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Postnatal Depression, Risk Factors,

Assessment, Identification &

Treatments

Dr Patricia Leahy-Warren, PhD, MSc (Research), HDipPHN, BSc, RPHN, RM, RGN

Presentation at the Emotional Wellbeing Education Conference

May 10th 2014

Objectives

• Background Literature

• Postnatal Mental Health

• Risk factors

• Assessment and screening instruments

• Importance of identification of PND

• Treatments

• Conclusion

Emotional Wellbeing Educational

Conference May 10th 2014



Postnatal Period

• Time of transition

• Major developmental change

• Becoming a mother for first-time

• Adaptation and coping

• Learning infant care skills

• Societal pressure ‘perfect mother’

• ‘Poor relation’ of perinatal research

Postnatal Mental Health

• Baby blues

• Postnatal Psychosis

• Postnatal depression

• Postnatal posttraumatic stress disorder

• Postpartum panic disorder

• Postpartum anxiety



Prevalence of risk of

Postnatal Depression

International rates:

4.4% to 73.7%

Irish rates: 11.4%-28.6%

Recent Irish study

At 6 weeks

13.2% (95% CI: 9.8-16.6%)

At 12 weeks

9.8% (95% CI: 6.5-13.1%)





Triggers or Events

Having a baby

Accident

Bereavement

Marital breakdown

Moving house

Illness

Traumatic experience

Vulnerability or Risk factors

Social isolation

Domestic abuse

Low self-esteem/efficacy

Physical ill health or exhaustion

Denial or

refusal to

face up to

issues

High

expectations

about being

able to cope

regardless

History of depression

or other mental health

problems

History of

physical or

sexual abuse

Not living

up to one

self

Always

seeing the

dark side

Cited from Nicolson, P (1988) Postnatal Depression Facing the paradox of loss, happiness and motherhood p. 13 Sussex: Wiley

Bio Psychosocial Model Explanation of Depression

Postnatal Depression

Mothers’ experiences I felt I was a

failure as

a mother

It was

lonely…nobody to

talk to…I never hit

him…(but)

grabbed

him…ignored his

crying

It was terrible,

like someone

else taking over. I

wasn’t the same

person

I felt ghastly …like a

physical weight

pulling me

down…everything

was an effort

I liked my

baby but I

wasn’t

interested

in her



Assessment & Identification

Holistic nursing clinical assessment plus

• Whooley questions:

1. ‘During the last month, have you often

been bothered by feeling down, depressed

or hopeless?’

2. ‘During the last month have you often

been bothered by having little interest or

pleasure in doing things?’ (NICE CG 45)



Arroll follow on question

• This is also supplemented with a third

question if the answer to either of the first

two is ‘Yes’:

• 3. ‘Is this something with which you would

like help?’ which has three possible

responses: ‘No,’ ‘Yes, but not today,’ and

‘Yes.’ (Arroll, Goodyear-Smith, Kerse, N., et al.2005).



Treatments • Antidepressants e.g. Selective serotonin

reuptake inhibitors (SSRIs)

• Cognitive Behavioural Therapy (CBT)

• Cognitive Behavioural Counselling (CBC)

• Interpersonal Therapy (IP)

• Counselling e.g. non-directive in home

visits

• Support



Social Support

• Structural Social

Support (Networks) • Persons

– Formal (Health

Professionals)

– Informal

(Family/Friends)

• Functional Social

Support • Informational

• Instrumental

• Emotional

• Appraisal



01020304050607080

% c

ha

ng

es

Partner Mother Neighbour Professional

Structural social support

Informational support- from birth to 6

weeks

Birth

6 weeks

0

20

40

60

80

100

% c

han

ges



Instrumental support- from birth to 6

weeks

Birth

6 weeks

0

20

40

60

80

100

% c

han

ges



Emotional support- from birth to 6

weeks

Birth

6 weeks

0

20

40

60

80

100

% c

ha

ng

es



Appraisal support- from birth to 6

weeks

Birth

6 weeks

At 12 weeks • Mothers who received no formal support at birth

had a significantly elevated risk of PND

(Odds ratio = 3.33, p < 0.01, 95% CI = 1.36 – 8.19)

• Mothers who received low levels of appraisal

support at 12 weeks were at greatly increased

risk of PND relative to those receiving high

levels of support

(Odds ratio = 6.42, p < 0.05, 95% CI = 1.44 – 28.7)

(Leahy-Warren et al., 2005, 2007, 2011, 2012)



Conclusion

• PND serious Public health issue

• Early identification of affected women in the

community

• Women’s preferences for effective treatments

• Health of women’s partners

• Significance of social support- structural and

functional dimensions



Recommendations

• Universal screening for postnatal depression in the community

• Greater emphasis on postnatal nursing care in the community

• Choices of different models of care and treatments in the community

• Partners and maternal mothers acknowledged as primary sources of support

• Further research to enhance early detection in primary care

• Further research on effective acceptable interventions in community





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References Arroll, B., Goodyear-Smith, F., Kerse, N., et al. (2005) Effect of the addition of a ‘help’

question to two screening questions on specificity for diagnosis of depression in general

practice: diagnostic validity study. British Medical Journal, 331, 884

Leahy-Warren, P., M. G., et al. (2011). Postnatal Depression in First-Time Mothers:

Prevalence and Relationships between Functional and Structural Social Support at 6 And

12 Weeks Postpartum. Archives of Psychiatric Nursing 25(3): 174-184.

Leahy-Warren, P., G. McCarthy, et al. (2011). First-Time Mothers: Social Support,

Maternal Parental Self-Efficacy and Postnatal Depression.Journal of Clinical Nursing DOI:

10.1111/j.1365-2702.2011.03701.x

Leahy-Warren, P. and G. McCarthy (2007). Postnatal depression: Prevalence, Mothers'

perspectives, and treatments. Archives of Psychiatric Nursing 21(2): 91-100.

Leahy-Warren, P. (2007). Social Support for First-Time Mothers: An Irish Study MCN,

American Journal of Maternal Child Nursing 32(6): 368-374.

Leahy-Warren, P. (2005). "First-time mothers: social support and confidence in infant care

Journal of Advanced Nursing 50: 479-488.

National Institute for Health and Clinical Excellence (2007) Antenatal and postnatal mental

health: clinical management and service guidance (NICE CG 45) (para 5.4.3 p116).

Whooley, M. A., Avins, A. L., Miranda, J., et al. (1997) Case-finding instruments for

depression. Two questions are as good as many. Journal of General Internal Medicine,

12; 439–445