Postpartum Depression (PPD) is defined as “severe depression lasting beyond 4 to 6 weeks during the weeks or months after delivery” (Drake, 2017) and is a common complication among women following childbirth. Paternal Postpartum Depression is also gaining recognition, proving that this is a family diagnosis not just a maternal one (Musser, Ahmed, Foli, & Coddington, 2013). Early detection, prenatal education, as well as continuing education and assessment helps to promote health and parent-infant bonding, however the period following childbirth is given less attention by healthcare professionals than the time from conception to delivery (Corrigan, Kwasky, & Groh, 2015).
PPD is severe in intensity and duration beginning within the first few weeks after delivery and lasting up to the first year of life. Symptoms of PPD are very similar to those once might experience in any other depressive state, but the motivation behind these symptoms are focused on the new baby. They include severe mood swings or a depressed mood, excessive crying, changes in appetite or ability to sleep, decreased pleasure or interest in activities usually enjoyed, overwhelming fatigue and/or loss of energy, a decrease in interaction with friends or family, an inability to think clearly or concentrate, difficulty making decisions, difficulty bonding with the new baby, feelings of worthlessness, guilt, shame, or inadequacy as a mother or father, panic attacks and severe anxiety, thoughts of harming oneself or the baby, and recurrent thoughts of death and/or suicide (Mayo Clinic, 2015). Treatment is crucial for those suffering with PPD as it does not resolve on its own and can lead to a chronic depressive disorder as well as increase the risk for episodes of major depression in the future (Mayo Clinic, 2015)
Demographics
There is no single cause or predisposing factor for PPD, it can affect any parent regardless of age, economic status, or ethnicity. However there is evidence suggesting that physical changes and emotional issues may increase an individual’s risk (Mayo Clinic, 2015) as well as environmental and situational factors (National Institute of Mental Health). After childbirth the body experiences a dramatic decrease in the hormones estrogen and progesterone, and the rapid decrease of these hormones after months of overproduction during pregnancy may contribute to a chemical imbalance, causing PPD (Mayo Clinic, 2015). Emotional risk factors include difficulty overcoming even minor obstacles due to sleep deprivation, anxiety over one’s ability to care for a newborn, feeling a loss of identity due to the new role of parenthood, feeling a loss of control over one’s own life, as well as feeling less attractive after pregnancy body changes (Mayo Clinic, 2015). Environmental and situational factors include stressful life events during pregnancy or after giving birth such as loss of employment/home or death of a loved one, marital problems, domestic violence, complications with childbirth including giving birth prematurely or to a newborn with medical problems, substance abuse problems, as well as a perceived or actual lack of support and assistance from significant other or friends and family (National Institute of Mental Health).
However, the strongest evidence to suggest a definitive risk factor lies in the individual’s personal and familial mental health history. The risk for PPD increases when the individual has a family history of PPD or other depression or mood disorders, when there has been a previous diagnosis of depression before and/or during pregnancy (Mayo Clinic, 2015). PPD can develop after every pregnancy, not just the first, though a previous diagnosis does increase the individual’s risk for additional recurrences (Mayo Clinic, 2015). Additionally, fathers whose spouse or partner is experiencing Maternal PPD are at an increased risk for experiencing it themselves (Musser et al., 2013).
Incidence in the Target Population
Each year an estimated 21.9% of mothers during the first twelve months after delivery (Wisner, Sit, McShea, Rizzo, Zoretich, Hughes, Eng, Luther, Wisniewski, Costantino, Confer, Moses-Kolko, Famy, Hanusa, 2013) experience symptoms of PPD. Due to the perceived stigma and a general lack of education concerning PPD, this estimate could be much higher as women go undiagnosed and untreated (Wisner et al., 2013). Suicide related to PPD is responsible for approximately 20% of deaths postpartum, making it the second most common cause of death in postpartum women (Wisner et al., 2013). In an article analyzing the findings of a study published in JAMA Psychiatry titled “Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women With Screen-Positive Depression Findings”, Rope, (2013) brings attention to the fact that “Thirty percent of the women who showed signs of depression after delivery had experienced an episode of the condition before pregnancy, 40 percent had one during pregnancy…”
As more research is being conducted into Paternal Postpartum Depression, studies are showing that an estimate 4% to 25% of new fathers experience PPD themselves within the first twelve months after their baby is born with a higher prevalence in households where Maternal PPD is also experienced (Musser et al., 2013). As there is limited resources available to screen for Paternal PPD and a lack of knowledge surrounding the diagnosis in men, in addition to the fact then men are statistically less likely to report depression symptoms (Faris, 2012), this estimate may be higher.
Role of the Nurse
Assessment
For the nurse to increase health postpartum in parents with PPD, education and support are the two most important factors (Horowitz, Murphy, Gregory, Wojcik, Pulcini, & Solon, 2013). Assessing both the mother and father’s knowledge of PPD including its symptoms, family history or other predisposing factors, as well as when and where to seek help should it be needed can begin as early as conception; early detection is important and symptoms can develop even before delivery (American Psychological Association).
Assessment should begin with the nurse asking what knowledge the parents already have concerning PPD including signs and symptoms, as well as previous experiences with the disorder. If either parent has previously been diagnosed with PPD or other depression/mood disorders, explain the increased risk of recurrence and inquire about treatments that may have helped in the past. After inquiring about previous experiences and parent knowledge base, the nurse should ask if the parents have any particular concerns, questions, or fears concerning PPD so that the nurse may address them. It is important for the nurse to determine what support the parents have from friends and family, or even each other (i.e. will one parent be more involved than the other?) Stress, lack of support, and lifestyle changes can lead to a diagnosis of PPD so assessment of these factors is crucial to examine what resources (e.g. support groups, therapists, classes, state funded assistance programs) should be made available to the parents and what education is needed to help them adjust to this new experience. The nurse should assess financial situation, stress caused by financial strain is a risk factor for PPD but this assessment is also an opportunity to educate the parents about resources such as WIC or other state funded resources available to help ease financial burdens. How do these parents prefer to learn? Are they technology oriented and prefer online material and resources? Or do they learn best through conversation and active listening. Assess how the parents want to learn so that teaching moments are productive. Lastly, the nurse should ask what goals the parents have in detecting, preventing, and treating PPD symptoms.
Planning
Education and support are integral for positive outcomes with PPD and are tailored to the individual needs of the parents and their situation. Goals and desired learning outcomes should be tailored to what the nurse learned during assessment and specific to those specific parents. Short-term and long-term goals should be discussed and related to the goals the parents expressed interest in accomplishing during assessment. An example of a short-term goal for parents who have deficient knowledge might be an ability to verbalize the signs and symptoms of PPD or an ability to verbalize the warning signs for when treatment is needed. For a parent who might already be experiencing symptoms or is predisposed to PPD, a different short-term goal might include establishing themselves with a mental health professional as a resource and for treatment as needed. A long-term goal for parents who would benefit from ongoing support might be to utilize visiting nurses upon discharge from the hospital for support, continuing education, and ongoing screening for PPD symptoms. In the study published by Horowitz et al. (2013) in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, mothers interviewed after the study’s completion “…agreed that the nurses’ visiting was supportive” and the diagnostic tools used by these nurses “…made them more aware of their emotional state and validated how they were feeling emotionally.”
Implementation
Teaching should occur at every interaction with the parents, however setting a specific time and place for teaching and learning is best. If the nurse meets with the parents at OB/GYN appointments throughout the pregnancy, and after delivery for follow-up appointments, then implementation, evaluation, and further teaching as needed will be most effective. The nurse should always show respect to beliefs and opinions when interacting with the parents, and should be able to maintain eye contact (i.e. sit with parents instead of standing over them). Clearly define the learning objectives for the session so that expectations from all involved are established. Speak objectively, never provide false assurances or offer promises that cannot be kept. For educating parents on the signs and symptoms of PPD give examples, written handouts, and introduce evaluation tools such as the Edinburgh Postnatal Depression Scale (EPDS) to teach recognition of signs and symptoms in a more understandable and relatable format. Introduce helpful websites as resources such as http://www.postpartum.net which contains additional information for parents, information about support groups, links to blogs written by mothers who have experienced PPD, as well as contact information for emergency services such as the National Suicide Prevention Hotline (1-800-273-8255). The nurse should appropriately time these teaching sessions to accommodate the learner’s preferences, let the parent set the pace for learning and fit the care plan to that criteria.
Evaluation
It is always important for the nurse to determine how effective the teaching was for the patient. By evaluating the parent’s knowledge after each teaching session, the nurse is then able to alter the care plan to accommodate further teaching or establish that the goal has been met and the care plan has been completed. Ways to evaluate the parent’s understanding and learning are their ability to verbalize their understanding in detail as well as teach-back of an objective. The parent should, at the end of teaching, be able to verbalize signs and symptoms of PPD as well as when and who to contact should the need arise. The patient should understand and be able to verbalize the benefit of a visiting nurse and how to receive this service if desired. If a goal was not met then the nurse and parents work collaboratively to address what needs further education and the nurse adjusts the care plan. The nurse always provides an opportunity for questions and concerns at each teaching session.
Summary
Postpartum Depression is a common disorder associated with pregnancy and childbirth, affecting both mother and father. While there is not one specific cause for PPD, there are many risk factors that may predispose a person to diagnosis. Lack of support after birth, previous mental health diagnoses, hormonal changes, and stress can trigger the disorder. Many parents who experience symptoms do not seek treatment, however treatment is important for preventing chronic depressive disorders from developing as a result of PPD. Through education and support, parents experiencing PPD can anticipate and receive treatment for this disorder. Nursing interventions can begin at conception and can continue after delivery and discharge in the form of a visiting nurse or assessment at OB/GYN follow-up appointments after delivery. Teaching parents what to expect, what to look for, and what to do if symptoms occur increases positive outcomes, as well as providing opportunities for support and where to find support if needed.
This is a topic that is of personal interest to me and through writing this paper I learned that there are ways nurses can help their patients understand and manage this disorder. Nurses give power back to parents with PPD through education and support by teaching them there is a reason they feel the way they do and that it was nothing that they did to cause it. The nurse also teaches the parent how to regain control of their situation and how to either prepare for or prevent a diagnosis of PPD. The nurse is responsible for promoting health of individuals in their care and to provide care that is evidence based and professional at every interaction.