The Early Detection of Postpartum Depression: Midwives and Nurses Trial a Checklist Barbara Hanna, Heather Jarman, Sally Savage, and Kim Layton

CLINICAL RESEARCH The Early Detection of Postpartum Depression: Midwives and Nurses Trial a Checklist Barbara Hanna, Heather Jarman, Sally Savage, and Kim Layton Objective: To evaluate the use of a standard pen-and-paper test versus the use of a checklist for the early identification of women at risk of postpartum depression and to investigate the experiences of nurses in using the checklist. Design: A prospective cohort design using repeated measures. Setting: The booking-in prenatal clinic at a regional hospital in Victoria, Australia, and the community-based postpartum maternal and child health service. Participants: 107 pregnant women over 20 years of age. Main Measures: Postpartum Depression Prediction Inventory (PDPI), Postpartum Depression Screening Scale (PDSS), Edinburgh Postnatal Depression Scale (EPDS), demographic questionnaire, and data on the outcome from the midwives and nurses. Results: The PDPI identified 45% of the women at risk of depression during pregnancy and 30% postpartum. The PDSS and EPDS both identified the same 8 women (10%), who scored highly for depression at the 8-week postpartum health visit. Nurses provided 80% of the women with anticipatory guidance on postpartum depression in the prenatal period and 46% of women at the 8-week postpartum health visit. Nurse counseling or anticipatory guidance was provided for 60% of the women in the prenatal period. Conclusion: The PDPI was found to be a valuable checklist by many nurses involved in this research, particularly as a way of initiating open discussion with women about postpartum depression. It correlated strongly with both the PDSS and the EPDS, suggesting that it is useful as an inventory to identify women at risk of postpartum depression. JOGNN, 33, 191-197; 2004. DOI: 10.1177/0884217504262972 Keywords: Maternal and child health Midwives Nurses Postnatal depression Postpartum Pregnancy Tools Accepted: April 2003 Postpartum depression is a nonpsychotic depressive episode that begins in or extends into the postpartum (Cox, Murray, & Chapman, 1993; O Hara, 1995). It affects 12% to 15% of childbearing women (Beck, 1998; Cox, Holden, & Sagovsky, 1987; O Hara & Swain, 1996). The condition usually is unreported and frequently undetected by health care professionals, making the early detection of postpartum depression an important issue for all midwives and nurses working with women in the prenatal and postpartum periods. It is likely that the incidence of postpartum depression is underestimated because many women suffer in silence (Beck & Gable, 2000, p. 272; Milgrom, Martin, & Negri, 1999). It is important to realize, however, that women are often unaware that their negative feelings are due to postpartum depression (McGill, Burrows, Holland, Langer, & Sweet, 1995). When they seek care from health care professionals, some women are exhausted and experiencing a range of difficulties with their infants or themselves. Typically, the woman experiencing postpartum depression appears to be unhappy, irritable, and unable to cope; has negative feelings about herself and her child or children; is anxious; has a low libido; has marriage problems; experiences difficulties managing household tasks; is tearful; has physi- March/April 2004 JOGNN 191

cal symptoms such as sleep and appetite disturbances; and displays obsessional behavior (Milgrom et al., 1999; National Health and Medical Research Council [NHMRC], 2000). The quality of life of such women and their families is severely compromised, and marital breakdown can result (Beck & Gable, 2000). The effects can be devastating in extreme cases, where suicide and infanticide have been known to occur (Davidson & Robertson, 1985). A meta-analysis of nine studies of postpartum depression indicated it had an adverse effect on maternal-infant interaction, with evidence of negative interaction styles, withdrawn mothers, and infants displaying lower activity levels (Beck, 1996). Long-term, chronic effects are 3-fold: on the mental health of the woman, on the child who is part of the mother-infant relationship and on the child s development, and on the marital relationship (Milgrom et al., 1999). Possible long-term cognitive and emotional effects on the child when he or she is older have also been suggested (Beck, 1998). Therefore, it is crucial that early and accurate identification and intervention occur to prevent long-term consequences for childbearing families and to prevent postpartum depression from becoming a significant mental health problem. Despite little scientific evidence to support routine prenatal screening for postpartum depression (Lumley & Austin, 2001), the use of measurement tools in the nursing assessment of postpartum depression is common. Although these tools are a useful assessment aid, Barker (2001, p. 291) warned that they do not give insight into the reality of a mother s level of depression, let alone explain the why and wherefore of her state of mind. He cautioned clinicians not to rely solely on these measures in preference to using their own clinical judgment. Being mindful of this concern, our study explored the convenience and benefit to nurses of a checklist for identifying women at risk of postpartum depression. Two relatively new research instruments for identifying postpartum depression were investigated in our study. The first was a checklist designed to assist in the early detection of risk factors for postpartum depression: the Postpartum Depression Prediction Inventory (PDPI). This checklist was developed by Beck (1998) after conducting a meta-analysis of risk factors associated with postpartum depression. It differs from other assessment tools for identifying PPD in that it is a discussion checklist for the clinician to use in interviewing a woman rather than being a formal instrument with psychometric properties. The PDPI comprises a series of questions that deal with individual risk factors such as prenatal depression, prenatal anxiety, history of depression, social support, marital satisfaction, and life stress. As a way of streamlining the consultation, we adapted the format for the prenatal stage to allow women to fill in the form themselves. We used the original, nurse-administered postpartum version, however. Additionally, two other factors are added to cover the postpartum period: child care stress and maternity blues. Further factors have recently been added to the checklist (Beck, 2002). The second tool investigated in our study was the Postpartum Depression Screening Scale (PDSS) (Beck & Gable, 2000). The PDSS consists of 35 items that cover seven areas: sleeping/eating disturbances, anxiety/insecurity, emotional lability, cognitive impairment, loss of self, guilt/shame, and contemplating harming oneself (Beck & Gable, 2000). The woman completes the PDSS herself, responding to each item using a 5-point scale ranging from strongly disagree to strongly agree. The psychometric properties of the PDSS have been tested and reported elsewhere (Beck & Gable, 2000). Beck and Gable (2001) found the PDSS demonstrated higher sensitivity (91%) and specificity (72%) when compared with two other instruments to measure postpartum depression. At the postpartum stage, the Edinburgh Postnatal Depression Scale (EPDS) was also used (Cox et al., 1987). The EPDS is a 13-item tool developed to assist health care providers in screening community samples of postnatal mothers for depressive symptoms after childbirth. It has been used extensively and has good sensitivity (86%), specificity (78%), and a positive predictive value of 73%. The aims of our research were (a) to evaluate the use of a standard pen-and-paper test versus the benefit and convenience of a discussion checklist for detecting women at risk of postpartum depression and (b) to investigate the experiences of nurses in using the checklist. This article reports on the outcomes of using the PDPI and midwives and nurses responses to the benefit and convenience of the checklist. The statistical results will be reported elsewhere. Method After ethical approval of the study by the affiliated institutions, women who attended an antenatal clinic in a Victorian regional hospital for their booking-in appointment at 28 weeks gestation were invited to take part in this study. During a 2-month period, women who consented to participate were asked to complete a demographic questionnaire and the PDPI, just prior to their appointment with the midwife. After discussion of women s responses, midwives recorded the type of action or intervention provided for women, plus nurses perception of the benefit and convenience of the PDPI. Action or intervention included (a) anticipatory guidance, or providing information on PPD before the woman could experience it; (b) nondirective counseling, or helping the woman at risk of PPD to manage her problems with sup- 192 JOGNN Volume 33, Number 2

port from the nurse; (c) referral to the psychiatric nurse; or (d) referral to a medical practitioner. Of 141 women invited to participate, 107 (76%) took part in the prenatal stage of the research, which involved completing the modified PDPI. These women were also invited to take part in the second stage of the research at their 6- to 8-week postpartum visit to a community-based maternal and child health service. Eighty-four of the 107 women (78%) participated in the postpartum stage. At this visit, the nurse completed the PDPI during an interview and the woman completed the PDSS and the short version of the EPDS (Cox et al., 1987). Nurses also recorded action and interventions taken, including referral and their perceptions of the benefit and convenience of the PDPI. Results Sample Participants in the prenatal stage of the study ranged from 20 to 43 years of age, with a mean age of 29 years. For 36% of participants, this was their first live birth, whereas 24% had experienced a miscarriage or stillbirth. Most participants (86%) were living with a partner, whether married or not; 32% had completed postsecondary education; and 43% reported having a gross household income of more than $40,000. The demographic characteristics of the 84 women who also participated in the postpartum stage of this study were similar to those of the prenatal group. The PDPI Completed at the Prenatal and Postnatal Visit The format of the adapted PDPI enabled pregnant women to complete the checklist themselves before consulting with the midwife. Additional yes-or-no check boxes were strategically aligned next to each question and prompt. Although the PDPI was not intended to be a selfreport checklist, discussion with the developer confirmed that our changes would not alter the intent. At the prenatal visit, 45% of the women reported feeling depressed during this pregnancy and 58% reported feeling anxious, whereas 44% reported having been depressed before the pregnancy. Almost all (94%) were satisfied with their marriages, and 44% reported experiencing some stressful events. At the postpartum visit, fewer women were recorded as having been depressed during the pregnancy (30%) or before the pregnancy (34%) or anxious during the pregnancy (36%). Twentyfive percent experienced stressful events, and 51% experienced maternity blues. Action or Intervention Taken by the Midwife and Nurses The midwife and nurses provided details of the actions taken and interventions implemented for each woman who participated in the prenatal and postpartum visits. Often, more than one action was taken as the result of a visit. It must be noted that a single midwife interviewed all participants at the prenatal stage of this research, whereas 29 maternal and child health nurses were involved in the postpartum stage. More action was taken as a result of the prenatal visit, however, with 80% of these women receiving anticipatory guidance on postpartum depression compared with 46% at the 8-week postpartum visit. Almost all of the women (94%) who reported that they had been depressed before their pregnancy received anticipatory guidance about postpartum depression from the midwife. Midwives and nurses provided counseling to 60% of the women in the prenatal stage compared with 48% in the postpartum stage. Women who reported feeling depressed during their pregnancy were the most likely to receive counseling by the midwife (63%) and referral to a psychiatric nurse (31%). Referrals to a medical practitioner or psychiatric nurse were made for 21% of the women during the pregnancy and 17% postpartum. At the postpartum visit, more than half of the women reporting risk factors for postnatal depression on the PDPI received anticipatory guidance by the nurses, as did 60% of those who reported being depressed before the pregnancy. Counseling by the nurses was also provided for 41% of women who reported being depressed before the pregnancy, for 32% of those depressed during the pregnancy, and for 56% of women reporting any type of child care stress. Nurses Responses to the PDPI at the Prenatal Stage Prenatal Stage. We were particularly interested in nurses perceptions of the benefits and convenience of the PDPI. The prenatal midwife was extremely positive about the PDPI. Because the PDPI was used as a self-report checklist, each pregnant woman had time to consider her responses before the prenatal consultation. According to the midwife, women appeared eager to explain their responses and were pleased to have the opportunity to discuss their feelings and to consider their situations as being a normal occurrence. This raised the women s consciousness about depression and provided opportunities for anticipatory guidance and referral where appropriate. Each section of the checklist allowed the midwife to walk women through their experiences and to enable appropriate interventions. According to the midwife, the value of the discussions prompted by the checklist was March/April 2004 JOGNN 193

that each woman was given time to address her individual concerns. Because the focus was on their responses to the checklist questions, women were listened to, had their feelings validated, and were better able to receive support, referral, or appropriate interventions. The midwife said, It works well not only because it attempts to identify whether women are depressed, but identifies those factors in their lives which cause stress and difficulty. The opportunity then exists to help modify some of these factors before the baby is born. The format ensures that we engage openly with the women to discuss issues and feelings otherwise not necessarily spoken about. Postpartum Stage The PDSS and the EPDS were used to obtain a score of risk factors for PPD at the 6- to 8-week postpartum visit. The women completed these two tools themselves. The PDSS provided information on each woman s score for the seven areas previously described. A high score in one of these areas (e.g., in eating/sleeping disturbances) indicates the likelihood of problematic symptoms in that area. A woman s total score on the PDSS is used to classify her risk of postnatal depression. Six women were excluded from the PDSS analyses because there were inconsistencies in their responses, which suggested that they had problems with completing the questionnaire (Beck & Gable, 2002). Of the remaining 78 women, 57 (73%) were classified by the PDSS as having normal adjustment, 13 (17%) as having significant symptoms of postpartum depression, and 8 (10%) as representing a positive screen for major postpartum depression. When the PDSS scores were compared with scores on the short version of the EPDS, we found that both tools identified the same eight women as being most at risk of postpartum depression. The EPDS also identified an additional three women as being at risk. Two of these were classified in the significant symptoms of PPD category on the PDSS but not in the positive screen category. There was a statistically significant correlation between total scores obtained on the PDSS and total scores obtained on the EPDS (r =.827, p =.0001), which suggests that the two tools are measuring similar concepts. It must be noted that a diagnosis of PPD was not made through the use of a psychiatric assessment. Those women who scored The correlation between scores obtained on the PDSS and the EPDS suggests that the two tools are measuring similar concepts. TABLE 1 Comments Made by Maternal and Child Health Nurses About the PDPI a Number of Comments Made by Nurses About the PDPI Comments Generally positive comment 17 Mother has no problems/not at risk 11 Useful to initiate discussion on postnatal depression 10 No use, negative comments 7 Found the format confusing on the form 6 Time an issue, more time needed 6 Mother already known to have postnatal depression 5 Mother felt tool was intrusive 3 Most questions would have been covered in a usual visit 2 Mother felt questions on PDPI more relevant than the PDSS b or EPDS c 1 Answers could be affected by the sort of day the mother is having 1 Direct talking/counselling just as useful 1 a Postpartum Depression Prediction Inventory. b Postpartum Depression Screening Scale. c Edinburgh Postnatal Depression Scale. in the positive screen for PPD using both the PDSS and EPDS were more likely to receive combinations of intervention such as counseling (69%), anticipatory guidance (70%), or referral (50%). Nurses Responses to the PDPI at the Postpartum Stage Nurses involved in the postpartum stage of this research were invited to comment on the usability and convenience of the PDPI. Twenty-nine nurses provided 56 comments. A thematic analysis of these comments is presented in Table 1. It was reported that some ambiguity existed in the questions. For instance, the questions about social support and marital dissatisfaction were confusing to the nurses because the first question was worded in the opposite direction to questions that followed. For example, under the heading Lack of Social Support came prompt questions such as Do you feel you can confide in your partner? A response box was provided for only the heading, but not the prompt questions, however. We were aware that the checklist was not designed as a self-reporting tool but wanted data on its usability for nurses working in hospitals and the community. Because of ambiguity in the responses, questions on lack of social support 194 JOGNN Volume 33, Number 2

and marital dissatisfaction were not included in the analyses for the postpartum. Many positive comments were made about the PDPI, with 17 generally positive comments written by the community nurses: Helps make consultation more specific providing mums co-operate. I would imagine it is harder for mums to avoid talking about PND with such specific questioning. It was useful to highlight antenatal issues which may have been relevant postnatally. Another 10 nurses stated that they found the PDPI useful to initiate discussion about postpartum depression: Aided open discussion, which enabled me to form an appropriate, accurate assessment, also ensuring networks set in place if needed in the future. Seven comments indicated that the checklist was of no use or were negative. These were often brief, such as not useful. Other nurses claimed that some questions were intrusive. Six nurses commented that time was a concern and more time was needed to discuss issues that were raised with the woman. Unfortunately fitting in the extra 10-15 minutes needed to go through the tool thoroughly is just not possible in the present workload/funding arrangements. It is useful but time needed is the issue. Some nurses commented on the mothers health rather than on the PDPI itself. Mother is under GP for PND and is on medication. Mother knows symptoms of PND. Because of the importance of early identification of risk factors for postnatal depression, it is of concern that some nurses had difficulty in asking sensitive questions. In addition, these nurses expressed concern about the amount of extra time that was needed to use the forms in their already busy consultation schedule. Some nurses may not need prompts like the PDPI to aid their practice, whereas others may find such checklists helpful. It is of note that the women identified as having risk factors for PPD during pregnancy were identified early. Moreover, the 8 (10%) women who had a positive screen for PPD at 8 weeks postpartum using the EPDS and PDSS received prenatal interventions at the time. It is not known whether these early interventions had an impact on the number of women with a positive screening postpartum. We found that the modifications made to the checklist for the prenatal stage greatly enhanced its usability and was a timesaver for the midwife. Before consultation with the midwife, women had time to think about the questions and to complete the checklist. From our experience, the original format was confusing. Although we acknowledge that the PDPI was not designed as a self-report tool, it easily adapts as a self-report checklist. Nurses comments indicated the PDPI could be improved by the addition of an explanatory introduction, as suggested by the midwife who used the modified PDPI in the prenatal stage of this research. An important finding from our study is An important finding is that the PDPI, with some modification, is appropriate as a selfreport instrument. Discussion Our aims in this study were to evaluate the PDPI as a screening checklist, which is used in clinical interviews for the early identification of women with PPD in the prenatal and postpartum periods, and to compare its use with the PDSS and the EPDS. It is noteworthy that women reported high levels of depression and anxiety during pregnancy but far less postpartum. The PDPI There was considerable support for the use of the PDPI from the midwife and nurses who took part in this study, particularly as a modified self-report checklist. The midwife who used the PDPI at the prenatal visits and most of the nurses using it in the postpartum stage of this research were positive about both versions of the checklist. They found it a useful way to initiate discussion about PPD and to explore relevant issues for each woman. that the PDPI, with some modification, has benefits as a self-report checklist and saves nurses time. On the basis of our study, we have made suggestions for future uses of the checklist. The midwife stated that if the PDPI is used as a self-report checklist, women need a brief written introduction of its purpose and the format should be improved. We found that some women wanted to more fully explain their responses. One advantage of the PDPI format over that of the EPDS, the midwife claimed, was that she needed to address each section rather than merely to rely on scan-processing or a numerical response as with the EPDS. The midwife preferred to discuss the woman s responses to the questions in an open and interactive way to ensure effective and early management when problems were identified. The tool thus helped the midwife make an informed clinical judgment (Barker, 2001). Overall, at the prenatal stage, the PDPI was preferred to the EPDS, which had been used previ- March/April 2004 JOGNN 195

ously in this setting. Use of the PDPI now has been adopted as routine practice in the prenatal clinic. The PDSS We found some evidence that the PDSS and the EPDS measure similar concepts and are likely to identify the same women as having or being at risk for PPD, which in this study was 10%. Action Taken by the Midwife and Nurses The overall pattern of interventions or recommendations made by the midwife and nurses after using the PDPI is consistent with the scores obtained by women on the PDSS and the EPDS. That is, women who scored in the ranges that indicate the presence or risk of PPD were substantially more likely than other women to receive anticipatory guidance by the midwife or nurse, counseling by the nurse, or a referral to another health care professional. Thus, both instruments and the PDPI enabled the midwife or nurse to identify women at risk of postpartum depression. The prenatal midwife responded quickly to any indication that a woman might be at risk of PPD. Positive scores on all of the risk factors in the prenatal PDPI were associated with the midwife taking some action in relation to PPD. This was most likely to be anticipatory guidance or counseling. At the postpartum visit, the lower proportion of women recorded as experiencing the risk factors included on the PDPI may indicate that more women were managing well. It is not known whether the prenatal use of the PDPI and the subsequent interventions constituted a factor in the lowered postpartum rate of depression. Limitations A limitation of this study is that it was not designed to identify women who had a diagnosis of PPD, only those at risk or reporting risk factors. A psychiatric assessment is needed to confirm a positive diagnosis. It must also be noted that only one midwife, totally committed to the study, was involved in the prenatal stage of the research whereas many nurses were involved in the postpartum stage. This may have been a factor in the higher levels of reported interventions antepartum compared with postpartum. A more serious limitation occurred through one item being inadvertently excluded from the EPDS. Scores were adjusted, although the data from the EPDS are less reliable. Conclusions Generally, our findings support the use of the PDPI to assist midwives and nurses to identify women at risk of PPD in the prenatal and postpartum periods, particularly if some modifications are made to the format of the checklist. We acknowledge the importance of raising the issue of postpartum depression and allowing time for women to discuss their concerns. We are aware that caution is needed in relying on the use of tools or instruments for the assessment of PPD (Barker, 2001). The danger may be that such hard measurement could oversimplify and lead to less understanding and misjudgment of the situation. Nevertheless, we found the PDPI to be useful for introducing the concept of PPD and engaging women in an open discussion of their emotional well-being. It also Self-reporting was beneficial in that it allowed women time to think about some of the questions raised by the nurse. provided opportunities for anticipatory guidance, counseling by nurses, and referral. We found it was feasible to use the PDPI as a selfreport instrument even though it was not designed to be used this way. Self-reporting was beneficial in that it allowed women time to think about some of the questions raised by the nurse. For future use of the PDPI, we believe it would be helpful to provide training for midwives and nurses to gain the most value from the checklist. The PDSS also would be a beneficial tool when detailed information on symptoms is required but should not take precedence over skilled clinicians professional judgment. Irrespective of the methods used to identify women at risk of PPD, nurses are well placed to help women in identifying their concerns. Acknowledgments This research was funded by a grant from the Faculty of Health and Behavioural Science, Deakin University, Geelong, Victoria, Australia. We thank the women and nurses who participated in this study and Amy Prosser, Catherina Dumaresq, Desma Cook, Coral Laing, Maree Crellin, Jan Edwards, and Pam Dolly. REFERENCES Barker, W. (2001). Measurement or intuition? Community Practitioner, 74, 291-293. Beck, C. (1996). A meta-analysis of predictors of postpartum depression. Nursing Research, 45, 297-303. Beck, C. (1998). A checklist to identify women at risk for developing postpartum depression. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 39-46. 196 JOGNN Volume 33, Number 2

Beck, C., & Gable, R. (2000). Postpartum Depression Screening Scale: Development and psychometric testing. Nursing Research, 49, 272-282. Beck, C., & Gable, R. (2002). Postpartum Depression Screening Scale (PDSS). Los Angeles: Western Psychological Service. Beck, C. T. (2002). Postpartum depression: A metasynthesis. Qualitative Health Research, 12, 453-472. Beck, C. T., & Gable, R. K. (2001). Comparative analysis of the performance of the Postpartum Depression Screening Scale with two other depression instruments. Nursing Research, 50, 242-250. Cox, J., Murray, D., & Chapman, G. (1993). A controlled study of the onset, duration, and prevalence of postnatal depression. British Journal of Psychiatry, 163, 27-31. 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, 150, 782-786. Davidson, J., & Robertson, E. (1985). A follow-up study of postpartum illness. Acta Psychiatrica Scandinavica, 71, 451-457. Lumley, J., & Austin, M. (2001). What interventions may reduce postpartum depression. Current Opinion in Obstetrics and Gynecology, 13, 605-611. McGill, H., Burrows, V., Holland, L., Langer, H., & Sweet, M. (1995). Postnatal depression: A Christchurch study. New Zealand Medical Journal, 108, 162-165. Milgrom, J., Martin, P., & Negri, L. (1999). Treating postnatal depression: A psychological approach for health care professionals. Chichester, UK: Wiley. National Health and Medical Research Council. (2000). Postnatal depression: A systematic review of published scientific literature to 1999. Canberra, UK: Author. O Hara, M. (1995). Postpartum depression: Causes and consequences. New York: Springer-Verlag. O Hara, M., & Swain, A. (1996). Rates and risk of postpartum depression: A meta-analysis. International Review of Psychiatry, 8, 37-54. Barbara Hanna, RN, Mid Cert, IWC, BN (Hons), PhD, MRCNA, is a senior lecturer, School of Nursing, Deakin University, Geelong, Victoria, Australia. Heather Jarman, RN, Mid Cert, BN, MN, PhD, FRCNA, is an associate professor, School of Nursing, Deakin University, Geelong, Victoria, Australia, and Barwon Health, Victoria, Australia. Sally Savage, BA(Hons), PhD, is a research fellow on the Faculty of Health and Behavioural Sciences, Deakin University, Geelong, Victoria, Australia. Kim Layton, RN, Mid Cert, is a maternity care coordinator, Barwon Health, Victoria, Australia. Address for correspondence: Barbara Hanna, RN, Mid Cert, IWC, BN (Hons), PhD, MRCNA, School of Nursing, Deakin University, Geelong, Victoria 3217 Australia. E-mail: bah@deakin.edu.au. March/April 2004 JOGNN 197