Mental Health Across the Lifespan Initiative

Postpartum Depression:

Facilitator’s Guide

About this Guide The National Institute of Mental Health (NIMH) has developed this Facilitator’s Guide to assist members of Delta Sigma Theta Sorority, Inc. (DST) in delivering the Postpartum Depression Module of the Mental Health Across the Lifespan Initiative – a public-private partnership between NIMH, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and DST. This Module aims to raise awareness of the signs and symptoms of postpartum depression and reinforce the importance of seeking help and treatment from a health professional. This easy to follow guide includes information on preparing for the presentation, a script to be read by the facilitator, resource information, and references. The word (Click) appears in the guide to instruct the facilitator to advance the presentation animation in the PowerPoint. If using an Adobe formatted PDF of the presentation, the facilitator should read to the end of the page that corresponds to the slide before advancing to the next page. Other NIMH products that can be used in conjunction with this guide and corresponding presentation include:

• Postpartum Depression Video – a short video containing information from clinicians and testimony from a woman who experienced postpartum depression

• Postpartum Depression Fact Sheet – a one-page document highlighting key facts about postpartum depression

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Tips for Preparing for the Postpartum Depression Presentation When scheduling the presentation, consider: • What day and time will attract the most attendees? Try to avoid having it at the same time or immediately following another popular activity, especially if you think it will make it difficult for people to arrive on time. • Do you want to have a panel of experts or speakers to present additional information? Try to secure speakers well in advance of the presentation and ensure any supportive materials from speakers are received before the presentation day. When setting up the room, consider: • Do you have the right technology to present the slides (i.e., laptop, projector, screen, power outlet, podium)? • How much time will you need to set up the technology? Do you have a back-up plan if something like the projector or computer doesn’t work? • Will the room be accessible for people who have difficulty walking? • Will people be able to see the screen from all seats? Should you print a few copies of the slides in case people can’t see the screen? • Depending on the expected size and preferences of the group, would it be best to have rows of chairs or have people sit around a table? • Will you need to secure an interpreter? When preparing for and delivering the presentation, consider: • Do you have a plan for people who are unable to see or hear well or who have difficulty writing? • What’s the best way to distribute any written materials? Try to hand them out before you get started to avoid taking time away from the presentation itself. • How will you keep track of time during an activity? • Following an activity, how will you reconvene the audience? • How will you handle questions? Do you want people to ask questions at any time or wait for set breaks in the discussion? Should people raise hands or just call out? • Remind attendees to turn off or silence their cell phones. Checklist of items to bring: • Copy of the Facilitator’s Guide • Any equipment for projecting the presentation • Enough copies of written materials or handouts for every attendee, plus a few extra for those who want to take an extra to share with a family member or friend • Pens or pencils for attendees who want to take notes • Timer or watch to keep track of time for activities and presentation

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I’d like to welcome you to this presentation about Postpartum Depression (PPD). Today, we’ll learn about what postpartum depression is and how you can support a friend or family member during the period following the birth of a child. Please note that I am not a doctor and do not have the medical expertise to address individual health concerns or provide medical advice. [Unless the facilitator is a qualifying health professional, e.g., physician, psychologist, social worker, nurse practitioner, physician assistant, or other type of clinician.] Our presentation will instead focus on sharing information about this condition, including the signs and symptoms, treatment options and tips on how encourage help-seeking behaviors and provide support. I will use the term “health professional” to describe a health care provider, this person could be a physician, psychologist, social worker, nurse practitioner, physician assistant, or other type of clinician. Before I get started, I want to point out that I have distributed a handout to help you recall some of the important points we will discuss today. The handouts are yours to keep. The information in this presentation has been developed by the National Institute of Mental Health, one of the 27 Institutes and Centers of the National Institutes of Health – a component of the U.S. Department of Health and Human Services. You can visit www.nimh.nih.gov for more information on this topic. (Click)

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Facilitator Note: Warm-up activity. Ask group the following question to help them begin actively thinking about the postpartum period. What are some words to describe feelings a woman may have in the weeks following the birth of a child? Facilitator Note: If the audience doesn’t call out words, you might try providing a few examples, such as joy, happiness, fatigue, etc. These are all great words used to describe feelings a woman may have in the weeks following childbirth. (Click)

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A few less common words used to describe this time include: (Click) overwhelming, anxious, and exhausting. (Click) These words are also associated with postpartum depression – a mood disorder that affects nearly 15% of women shortly before or soon after childbirth. (Click)

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We are going to cover a number of facts about postpartum depression. There are a few basic messages that I want you to keep in mind as we progress. They are (Click)

1. As with other mental illnesses, or disorders of the brain, postpartum depression does not occur because of something the mother does or does not do; (Click)

2. This condition can affect any woman regardless of race, age, social, economic, or educational background. Postpartum depression does not discriminate and can occur with any pregnancy (i.e., first, second, etc.); (Click)

3. Most importantly – treatment is available. Postpartum Depression can be effectively treated by a health professional; friends and family can help.

Our goal today is to share information about this condition that affects a half million women each year. Our hope is that you will then share this information with others and encourage women who may be experiencing postpartum depression to seek help. (Click)

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Facilitator Note: Ask the audience activity. By a show of hands – how many of you have heard of Postpartum Depression? Wait for a show of hands and then continue.

So, what is postpartum depression? Postpartum depression is a mood disorder that can affect women shortly before or soon after childbirth, but commonly begins within a month after delivery. While many believe that welcoming a new baby is one of the most wonderful times in a woman’s life, mothers with postpartum depression may experience feelings of extreme sadness, anxiety, and exhaustion that make it difficult to complete daily care activities for themselves or their family. (Click)

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What causes postpartum depression? Researchers have not identified a single cause for postpartum depression, but it is likely the result of a combination of physical and emotional factors. Researchers at the National Institute of Mental Health are studying a number of factors that may contribute to postpartum depression including an extreme drop in hormone levels (estrogen and progesterone) in a woman’s body after childbirth. This extreme change can lead to chemical changes in a woman’s brain that may trigger mood swings. In addition, many mothers are unable to get the rest they need to fully recover from giving birth. Constant sleep deprivation and increased responsibilities can lead to physical discomfort and exhaustion, which can contribute to the symptoms of postpartum depression. Again, postpartum depression does not occur because of something a mother does or does not do. (Click)

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Common symptoms As you can see from this slide, there are a number of symptoms associated with postpartum depression. Women who have experienced postpartum depression have reported feelings of anxiety, irritability, restlessness or insomnia; withdrawing from interactions with others; and difficulty bonding with the baby or feeling numb. These symptoms can occur individually or in combination. It is important to note that just one of these symptoms can impair a woman’s ability to care for herself or her family. As evidenced by these symptoms – postpartum depression can affect any woman regardless of race, age, social, economic, or educational background and can occur following any pregnancy. (Click)

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Baby Blues vs. Postpartum Depression Facilitator Note: Ask the audience activity. By a show of hands – how many of you have heard of “the Baby Blues?” Wait for a show of hands and then continue to the next question. How many have heard about Postpartum Psychosis? Wait for a show of hands and then continue. Mood disorders affecting women after childbirth vary in intensity and length of time. These two factors – intensity and length of time – distinguish the “baby blues” from postpartum depression and postpartum depression from postpartum psychosis. (Click) The "baby blues" is a common term used to describe the feelings of worry, unhappiness, fatigue, and rapid and often exaggerated mood swings (i.e., sudden tearfulness) that many women experience after having a baby. Babies require a lot of care, so it's normal for a mother to be worried about her baby or tired from providing care. The “baby blues” may affect up to 80 percent of mothers. It includes feelings that are somewhat mild, last a week or two, and go away on their own. (Click) The symptoms of postpartum depression, which occurs in nearly 15 percent of births, do not go away on their own. The condition may begin shortly before or soon after childbirth, but commonly begins within a month after delivery. Symptoms can persist for weeks to months. With postpartum depression, the feelings of sadness and anxiety can be persistent and might interfere with a woman's ability to care for herself or others. Because of the severity of the symptoms, postpartum depression requires treatment. (Click)

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Postpartum Psychosis Psychosis is a mental disorder characterized by symptoms such as delusions or hallucinations which cause a break with reality. Postpartum psychosis is the most severe and dangerous of the postnatal mood disorders discussed today. (Click) This condition is rare – occurring in roughly one (1) in one thousand (1000) births. With postpartum psychosis, a woman experiences a break with reality which impairs her judgment. Severe symptoms often occur 1 to 2 weeks following childbirth and may include delusions, hallucinations, heightened irritability, rapid mood swings, and paranoia. Postpartum psychosis requires immediate treatment from a doctor. Symptoms will not go away on their own, but will get worse – putting the mother and baby at risk for harm. (Click)

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Is it postpartum depression or something else? A health professional can determine if a woman has postpartum depression. Because symptoms of this condition are broad and vary in intensity and length of time, a health professional is in the best position to determine whether the symptoms are from postpartum depression or from another cause. A woman who experiences any of the symptoms that we’ve discussed today should see a health professional right away. (Click)

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Who is at risk? Since postpartum depression can affect any woman regardless of race, age, social, economic, or educational background – any woman of childbearing age is at risk for this condition. Some women are at greater risk for developing postpartum depression because they have one or more risk factors. A risk factor is something that increases a person's chances of developing a disease or illness. For example, cigarette smoking is a risk factor for lung cancer. Risk factors for postpartum depression include: • Symptoms of depression during or after a previous pregnancy • Experienced depression or bipolar disorder at another time in life • A family history of depression or other mental illness • Medical complications during childbirth, including premature delivery or having a baby with

medical problems • A stressful life event during or shortly after giving birth (i.e., personal illness, domestic violence,

death of a loved one, etc.) • Mixed feelings about the pregnancy, whether it was planned or unplanned • A lack of strong emotional support from a spouse, partner, family, or friends • Alcohol or other drug abuse (Click)

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Now that we know what postpartum depression is, the symptoms and who is at risk – let’s do a quick review. Facilitator Note: Read the questions to the group and encourage participants to respond before revealing the answers. Question 1. Is postpartum depression the result of something a woman does or does not do? Yes or No? (Click)

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Answer: NO. As we learned from “Today’s Basics” – postpartum depression does not occur because of something a woman does or does not do. (Click)

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Question 2. Are wealthy, educated women of childbearing age at risk for postpartum depression? (Click)

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Answer: Yes. All women of childbearing age are at risk for postpartum depression. This condition does not discriminate and can affect any woman regardless of race, age, social, economic, or educational background. Postpartum depression can occur with any pregnancy (i.e., first, second, etc.). (Click)

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Question 3. Can you name a common symptom of postpartum depression? (Click)

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Answer: Common symptoms include: Women who have experienced postpartum depression have reported feelings of anxiety, irritability, restlessness or insomnia; withdrawing from interactions with others; and difficulty bonding with the baby or feeling numb. Other symptoms are listed here. (Click) Facilitator Note: Participants may also mention some of the symptoms noted on the slide. Feel free to read a few of the symptoms listed on the slide. • Feeling sad, hopeless, empty, or overwhelmed • Crying more often than usual, or for no apparent reason • Worrying or feeling overly anxious • Feeling moody, irritable, or restless • Oversleeping or being unable to sleep, even when her baby is asleep • Having trouble concentrating, remembering details, and making decisions • Experiencing anger or rage • Losing interest in activities that are usually enjoyable • Suffering from physical aches and pains, including frequent headaches, stomach problems, and

muscle pain • Eating too little or too much • Withdrawing from or avoiding friends and family • Having trouble bonding or forming an emotional attachment with her baby • Persistently doubting her ability to, or not being able to care for her baby • Thinking about harming herself or her baby

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Question 4. Will symptoms of postpartum depression or postpartum psychosis go away on their own? Yes or No (Click)

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Answer: No, symptoms of postpartum depression or postpartum psychosis will not go away on their own. These conditions vary in intensity and length of time. Both require treatment from a health professional. (Click) Facilitator Note: Say something encouraging to the group for actively participating in the review.

• You did great! • Good job!

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Treating Postpartum Depression The third thing that I asked you to keep in mind is that postpartum depression can be effectively treated by a health professional. (Click) Effective treatments may include: • Counseling/Talk Therapy: This treatment involves talking one-on-one with a mental health

professional (a counselor, therapist, psychologist, psychiatrist, or social worker). Two types of counseling are shown to be particularly effective in treating postpartum depression. They are: o Cognitive behavioral therapy (CBT), which helps people recognize and change their negative

thoughts and behaviors; and o Interpersonal therapy (IPT), which helps people understand and work through problematic

personal relationships. (Click) • Medication: Antidepressant medications act on the brain chemicals that are involved in mood

regulation. Many antidepressants take a few weeks to be most effective. While these medications are generally considered safe to use during breastfeeding, a woman should talk to her health care provider about the risks and benefits to both herself and her baby.

These and other treatment options can be used alone or together to treat postpartum depression. A woman’s health care provider can help her choose the best treatment. (Click)

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Untreated Postpartum Depression If left untreated, postpartum depression can last for months or years – putting the mother and baby at risk of harm. In addition to affecting the mother’s health and wellbeing, postpartum depression can interfere with her ability to connect with and care for her baby and may cause the baby to have problems with sleeping, eating, and behavior as they grow. (Click)

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How can YOU help? A woman experiencing postpartum depression may not recognize symptoms in herself. As with many other mental illnesses or brain disorders, family members and friends may be the first to recognize changes in the mood or behavior of a loved one. If you know a woman who may be exhibiting the symptoms we’ve discussed today, you can (Click)

1. Encourage her to talk with a health professional as soon as possible. Let her know that there is help to assist her through this period of transition. Tell her that postpartum depression can be effectively treated, but first it must be appropriately diagnosed by a health professional. (Click)

2. Offer her emotional support. Listen as she describes her feelings. Never belittle her feelings,

rather point out realities of hope and reassure her that the feelings are not the result of something she has done or has not done. (Click)

3. Assist with daily tasks such as caring for the baby or the home. Babies require a lot of care, so

it's normal for a mother to be worried about her baby or tired from providing care. It is also important for mothers to rest and not isolate themselves. Even if she does not ask for it, offer to help out. (Click)

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Finally, one of the best ways to help a mother during this transitional period is to gently and lovingly share the information you have learned today about postpartum depression. Engage her in conversation and listen carefully as she talks about her feelings or symptoms. Don’t make light of or mock her feelings and never ignore comments about harming herself or her baby. This might not be an easy conversation, but it is an important conversation to have. Researchers believe that women who have a strong support system and are educated about postpartum depression are more likely to seek help sooner than those who are not aware of this condition. For instance, a person who knows the signs and symptoms of a heart attack is more likely to identify the early signs in themselves or others and seek appropriate care. Likewise an individual who knows about postpartum depression is better prepared to identify the symptoms in themselves or others. (Click)

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In closing, here are our 3 basic take-away messages from today’s presentation:

1. As with other mental illnesses, or disorders of the brain, postpartum depression does not occur because of something the mother does or does not do;

2. This condition can affect any woman regardless of race, age, social, economic, or educational background. Postpartum depression does not discriminate and can occur with any pregnancy (i.e., first, second, etc.);

3. Most importantly – treatment is available. Postpartum depression can be effectively treated by a health professional; friends and family can help. (Click)

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This brings me to the end of the presentation. In addition to the handout provided, more information on postpartum depression and free resources can be found on the NIMH Website www.nimh.nih.gov If you or someone you know is in crisis and needs immediate help, call the toll-free 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889). Thank you for joining us today. Facilitator Note: Now may be a good time to transition to a question and answer period or encourage participants to complete any post-presentation materials. You may consider asking the questions below to generate discussion and highlight some of the major points from the presentation:

• What information in today’s presentation did you find particularly helpful or interesting? • What are some ways that you could share this information with a friend or family member? • Does anyone have questions about the information covered today?

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Postpartum Depression Resources Here is a sampling of resources that may be helpful. You may find more information through the Internet, brochures, books and articles available at libraries, hospitals or health providers, national organizations or associations, or other institutes within the National Institutes of Health (NIH). If you or someone you know is in crisis, get help quickly. Call your doctor. Call 911 for emergency services. Go to the nearest hospital emergency room. Call the toll-free 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889).

Federal Resources

National Institute of Mental Health (NIMH) http://www.nimh.nih.gov 1-866-615-NIMH (6464) toll-free / TTY: 1-866-415-4279 toll-free The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. NIMH has free information online and in print publications. NIMH Section on Behavioral Endocrinology (SBE) http://www.nimh.nih.gov/labs-at-nimh/join-a-study/adults/adults-postpartum-depression.shtml 1-301-496-9576 / TTY: 1-866-411-1010 Doctors at the NIMH SBE are conducting research to learn more about the causes of, treatments for, and genetic factors in postpartum depression. Staff is available to answer questions on NIMH research studies and recruitment. Individuals who currently have postpartum depression, or had postpartum depression in the past are encouraged to call to learn more about opportunities to participate in research. Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov 301- 427-1364 The mission of the AHRQ is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used. Centers for Disease Control and Prevention (CDC) http://www.cdc.gov 1-800-CDC-INFO (232-4636) toll-free / TTY: 1-888-232-6348 toll-free The CDC has information about health issues in America and abroad, disease and injury prevention, and emergency preparedness. ClinicalTrials.gov http://www.ClinicalTrials.gov ClinicalTrials.gov is a web-based registry and results database of publicly and privately supported clinical studies of human participants conducted around the world.

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MedlinePlus http://www.medlineplus.gov 1-888-FIND-NLM (346-3656) toll-free / TTD: 1-800-735-2258 toll-free This website from the National Library of Medicine provides information about a variety of diseases and conditions, as well as descriptions of medical (“laboratory”) tests. National Institutes of Health (NIH) http://www.nih.gov 301-496-4000 / TTY: 301-402-9612 The NIH is the nation’s medical research agency. The agency conducts and supports research on the causes, treatments, and cures for both common and rare diseases. Office on Women’s Health (OWH) http://womenshealth.gov 1-800-994-9662 toll-free / TDD: 1-888-220-5446 toll-free The OWH, which is part of the U.S. Department of Health and Human Services, works to improve the health and sense of well-being of all U.S. women and girls. OWH serves as the focal point for women's health activities across HHS offices and agencies and leads HHS efforts to ensure that all women and girls achieve the best possible health. Substance Abuse and Mental Health Services Administration (SAMHSA) https://findtreatment.samhsa.gov 1-800-662-HELP (4357) toll-free / TTD: 1-800-487-4889 toll-free SAMHSA is an agency within the U.S. Department of Health and Human Services. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities. SAMHSA’s National Helpline (also known as the Treatment Referral Routing Service) is a confidential, free, 24-hour-a-day, information service, in English and Spanish, for individuals and family members facing mental health and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations.

Non-Federal Resources Postpartum Support International (PSI) http://www.postpartum.net 1-800-944-4PPD (4773) toll-free PSI has more than 250 Support Coordinators around the world. PSI Volunteer Coordinators provide support, encouragement, and resources on the phone and email to pregnant and postpartum moms and families, and help you connect to community or internet resources. PSI also offers specialized support to dads and partners, Military families, and Spanish-speaking families. Anxiety and Depression Association of America (ADAA) http://www.adaa.org 240-485-1001 The ADAA is a national nonprofit organization. ADAA’s mission is to promote the prevention, treatment, and cure of anxiety, depression, obsessive compulsive disorder, post-traumatic stress disorder, and related disorders and to improve the lives of all those who suffer from them through education, practice, and research.

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Depression and Bipolar Support Alliance http://www.dbsalliance.org 1-800-826-3632 toll-free The DBSA is the leading peer-directed national organization focusing on the two most prevalent mental health conditions, depression and bipolar disorder. DBSA’s peer-based, wellness-oriented services and resources are available online, in local support groups, in audio and video casts, or in printed materials distributed by DBSA chapters and mental health care facilities across America. Mental Health America (MHA) http://www.mentalhealthamerica.net 1-800-969-6642 toll-free MHA is a nonprofit organization addressing all aspects of mental health and mental illness. With more than 340 affiliates nationwide, MHA works to improve the mental health of all Americans through advocacy, education, research and service. National Alliance on Mental Illness (NAMI) http://www.nami.org 1-800-950-NAMI (6264) toll-free NAMI is a nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses. The organization consists of hundreds of NAMI State Organizations, NAMI Affiliates and volunteer leaders who work in local communities across the country to raise awareness and provide essential and free education, advocacy and support group programs. American Psychological Association (APA) http://www.apa.org 1-800-374-2721 toll-free The APA is the largest scientific and professional organization representing psychology in the United States. The mission of the APA is to advance the creation, communication and application of psychological knowledge to benefit society and improve people's lives. American Congress of Obstetricians and Gynecologists (ACOG) http://www.acog.org 1-800-673-8444 toll-free The ACOG is a private, voluntary, nonprofit membership organization of health professionals providing health care for women.

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References:

Postpartum Depression Facts. U.S. Department of Health and Human Services. National Institutes of Health. 2013. NIH Publication No. 13-8000

Women and Depression: Discovering Hope. U.S. Department of Health and Human Services. National Institutes of Health. 2009. NIH Publication No. 09-4779

Prevalence of Self-reported Postpartum Depressive Symptoms—17 states, 2004-2005. MMWR 2008;57(14):361-366.

Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. 2005. AHRQ Publication No. 05-E006-2

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing, 2013.

Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am. 2010;33:273-93.

Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician. 2010;82:926-33.

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