Public health nurses (PHN) in Family Home Visiting are increasingly screening for postpartum depression. Tools to assist the PHN in decision-making when positive screens are identified can be useful in providing the best outcome. These algorithms can be used to address the results of perinatal depression screening and/or response to a mental health crisis by offering the public health nurse family home visitor guidance to appropriate responses to various results of screening.

Background

Depression is the leading disability in women and 15-20% of women feel moderate to severe depression or anxiety during the periods of pregnancy and/or postpartum (ACOG, 2010). These women are not limited to a particular culture, race, age, income or education levels. No single cause has been identified for depression or anxiety during pregnancy or postpartum, however there are several factors linked to the development of these conditions.

Key Factors

History of depression, anxiety or other mental health concerns
Stress
Hormone changes
History of trauma
Lack of or poor support
Family history
Other stressful experiences (MDH, 2014).

Other factors that may place a woman at risk for perinatal depression

History of emotional support from own mother
Perceived level of support after the birth of the baby
Life stresses in the last 12 months
Personality style (esp. presence of anxious or perfectionistic traits)
History of abuse (emotional, sexual or physical)
History of mental health or substance abuse issues
Current scoring on PHQ-9 or EPDS
General physical health
Amount of sleep
Financial stresses
Maternal feelings towards the pregnancy and baby (Johnson et al, 2012)

Infants are understood in the context of their primary caregiving relationships; best practice in public health addresses the parent/child pair, as well as the family as a whole. A caregiver experiencing depressive symptoms may have difficulty responding adequately to the infant or child, and the child's development, both emotional and physical, may therefore be at risk.

Infants of mothers with diagnosed depressive disorders have shown delays in cognitive, neurologic, psychological and motor development. It has also been seen that children with mental and behavior disorders whose mothers are depressed show improvement in behaviors when their mother's depressive symptoms are in remission. Partners of the depressed woman also suffer with increased rates of depression. For these reasons, it is critical to identify women with depression through screening in order to encourage prompt diagnosis and treatment (ACOG, 2010).

Description of the algorithms

Three algorithms have been developed to offer appropriate responses to screening results of the Edinburgh Postpartum Depression Scale (EPDS) and the PHQ-9. The third algorithm is a crisis response algorithm if it is found that a woman is currently at risk of suicidal behavior or harm to her baby or others.

These algorithms are templates offered for use in your agency as guides and can be customized to meet your individual agency needs. Resources and needs vary by individual communities and protocols for referral and follow-up vary by agencies and providers. These documents are provided as editable documents to allow modification or addition of individual protocol and resources.

A “What's Next” informational document is provided to give basic information on depression screening and how to care for the perinatal woman who is experiencing depression. Resources and references are presented for you to seek more information on this topic as well as space to include information on your local resources.

It is important that your agency or community develop individual procedures and/or protocol for responding to various situations using the unique resources available in your community. Also, with the implementation of postpartum depression screening, staff should receive educational training on depression to increase their understanding of this issue and to improve skill and comfort level when responding to mothers who score positively for depression.

It is hoped that these tools will be helpful to you as you work to advance the mental health care of the families that you serve.

References

American College of Obstetricians and Gynecologists (ACOG, (2010). Committee opinion on Screening for Depression during and after pregnancy. Retrieved from: ACOG opinion on screening for depression during and after pregnancy

Johnson, M.; Schmeid, V.; Lupton, S. J.; Austin, M. P.; Matthey, S. M.; Kemp, L.; Meade, T.; Yeo, A. E. (2012). Measuring perinatal mental health risk. Archives in Women's mental health, 15, 375. DOI 10.1007/s00737-012-0297-8.

Minnesota Department of Health, (2014). Perinatal Mood and Anxiety Disorders. Retrieved from: MN Dept of Health Perinatal Mood and Anxiety Disorders