Postpartum Depression and Nursing Challenges
What is Postpartum Depression
Postpartum depression (PPD) is an important women's mental health problem because of its timing, prevalence, and associated risks. PPD is believed to affect approximately 13% of women following delivery; However, when self-report depression measures are used to identify women with milder symptom levels, higher percentages are reported.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000), diagnostic criteria specify onset within 4 weeks postpartum.
The most frequent symptoms are feelings of inadequacy, sadness, fatigue, anxiety, worry, compulsive thoughts, and diminished functioning that can occur from within 2 weeks postpartum to beyond 1 year.
Women experiencing PPD can experience symptoms severe enough to require a combination of pharmacological interventions and either short or long-term counseling and therapy and even hospitalization.
Nevertheless, after a comprehensive review of PPD treatment
literature, Boath and Henshaw (2001) concluded that treatment efficacy has not
been clearly established, with recovery varying from 2-3 months to as long as 2
or more years.
Differentiate Between Postpartum Depression and Postpartum Blues
PPD is distinguished from commonly experienced “postpartum or maternity blues” and postpartum psychosis. Postpartum blues is characterized by onset during the first 2 weeks after delivery, presence of mild depressed symptoms with typically rapid resolution, and prevalence as high as 80% in the United States.
In addition, postpartum blues wane without needs for intervention. Postpartum psychosis, in contrast, is a rare (1-2/1,000) and severe disorder. Symptoms may emerge as early as 1 month before delivery, and rapid postpartum onset within 4 weeks postpartum is characteristic.
Hallucinations, delusions, and paranoia are hallmarks and can be associated with suicidal and homicidal ideation. Therefore, risk of harm to the infant is a major concern with psychosis and with severe PPD when cognitive distortions are present (American Psychiatric Association, 2000).
A more recently identified disorder, postpartum obsessive-compulsive disorder (OCD) (Sichel & Driscoll, 1999), is not specified within the diagnostic nomenclature as a recognized postpartum syndrome.
However, expert practitioners have described
heightened surveillance about the possibility of harm to the baby as
characteristic of postpartum OCD.
Risk Factors of Postpartum Depression
A range of risk factors have been identified with the development of PPD, including a history of depression, difficult infant temperament, marital or partner relationship problems , child care stress, low self-esteem and poor social support.
Researchers have extended examination of PPD to include samples from various cultures and countries around the world.
For example, a multisite study involving 892 women from nine countries was designed to compare differences in postpartum depressive symptomatology across samples at 4-6 weeks and 10-12 weeks postpartum (Affonso, De, Horowitz, Andrews, & Mayberry, 2000).
Average depression scores for women from countries in which postpartum cultural traditions are practiced were significantly higher than depression scores for women from Europe, Australia, and the United States-“western” industrialized countries without such wide-spread rituals.
In focus groups conducted in each of the countries, similar patterns of symptoms were described (Horowitz, JA, Chang, Das, & Hayes, 2001).
Fatigue and pain were common physical symptoms, with irritability, anxiety, loneliness, worrying, indecisiveness, and poor concentration being emotional and cognitive symptoms. Role and relationship conflicts were described within the context of cultural variations.
These findings demonstrate that additional research is needed to explore postpartum cross-cultural adjustment problems and to test strategies for relieving distressing symptoms.
Furthermore, a growing body of
literature indicates that PPD affects women around the world and challenges
earlier assumptions that PPD is a culturally based syndrome primarily
associated with westernized countries without widespread postpartum traditions
(Affonso et al., 2000; Posmontier & Horowitz, 2004).
Maternal Interaction and Effects
PPD disrupts maternal-infant interactions and children's cognitive and emotional development. Withdrawn, disengaged, and intrusive maternal behavior patterns may result in fussy, aggressive, less affectionate, and less. responsive infants.
Reduced vocalization and slower neurological growth and motor skill development have been documented among infants of depressed mothers (Abrams, Field, Scafidi, & Prodromidis, 1995; Field, T., 1995; Tronick & Weinberg, 1997).
In response to growing evidence of PPD's negative effects on infant development, researchers have begun to focus on evaluating interventions to promote improved mother infant relationships.
One clinical trial designed to test the effectiveness of an interactive coaching approach delivered by a trained home visiting nurse produced promising findings (Horowitz, JA, Bell, et al., 2001). The intervention had a positive effect on maternal infant responsiveness among mothers.
According to the nurse
investigators, subsequent research is needed with diverse samples to test
additional interventions to reduce negative effects of maternal depression on
child development. Inclusion of partners or other family members to examine
family processes related to maternal depression was also recommended (Horowitz,
JA, Bell, et al.).
Nursing Implementations
Nurse investigators are also involved in testing better tools for early detection of PPD. The Postpartum Depression Screening Scale (PDSS) (Beck & Gable, 2001) is a promising one. 35-item self-report instrument to identify women who are at high risk for postpartum depression.
Given the importance of PPD as a clinical problem, mental health evaluation of all postpartum women should be standard care. Recommendations for future research directions are:
(a) a screening feasibility project to demonstrate ways to implement cost-effective early PPD identification
(b) clinical trials to test non-pharmacologic treatments for PPD and interventions to enhance the quality of mother-child interaction
(c) longitudinal studies to examine the course of maternal depression over time
(d) family research to explore consequences of PPD on family health and test family oriented interventions
(e) cross-cultural studies and inclusion of diverse samples within the United States to document prevalence rates, discern risk and protective factors, and test culturally relevant interventions.
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