 3. The EPDS is the recommended self-report tool to conrm 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 clinical practice (RNAO, 2005). It has demonstrated reliability, sensitivity (or proportion of mothers correctly identied as having depressive symptoms), specicity (proportion of mothers correctly identied as not having 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 identied as supportive for the clinical applicability of the EPDS (Dennis, 2003a). Since the development of this recommendation, two systematic reviews have been conducted to evaluate screening tools for postpartum depression in the postnatal period (Boyd, Le, & Somberg, 2005; Gaynes et al., 2005). Boyd et al. reviewed 36 studies evaluating eight self-report measures used to assess for depressive symptoms in the postpartum period. Their ndings concurred with the RNAOs recommendation that the EPDS is the most extensively studied postpartum assessment tool with moderate psychometric soundness. Although the PDSS also demonstrates promise as a valid tool,

ples that are representative of the population, diverse racial and ethnic mix, and other demographic variables. See Table 3 for future potential research studies. Additionally, 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 specied a clinical assessment or structured clinical interview to conrm depressive symptoms. Boyd et al. (2005) and RNAO (2005) did not require a clinical interview and therefore included studies with self-reported depressive symptoms. Recommendation 4. The EPDS can be administered anytime throughout the postpartum period (birth to 12 months) to conrm depressive symptoms (Level of Evidence = III). For the majority of women, the onset of depression usually occurs within the rst 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). A systematic review of 30 studies evaluating the prevalence and incidence of postpartum depression found that the prevalence of major and minor depressions began to rise following delivery with the highest increase of 12.9% at 3 months, declining slightly in the 4th through 7th month (9.9%-10.6%), and declining even further (approximately 6.6%) from the 8th to 12th month (Gaynes et al., 2005). As such, the presence of depressive symptoms remains fairly high for the rst 6 months postpartum before it starts to decrease. It is noteworthy that research has not specied an optimal

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clinical time to employ the EPDS or the implications of repeatedly applying the EPDS to assist with assessment. The validity, sensitivity, and specicity 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 to obtain professional assistance (Small, Johnston, & Orr, 1997). Furthermore, the EPDS can be effectively administered during a phone conversation with a mother (Dennis, 2003b; Zelkowitz & Milet, 1995). The RNAO Best Practice Guideline (2005) provides sample lead-in questions and administration protocol. Recommendation 6. An EPDS cutoff score 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 nonEnglish speaking, (b) use English as a second language, and/or (c) are from diverse cultures (Level of Evidence = III). Research has demonstrated that the EPDS is most effective in the conrmation of depressive symptoms (sensitivity and specicity) 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 identied concerns. Rather, an EPDS score indicates the mothers perception of her mood. In addition, different cutoff scores may be required for non-English versions of the EPDS (Dennis, 2003b). For example, with Japanese subjects, using a 12/13 cutoff score, no mothers obtained an EPDS score of 13 or higher (Okano et al., 1998; Yoshida, Yamashita, Ueda, & Tashiro, 2001). Researchers suggest that, due to cultural expectations, Japanese mothers may be reluctant to disclose depressive symptoms and, therefore, a lower cutoff of 8/9 may be more suitable for this population (Okano et al., 1998). When used with Arabic women, a threshold score of 11/12 was adopted to conrm deQuestion number 10 on the EPDS assesses any thoughts specic to self-harm ideation. In a Canadian population of 594 mothers, 4.5% (n = 27) expressed Recommendation 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 (Level of Evidence = IV). Recommendation 7. The EPDS must be interpreted in combination with clinical judgment to conrm postpartum mothers with depressive symptoms (Level of Evidence = III). 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, identication, 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.

The EPDS may be used as part of a comprehensive assessment to identify depressive symptoms early so that referral and treatment may be initiated.
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 ndings 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. While the systematic review by Gaynes et al., (2005) did not recommend any specic cutoff value, they emphasized that the relative cost, or value, of errors in screening tests is of utmost importance in setting cutoff scores. For example, a false-negative result may lead to a prolonged and untreated depression, whereas a falsepositive result may lead to unnecessary treatment or stress associated with an incorrect screen. Thus, the screening test should try to maximize the most effective cutoff.

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Table 4: Assessment of Self-Harm

1. How often do you have thoughts of harming yourself? 2. How severe are these feelings? How much have they been bothering you? 3. Have you had these kinds of feelings before? If so, what happened? How did you cope with them? 4. Have you made any previous suicide/self-harm attempts? 5. Have you thought about how you would harm yourself? 6. What support do you have at home? 7. (If she has a partner) Have you talked about your feelings with him/her? 8. Are you close to your parents/other family members? Do they know how you have been feeling? 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).

purposeful listening in order to promote a safe space for the exploration of the womans reality (RNAO, 2005). Additional support for the effectiveness of nondirective counseling comes from qualitative literature of mothers expressed needs to disclose their emotional concerns with a compassionate listener (Ritter, Hobfoll, Lavin, Cameron, & Hulsizer, 2000; Small et al., 1994). With training, this interactive approach can be used by a variety of health care providers with women with mild-tomoderate depression (Holden et al., 1989; Wickberg & Hwang, 1996). For women experiencing severe depression, other treatments are often required. The degree of depression alone is not the sole indicator of a specic 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 4.3% (n = 23) at 4 weeks, which increased slightly to 6.3% (n = 32) at 8 weeks (Dennis, 2004a). Additional researchers have identied similar percentages of suicidal 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. Recommendation 9. Nurses provide supportive weekly interactions and ongoing assessment focusing on maternal mental health needs of postpartum mothers experiencing depressive symptoms (Level of Evidence = Ib). Diverse psychological/psychosocial interventions delivered on a weekly basis have been identied as effective in the treatment of postpartum depression. These include interpersonal psychotherapy (Klier, Muzik, Rosenblum, & Lenz, 2001), cognitive behavioral therapy (Honey, Bennett, & Morgan, 2002), and nondirective counseling (Cooper, Murray, Wilson, & Romaniuk, 2003; Holden, Sagovsky, & Cox, 1989; Wickberg & Hwang, 1996). While all the interventions evaluated were effective, nondirective counseling may be of particular interest as nurses can implement it into their practice. Nondirective counseling involves the art of presencing (i.e., being there), displaying nonjudgment as well as

postpartum depression require access to support from physicians, psychiatrists, psychologists, or community psychiatric nurses so that referrals can be made in a timely fashion (Holden, 1996). More recent ndings also provide additional support for the effectiveness of diverse treatments for postpartum depression. In particular, British Medical Journal s Clinical Evidence search and appraisal identied cognitive behavioral therapy, interpersonal therapy, and nondirective counseling as likely to be effective nondrug treatments for postpartum depression (Howard, 2006). Similarly, Bledsoe and Grotes (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 ndings combined both the antenatal and the postnatal studies and therefore cannot be generalizable to this postpartum treatment recommendation. Finally, a literature review by Chabrol and Callahan (2007) suggests equivalent effectiveness among the psychological interventions (nondirective counseling, cognitive behavioral therapy, and interpersonal therapy) with no one intervention identied as being optimal. There are also some preliminary ndings that suggest that additional therapies such as group interpersonal therapy (Reay et al., 2006), telecare support (Ugarriza & Schmidt, 2006), and exercise (Daley, Macarthur, & Winter, 2007) may potentially have therapeutic effects on depressive symptoms. However, these ndings are preliminary and based on pilot work, and more research is required before any recommendations can be made regarding their use as an adjunct or primary treatment 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). Many studies identied a lack of support as a strong risk factor in the development of postpartum depression (Dennis, 2003b, 2004b). Presence of a trustworthy, available, and understanding listener and/or belonging to a group of similar others may be effective in reducing the potential severity of depressive symptoms particularly when women describe postpartum depression in terms of isolation, as being misunderstood and as being alone (Brugha et al., 1998; Eberhard-Gran, Eskild, Tambs, Schei, & Opjordsmoen, 2001). Limited research, however, has been conducted specically evaluating the efcacy of social support and postpartum depression, and the research that has been conducted has been inconclusive (Chen, Tseng, Chou, & Wang, 2000; Dennis, 2003b, 2004a; Fleming, Klein, & Corter, 1992; Morgan, Matthey, Barnett, & Richardson, 1997). 2000). Therefore, health care providers need to be aware of the potential signicance of depressive symptoms in the early postpartum period and valid measurements to conrm the presence of depressive symptoms in postpartum mothers. However, numerous barriers have been documented related to the identication of women with postpartum depression. These include culture (Okano et al., 1998), reluctance to seek professional help (Small et al., 1997), reluctance to disclose emotional problems (Brown & Lumley, 2000), and lack of knowledge related to postpartum depression (Edge, Baker, & Rogers, 2004). As such, the use of a tool, such as the EPDS for the conrmation of mothers with depressive symptoms, may assist to address some of the barriers related to identication. While a large systematic review identied that several

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.

Summary
Although several well-designed studies have been conducted evaluating diverse interventions for the prevention of postpartum depression, no one intervention has been identied as effective. When considering the multifactorial etiolology of postpartum depression, this may not be surprising. Overall, promising ndings regarding prevention indicate that interventions that are exible, are individually based, target at-risk women, and are delivered postnatally are more likely to be effective in the prevention of postpartum depression (Dennis, 2005; Dennis & Creedy, 2004). 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 specic 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 signicance 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 depressive symptoms and make appropriate referral may hold the most promise for reducing negative outcomes associated with prolonged and untreated postpartum depression (Austin & Priest, 2005; Gjerdingen & Yawn, 2007). Additionally, research supports the need for structured or validated tools for assessment rather than unstructured interviews (Evins, Theofrastous, & Galvin,

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 identication 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, specicity, and predictive power (Dennis, 2004a). Additionally, it has been identied as the most extensively evaluated tool for the assessment of depressive symptoms in postpartum women (Boyd et al., 2005). When used as a screening tool to identify depressive 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 clinicians understanding of its specic 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. The use of the EPDS for the conrmation of depressive symptoms in mothers requires knowledge specic to the administration and interpretation of the EPDS, including cutoff scores, use in diverse populations, assessment for any positive response to the self-harm item, and avoidance of overreliance on EPDS scores. Furthermore, when health professionals are assessing

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mothers for the presence of depressive symptoms, there must be policies and procedures in place to ensure that women who are identied as having depressive symptoms have access to treatment. In particular, evidence from experts supports the implementation of harm reduction methods especially with regard to a womans expression of self-harm ideation. Regardless of the EPDS score, if a clinician is concerned about a womens safety, it is more direct to inquire about her suicidal risk in a sensitive and respectful manner (Cardone, Kim, Gordon, Gordon, & Silver, 2006). Through a focused risk assessment, a skilled clinician can determine if the presenting behavior reects psychopathology, contextual stressors, or a combination of both. 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 identied. 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. While diverse treatments are identied as effective in the care of mothers with postpartum depression, treatment should be initiated based on maternal need (severity of symptoms), preference of treatment options, and availability of services. Women with mild-to-moderate depressive symptoms may benet 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 moderate or severe depression often require pharmacologic therapy provided by a physician or advanced practice nurse or specialized nonpharmacologic treatment including interpersonal therapy or cognitive behavioral therapy. Any of these nonpharmacologic interventions may also be used as an adjunct to pharmacologic treatment. However, due to the concerns about infant exposure to antidepressants with breastfeeding women, many mothers are reluctant to accept this form of treatment (Chabrol & Callahan, 2007). Therefore, the overriding goal should be prompt access to effective treatment to reduce the adverse outcomes associated with prolonged and untreated postpartum depression. Maternal preference for treatment also addresses a limitation of the hierarchical approach to appraising research studies. While systematic reviews and randomized controlled trials will identify the effectiveness of an intervention, they will not identify the clinical utility or usefulness of an intervention or how the participants perceived the intervention. Thus, research is also required on mothers preference for preventative and treatment interventions for postpartum depression.

The BPG Interventions for Postpartum Depression is one resource to support evidence-based decision making in nursing practice. The implementation of evidencebased care specic to mothers with postpartum depression has the potential to improve outcomes for mothers, infants, and families through early identication of depressive symptoms, with referral and treatment sensitive to individual mothers needs. However, the magnitude of the outcomes associated with evidencebased guidelines is often inconsistent and dependent on several variables including the quality of the evidence, the method of guideline development, and the strategies used to disseminate and implement the guideline recommendations into practice (RycroftMalone, 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.

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

REFERENCES
AGREE Collaboration. (2001). Appraisal of guidelines for research & evaluation (AGREE) instrument. London, England: Author. Armstrong, K. L., Fraser, J. A., Dadds, M. R., & Morris, J. (1999). A randomized, controlled trial of nurse home visiting to vulnerable families with newborns. Journal of Paediatrics and Child Health, 35, 237-244. Austin, M. P., & Priest, S. R. (2005). Clinical issues in perinatal mental health: New developments in the detection and treatment of perinatal mood and anxiety disorders. Acta Psychiatrica Scandinavica, 112, 97-104. Beck, C. T. (2002). Postpartum depression: A meta-synthesis. Qualitative Health Research, 12, 453-472. Bledsoe, S. E., & Grote, N. K. (2006). Treating depression during pregnancy and the postpartum: A preliminary meta-analysis. Research on Social Work Practice, 16, 109-120. Boath, E., Bradley, E., & Henshaw, C. (2005). The prevention of postnatal depression: A narrative systematic review. Journal of Psychosomatic Obstetrics and Gynecology, 26, 185-192. Boyce, P., Stubbs, J., & Todd, A. (1993). The Edinburgh Postnatal Depression Scale: Validation for an Australian sample. Australian and New Zealand Journal of Psychiatry, 27, 472-476. Boyd, R. C., Le, H. N., & Somberg, R. (2005). Review of screening instruments for postpartum depression. Archives of Womens Mental Health, 8, 141-153. British Columbia Reproductive Care Program. (2003). Reproductive mental illness during the perinatal period. Vancouver, BC, Canada: Author.

134

JOGNN, 37, 127-136; 2008. DOI: 10.1111/j.1552-6909.2008.00215.x

http://jognn.awhonn.org

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

P RINCIPLES

&

P RACTICE

Brown, S., & Lumley, J. (2000). Physical health problems after childbirth and maternal depression at six to seven months postpartum. BJOG: An International Journal of Obstetrics and Gynaecology, 107, 1194-1201. Brugha, T. S., Sharp, H. M., Cooper, S. A., Weisender, C., Britto, D., Shinkwin, R., et al. (1998). The Leicester 500 project. Social support and the development of postnatal depressive symptoms, a prospective cohort survey. Psychological Medicine, 28, 63-79. Cardone, I. A., Kim, J. J., Gordon, T. E., Gordon, S. M., & Silver, R. K. (2006). Psychosocial assessment by phone for high-scoring patients taking the Edinburgh Postnatal Depression Scale: Communication pathways and strategies. Archives of Womens Mental Health, 9, 87-94. Chabrol, H., & Callahan, S. (2007). Prevention and treatment of postnatal depression. Expert Review of Neurotherapeutics, 7, 557-576. Chen, C. H., Tseng, Y. F., Chou, F. H., & Wang, S. Y. (2000). Effects of support group intervention in postnatally distressed women. A controlled study in Taiwan. Journal of Psychosomatic Research, 49, 395-399. Cooper, P. J., Campbell, E. A., Day, A., Kennerley, H., & Bond, A. (1988). Non-psychotic psychiatric disorder after childbirth. A prospective study of prevalence, incidence, course and nature. British Journal of Psychiatry; the Journal of Mental Science, 152, 799-806. Cooper, P. J., & Murray, L. (1995). Course and recurrence of postnatal depression. Evidence for the specicity of the diagnostic concept. British Journal of Psychiatry; the Journal of Mental Science, 166, 191-195. Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. Impact on maternal mood. British Journal of Psychiatry; the Journal of Mental Science, 182, 412-419. Cox, J. L., & Holden, J. M. (2003). Perinatal mental health: A guide to the Edinburgh Postnatal Depression Scale. London: Gaskell. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry; the Journal of Mental Science, 150, 782-786. Daley, A. J., Macarthur, C., & Winter, H. (2007). The role of exercise in treating postpartum depression: A review of the literature. Journal of Midwifery & Womens Health, 52, 56-62. Dennis, C. L. (Ed.). (2003a). The detection, prevention, and treatment of postpartum depression. Toronto, Ontario, Canada: Toronto Public Health. Dennis, C. L. (2003b). The effect of peer support on postpartum depression: A pilot randomized controlled trial. Canadian Journal of Psychiatry, 48, 115-124. Dennis, C. L. (2004a). Can we identify mothers at risk for postpartum depression in the immediate postpartum period using the Edinburgh Postnatal Depression Scale? Journal of Affective Disorders, 78, 163-169. Dennis, C. L. (2004b). Preventing postpartum depression part II: A critical review of nonbiological interventions. Canadian Journal of Psychiatry, 49, 526-538. Dennis, C. L. (2005). Psychosocial and psychological interventions for prevention of postnatal depression: Systematic review. BMJ (Clinical research ed.), 331, 15. Dennis, C. L., & Chung-Lee, L. (2006). Postpartum depression helpseeking barriers and maternal treatment preferences: A qualitative systematic review. Birth, 33, 323-331.

Dennis, C. L., & Creedy, D. (2004). Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews (Online: Update Software) (4), CD001134. Eberhard-Gran, M., Eskild, A., Tambs, K., Schei, B., & Opjordsmoen, S. (2001). The Edinburgh Postnatal Depression scale: Validation in a Norwegian community sample. Nordic Journal of Psychiatry, 55, 113-117. Edge, D., Baker, D., & Rogers, A. (2004). Perinatal depression among black Caribbean women. Health & Social Care in the Community, 12, 430-438. Effective Public Health Practice Project. (2003). Quality Assessment Tool for Quantitative Studies. Hamilton, Ontario, Canada: McMaster University. Elliott, S., & Leverton, T. J. (2000). Is the EPDS a magic wand? 2. Myths and the evidence base. Journal of Reproductive and Infant Psychology, 18, 297-307. Evins, G. G., Theofrastous, J. P., & Galvin, S. L. (2000). Postpartum depression: A comparison of screening and routine clinical evaluation. American Journal of Obstetrics and Gynecology, 182, 1080-1082. Fleming, A. S., Klein, E., & Corter, C. (1992). The effects of a social support group on depression, maternal attitudes and behavior in new mothers. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 33, 685-698. Freeman, M. P., Wright, R., Watchman, M., Wahl, R. A., Sisk, D. J., Fraleigh, L., et al. (2005). Postpartum depression assessments at well-baby visits: Screening feasibility, prevalence, and risk factors. Journal of Womens Health, 14, 929-935. Gaynes, B., Meltzer-Brody, S., Lohr, K., Swinson, T., Gartlehner, G., Brody, S., et al. (2005). Perinatal depression; prevalence, screening accuracy, and screening outcomes (Evidence Report/Technology Assessment No. 119). Rockville, MD: Agency for Healthcare Research and Quality. Ghubash, R., Abou-Saleh, M. T., & Daradkeh, T. K. (1997). The validity of the Arabic Edinburgh Postnatal Depression Scale. Social Psychiatry and Psychiatric Epidemiology, 32, 474-476. Gjerdingen, D. K., & Yawn, B. P. (2007). Postpartum depression screening: Importance, methods, barriers, and recommendations for practice. Journal of the American Board of Family Medicine, 20, 280-288. Goodman, J. H. (2004). Postpartum depression beyond the early postpartum period. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNNAACOG, 33, 410-420. Harris, B., Huckle, P., Thomas, R., Johns, S., & Fung, H. (1989). The use of rating scales to identify post-natal depression. British Journal of Psychiatry; the Journal of Mental Science, 154, 813-817. Holden, J. (Ed.). (1994). Using the Edinburgh Postnatal Depression Scale in clinical practice. London: Gaskell. Holden, J. (1996). The role of health visitors in postnatal depression. International Review of Psychiatry, 8, 79, 86. Holden, J. M., Sagovsky, R., & Cox, J. L. (1989). Counselling in a general practice setting: Controlled study of health visitor intervention in treatment of postnatal depression. BMJ (Clinical research ed.), 298, 223-226. Honey, K. L., Bennett, P., & Morgan, M. (2002). A brief psychoeducational group intervention for postnatal depression. British Journal of Clinical Psychology/the British Psychological Society, 41(Pt 4), 405-409. Horowitz, J. A., & Cousins, A. (2006). Postpartum depression treatment rates for at-risk women. Nursing Research, 55(Suppl.), S23-S27. Howard, L. (2006). Postnatal depression. Clinical Evidence, 15(6), 1919-1931.

JOGNN 2008; Vol. 37, Issue 2

135

P RINCIPLES

&

P RACTICE

Depressive Symptoms in Postpartum Women

Klier, C. M., Muzik, M., Rosenblum, K. L., & Lenz, G. (2001). Interpersonal psychotherapy adapted for the group setting in the treatment of postpartum depression. Journal of Psychotherapy Practice and Research, 10, 124-131. Lee, D. T., Yip, S. K., Chiu, H. F., Leung, T. Y., Chan, K. P., Chau, I. O., et al. (1998). Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. British Journal of Psychiatry; the Journal of Mental Science, 172, 433-437. Lundh, W., & Gyllang, C. (1993). Use of the Edinburgh Postnatal Depression Scale in some Swedish child health care centres. Scandinavian Journal of Caring Sciences, 7, 149-154. MacArthur, C., Winter, H. R., Bick, D. E., Knowles, H., Lilford, R., Henderson, C., et al. (2002). Effects of redesigned community postnatal care on womens health 4 months after birth: A cluster randomised controlled trial. Lancet, 359, 378-385. Matthey, S., Kavanagh, D. J., Howie, P., Barnett, B., & Charles, M. (2004). Prevention of postnatal distress or depression: An evaluation of an intervention at preparation for parenthood classes. Journal of Affective Disorders, 79, 113-126. Mayberry, L. J., & Affonso, D. D. (1993). Infant temperament and postpartum depression: A review. Health Care for Women International, 14, 201-211. McIntosh, J. (1993). The experience of motherhood and the development of depression in the postnatal period. Journal of Clinical Nursing, 2, 243-249. Morgan, M., Matthey, S., Barnett, B., & Richardson, C. (1997). A group programme for postnatally distressed women and their partners. Journal of Advanced Nursing, 26, 913-920. Morris-Rush, J. K., Freda, M. C., & Bernstein, P. S. (2003). Screening for postpartum depression in an inner-city population. American Journal of Obstetrics and Gynecology, 188, 1217-1219. Mosack, V., & Shore, E. R. (2006). Screening for depression among pregnant and postpartum women. Journal of Community Health Nursing, 23, 37-47. Murray, L., & Cooper, P. J. (1997). Postpartum depression and child development. Psychological Medicine, 27, 253-260. OHara, M. W., & Swain, A. M. (1996). Rates and risk of postpartum depressionA meta-analysis. International Review of Psychiatry, 8, 37-54. Okano, T., Nomura, J., Kumar, R., Kaneko, E., Tamaki, R., Hanafusa, I., et al. (1998). An epidemiological and clinical investigation of postpartum psychiatric illness in Japanese mothers. Journal of Affective Disorders, 48, 233-240. Reay, R., Fisher, Y., Robertson, M., Adams, E., Owen, C., & Kumar, R. (2006). Group interpersonal psychotherapy for postnatal depression: A pilot study. Archives of Womens Mental Health, 9, 31-39.

Registered Nurses Association of Ontario. (2005). Interventions for postpartum depression. Toronto, Ontario, Canada: Author. Ritter, C., Hobfoll, S. E., Lavin, J., Cameron, R. P., & Hulsizer, M. R. (2000). Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women. Health Psychology: Ofcial Journal of the Division of Health Psychology, American Psychological Association, 19, 576-585. Rycroft-Malone, J. (2004). The PARIHS frameworkA framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quality, 19, 297-304. Scottish Intercollegiate Guidelines Network. (2002). Postnatal depression and puerperal psychosis. Edinburgh, Scotland: Author. Sharp, L. K., & Lipsky, M. S. (2002). Screening for depression across the lifespan: A review of measures for use in primary care settings. American Family Physician, 66, 1001-1008. Shaw, E., Levitt, C., Wong, S., Kaczorowski, J., & The McMaster University Postpartum Research Group. (2006). Systematic review of the literature on postpartum care: Effectiveness of postpartum support to improve maternal parenting, mental health, quality of life, and physical health. Birth, 33, 210-220. Small, R., Brown, S., Lumley, J., & Astbury, J. (1994). Missing voices: What women say and do about depression after childbirth. Journal of Reproductive and Infant Psychology, 12, 19-22. Small, R., Johnston, V., & Orr, A. (1997). Depression after childbirth: The views of medical students and women compared. Birth, 24, 109-115. Thompson, W. M., Harris, B., Lazarus, J., & Richards, C. (1998). A comparison of the performance of rating scales used in the diagnosis of postnatal depression. Acta Psychiatrica Scandinavica, 98, 224-227. Ugarriza, D. N., & Schmidt, L. (2006). Telecare for women with postpartum depression. Journal of Psychosocial Nursing and Mental Health Services, 44(1), 37-45. Wickberg, B., & Hwang, C. P. (1996). The Edinburgh Postnatal Depression Scale: Validation on a Swedish community sample. Acta Psychiatrica Scandinavica, 94, 181-184. Yamashita, H., Yoshida, K., Nakano, H., & Tashiro, N. (2000). Postnatal depression in Japanese women. Detecting the early onset of postnatal depression by closely monitoring the postpartum mood. Journal of Affective Disorders, 58, 145-154. Yoshida, K., Yamashita, H., Ueda, M., & Tashiro, N. (2001). Postnatal depression in Japanese mothers and the reconsideration of satogaeri bunben. Pediatrics International: Ofcial Journal of the Japan Pediatric Society, 43, 189-193. Zelkowitz, P., & Milet, T. H. (1995). Screening for post-partum depression in a community sample. Canadian Journal of Psychiatry, 40, 80-86.

136

JOGNN, 37, 127-136; 2008. DOI: 10.1111/j.1552-6909.2008.00215.x

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