Crit Care Nurs QVol. 33, No. 3, pp. 212–218Copyright c© 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Best Practice Guidelinesfor the Nurse PractitionerRegarding Screening,Prevention, and Managementof Postpartum Depression

Stephanie Neiman, BSN, RN; Sherry Carter, PhD, RN, WNP;Sharon Van Sell, EdD, RN, PAHM; Chris Kindred, MS, CPNP

Purpose: The purpose of this study was to design a means to educate the registered nurse or nursepractitioner on epidemiology, signs and symptoms, risk factors, screening tools, management, andcomplications that can occur with delayed diagnosis of postpartum depression. A decision treewas also developed to help the registered nurse or nurse practitioner understand the best clinicalpractice guidelines regarding the best screening tool to use, when the tool should be used, andmanagement of patients identified with postpartum depression. Results: Best practice guidelineswere developed from the literature review. Key words: best practice, guidelines, nurse practi-tioner, postpartum depression, screening tools

PURPOSE

This study was designed to find the best wayto educate the registered nurse (RN) or nursepractitioner (NP) on epidemiology, signs andsymptoms, risk factors, screening tools, man-agement, and complications that can occurwith delayed diagnosis of postpartum depres-sion (PPD). A decision tree was also devel-oped to help the RN or NP understand thebest clinical practice guidelines regarding thebest screening tool to use, when the toolshould be used, and management of patientsidentified with PPD.

Author Affiliations: Texas Woman’s UniversityCollege of Nursing, Dallas Center-Parkland Campus,Dallas.

Correspondence: Stephanie Neiman, BSN, RN, 5009Alexandria Dr, Rowlett, TX 75088 (princess stephanie85@yahoo.com).

METHODS

A systematic evidence-based literature re-view was conducted with the assistance ofTexas Woman’s University and Texas HealthPresbyterian Hospital of Dallas online libraryservices. The electronic databases that wereused included (a) CINAHL, (b) Cochrane Li-brary, (c) National Guideline Clearinghouse,(d) MEDLINE, (e) PubMed, (f) OVID, (g) El-sevier, and (h) ScienceDirect, as well as theWorld Wide Web through the Google searchengine. Medical and nursing textbooks werealso used.

REVIEW OF THE LITERATURE ON PPD

Prevalence

Postpartum depression is a serious condi-tion that affects approximately 10% to 20%of mothers, which makes PPD the mostcommon serious postpartum disorder.1

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Postpartum depression usually starts withinthe first 4 weeks after delivery, and the riskfor development of depression remains highduring the first year postpartum.1 Postpartumdepression is a debilitating disease and affectsnot only the patient but also the family.Children of depressed mothers are morelikely to have delayed motor developmentas well as cognitive, psychological, or neu-rological problems; these children are alsoat higher risk of avoidance and distressedbehaviors.1

Despite the negative outcomes associatedwith PPD, rates of diagnosis and treatmentare low mainly because of lack of recogni-tion by the health care provider.1 In addition,PPD is the most misinterpreted, frequentlydismissed, and most undiagnosed postpartumcomplication.2 Early recognition of PPD caneliminate the length of time that women haveto suffer with this debilitating condition andcan decrease the potentially harmful effectson the infants involved. According to Manciniet al, “too often, obstetric clinicians do notscreen for postpartum depression because ofthe lack of training in the recognition andtreatment of depression, the lack of [a] con-venient and reliable screening tool, the stigmaof mental illness, and a belief that confrontingmental health issues will create a therapeu-tic burden on the caregiver.”3(p429) It is, there-fore, important to develop clinical guidelinesfor NPs regarding screening, prevention, andmanagement of PPD.

Cause

The cause of PPD is not known, butresearch suggests that it is multifactorial.According to the American Congress of Obste-tricians and Gynecologists, “postpartum de-pression is likely to result from body, mind,and lifestyle factors combined.”4(p2) The lev-els of estrogen, progesterone, serotonin, andthyroid decrease sharply and return to nor-mal during the immediate postpartum pe-riod, which can trigger depression and canchange a woman’s mood and behavior.4,5

Other aspects that can lead to PPD include

(a) unresolved feelings about the pregnancy,(b) fatigue after delivery from lack of sleep orbroken sleep, (c) feelings of being less attrac-tive, (d) doubts about the ability to be a goodmother, (e) stress from changes in work andhome routines, and (f) loss of freedom and oldidentity.4,6

Clinical manifestations

Different from the baby blues, symptomsof PPD last longer, are more severe, and re-quire treatment.6 Some signs and symptomsof PPD include feeling the following: (a) rest-less, (b) worthless, (c) guilty, (d) hopeless,(e) moody, (f) sad, or (g) overwhelmed. Thenew mother may also (a) cry a lot; (b) exhibita lack of energy and motivation; (c) be un-able to make decisions or focus; (d) lose hermemory; (e) experience a lack of pleasure;(f) have changes in appetite, sleep, or weight;(g) show a lack of concern for herself;(h) withdraw from friends and family; (i) havepains in her body that do not subside; (j) feelnegatively toward her baby; (k) lack interestin her baby; (l) worry about hurting the baby;and (m) have recurrent thoughts of suicideand death.6

Risk factors

The relationship between stressful lifeevents, such as losing a job, death of a lovedone, moving, and relationship breakdown ordivorce, and the development of depressionis well established.5 Symptoms of depressionand anxiety during pregnancy, a history of de-pression or psychiatric illness, and inadequatesupport at home are strong to moderate pre-dictors for developing PPD.7,8

In a retrospective investigation and litera-ture review, McCoy et al9 found that formulafeeding, cigarette smoking, and a history ofdepression were all associated with signifi-cantly higher incidence of PPD. Other fac-tors found to be associated with increasedrisk for development of PPD include com-plications that occurred during childbirth orthe pregnancy. In addition, women with less

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education, low self-esteem, a history of a mis-carriage, and a history of childhood sexualabuse are more prone to PPD.7,8

Consequences of PPD when

left untreated

Postpartum depression negatively in-fluences a mother’s ability to interactwith her family and infant cognitively andemotionally.10 According to Delatte et al,11

depressed mothers report fewer healthychild development practices, fewer safetypractices, and more frequent use of harshdiscipline. Furthermore, a secondary dataanalysis completed by McLearn et al12 showedthat mothers with depressive symptoms had asignificantly reduced likelihood of continuingto breast-feed the infant, playing and talkingto the infant, showing books to their children,and following 2 or more routines to promotepositive child development.

Pawlby et al13 completed a prospective lon-gitudinal study that found that the risk for psy-chiatric disorders in children whose mothershad PPD was 4 times greater than in childrenwhose mothers did not have it. Boys and girlshad an equal chance of developing a psychi-atric disorder.

Diagnosis

According to the diagnostic criteria setforth by the American Psychiatric Associa-tion in the Diagnostic and Statistical Man-ual of Mental Disorders (Fourth Edition,Text Revision), PPD falls under major depres-sive episode with a postpartum onset.14 TheAmerican Psychiatric Association stated thatto be diagnosed with PPD, a patient mustpresent with a depressed mood or loss of in-terest or pleasure that lasts for 2 weeks. Shemust also have exhibited any of the following5 symptoms over the same 2-week interval:(a) depressed mood; (b) change in appetite orchange of 5% or more in body weight; (c) de-crease in pleasure or interest in all, or almostall, daily activities; (d) insomnia or hypersom-nia; (e) feelings of lack of energy or fatigue;

(f) psychomotor retardation or agitation;(g) feelings of inappropriate or extreme guiltor worthlessness; (h) repetitive thoughts ofsuicidal ideation with or without a specificplan, or a suicide attempt; and (i) indeci-siveness or attenuated concentration. Thesesymptoms must also be causing significantimpairment or distress in social, vocational,or other important daily functions, and theonset must occur during the first 4 weekspostpartum.14 Moreover, although the Diag-nostic and Statistical Manual of Mental Dis-orders (Fourth Edition, Text Revision) indi-cates that these symptoms must occur withinthe first 4 weeks postpartum in order to beclassified as PPD, several experts think thatwomen remain at higher risk for developingPPD for up to 1 year postpartum.1,14

Differential diagnosis

Although PPD is the most common post-partum affective disorder, a number of otherdisorders can occur during the postpartumperiod. Some of the differential diagnosticsymptoms that health care providers shouldbe aware of include (a) anemia, (b) thy-roid disorders, (c) substance abuse, (d) post-partum psychosis, and (e) anxiety disorderssuch as postpartum panic disorder, postpar-tum obsessive-compulsive disorder, and post-partum posttraumatic stress disorder.5 Thesedifferential diagnoses can be ruled out by or-dering a urine drug screen, thyroid studies, ora complete blood cell count.5 In addition, dis-orders such as anemia and those of the thyroidcan cause weight loss, agitation, and anxiety,similar to symptoms of PPD, and the differ-ential diagnosis for postpartum psychosis in-cludes these symptoms: (a) disorganized be-havior, (b) delusions, (c) rapid mood swings,and (d) hallucinations.5

Screening tools

Routine use of validated screening toolsto identify women at risk for PPD is aneasy, effective, and economical way to rec-ognize them1; and pediatric and maternal

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appointments are sensible opportunities forlongitudinal and routine screening for PPD.1,3

Gjerdingen and Yawn1 reported that morethan 80% of mothers are receptive to be-ing screened for PPD, although the currentscreening rate is less than 50%. Similarly, fromtheir study, Fergerson et al15 concluded thatthe use of a routine screening tool that hasbeen identified to screen for PPD, such as theEdinburgh Postnatal Depression Scale (EPDS),enhances the detection of PPD and improvesearly recognition of PPD by clinicians com-pared with a routine clinical evaluation.

Edinburgh Postnatal Depression Scale

The EPDS is the most thoroughly re-searched and most recognized screening toolfor PPD.16 It is a self-report, quick, and easyscreening tool for PPD that consists of 10questions with 4 possible responses.17 Thewomen fill out the tool according to theirsymptoms over the last 7 days, with each re-sponse given a score of 0 to 3 points, creat-ing a maximum score of 30.16 Using a cut-off score of 9 or 10, the sensitivity is 86%;the specificity, 78%; and positive predictivevalue, 73%.16 According to Schumacher andZubaran, “this value is capable of detectingmost cases of potential depression.”16(p1756)

The EPDS takes 5 minutes or less to com-plete and is easily accessible online at nocost. According to Cole, “The tool is writ-ten at the 5th grade reading level, yet iseffective in identifying women of all socioe-conomic status.”2(p461) The EPDS is an assess-ment/screening tool that identifies those atrisk for PPD, but it does not diagnose de-pression; therefore, the EPDS should not besubstituted for psychiatric evaluation or aclinical interview, essential for diagnosis ofdepression.16

Postpartum Depression Screening Scale

The Postpartum Depression Screen-ing Scale (PDSS) is a self-report, 35-itemLikert-type response scale divided into 7conceptual domains: (a) anxiety/insecurity,

(b) sleep/eating disturbance, (c) emotional li-ability, (d) loss of self-esteem, (e) guilt/shame,(f) cognitive impairment, and (g) suicidalthoughts.16,17 The scores range from 35 to175; the scale has 5 symptoms for eachdomain, and the woman is asked to identifyher degree of disagreement or agreementon the basis of her feelings over the last 2weeks.16 The sensitivity of the PDSS is 91%;the specificity is 72% for detecting PPD. ThePDSS takes 5 to 10 minutes to administer andis used during the postpartum period.2

Postpartum Depression PredictorInventory-Revised

The Postpartum Depression PredictorInventory-Revised (PDPI-R) was derived toidentify women at risk for developing PPDand seeks information on social supports,prenatal depression, marital satisfaction, lifestressors, and other topics.16,17 The PDPI-Rshould be administered through clinicalinterview, and it is used to encourage dia-logue between the woman and the provider,but the PDPI-R has neither psychometricproperties nor a scoring system.16,17 Whilethe postpartum version consists of all 13 riskfactors specifically for PPD, the first 10 arefor the prenatal version and the last 3 arespecific for the postpartum period.16

Few studies have compared the utility of thescreening tools, but the instruments with thebest supporting evidence at this time arethe EPDS or the PDSS.18 According to a sys-tematic review completed by Gjerdingen andYawn, “EPDS is the most extensively studiedpostpartum measure with moderate psycho-metric soundness.”1(p284)

RESULTS

On the basis of the literature, the researcherdeveloped best practice guidelines on screen-ing, prevention, and management of PPD. Inaddition, a screening protocol was designedto aid the provider in screening and treatingPPD (Figure 1).

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Figure 1. Screening for postpartum depression using the EPDS. Abbreviations: DSM-IV, Diagnostic andStatistical Manual of Mental Disorders (Fourth Edition); EPDS, Edinburgh Postnatal Depression Scale, OB,

obstetrician; PP, postpartum; PPD, postpartum depression.

Screening

Antenatal screening for psychosocial riskfactors is not useful as a predictor of PPD,but it can be used to identify problems dur-ing the antenatal period.19 In fact, no screen-ing tools are appropriate for prenatal predic-tion of PPD.20 Consequently, providers shouldscreen all women using the EPDS before theyare discharged from the hospital and con-tinue to screen them throughout the first yearpostpartum because evidence indicates thatPPD can occur anytime during the first yearpostpartum.1,21 Three time points are mostappropriate for screening for PPD: (a) duringthe postpartum follow-up appointment, (b)during pediatric follow-up appointments, and(c) during primary care appointments follow-ing childbirth.5

To screen using the EPDS, the NP or RNshould administer the scale to the new moth-

ers 2 to 3 days postpartum. The cutoff scoresof 10 to 11 at that point indicate no PPD;these scores are highly correlated with com-parable scores at 4 to 6 weeks postpartum andare considered predictive.21 Similarly, Jardriet al22 validated the early use of the EPDS 3to 5 days postpartum with a cutoff score of9.5. Based on these findings, the recommen-dation for screening is to use the EPDS at 2, 3,or 5 days postpartum before discharge fromthe hospital, if possible. The recommendedcutoff score is 10. At 6 weeks postpartum andduring other follow-up visits throughout thefirst year, screening with the EPDS should beconducted with a cutoff score of 11.21,22

Prevention

In small studies, estrogen given 48 hoursbefore delivery and intense postpartum

Best Practice Guidelines for Postpartum Depression 217

support and education provided by thehealthcare provider have been shown to bebeneficial in preventing PPD. Therefore, ad-ministration of estrogen should be consideredby NPs for preventing PPD.23,24

Nonpharmacologic and

pharmacologic management

Both nonpharmacologic and pharmaco-logic treatments have proven effective in thetreatment of PPD. Nonpharmacologic treat-ment of PPD includes (a) interpersonal psy-chotherapy, (b) cognitive-behavioral therapy,(c) family and marital group therapy, (d)psychodynamic therapy, (e) light therapy,(f) peer-support therapy, and (g) electrocon-vulsive therapy.5 A few studies have shownthat the use of nonspecific counseling andcognitive-behavioral therapy is equally effec-tive as pharmacologic agents in treating PPD,and the combination of both nonpharmaco-logic and pharmacologic treatment has notbeen proven to have additional benefits.5

Pharmacologic agents that have been re-searched in the treatment of PPD includedrugs in various classes of antidepressantssuch as tricyclic antidepressants, serotonin re-uptake inhibitors, and bupropion SR.

When choosing a pharmacologic treatmentof PPD, breast-feeding women, in particular,must weigh the potential risks of antidepres-sant drug exposure to the infant.23 For thisreason, administering low doses of antide-pressant medication right after delivery andtitrating the dose up while monitoring the in-fant for adverse effects are recommended.23

Furthermore, avoiding breast-feeding at thepeak concentration time can minimize in-

fant’s exposure to the antidepressant, and de-creasing the antidepressant dose, changingthe medication, or introducing partial or com-plete bottle-feeding should occur if the infanthas adverse effects.23 Pharmacologic treat-ment should be continued for 6 months toprevent relapse; if no improvement or relapseoccurs before 6 months, a referral to a psychi-atric mental health NP or a psychiatrist mustbe completed.5

CONCLUSION

Early identification, screening, prevention,and treatment of PPD are crucial for im-proving overall outcomes for the mother andbaby, as well as for decreasing mortality andmorbidity.5 This is why it is crucial that RNsand NPs understand and know about the riskfactors, signs and symptoms, prevention, useand interpretation of screening tools, and ap-propriate referral point for treatment of PPD.

Mass screening for PPD using a validatedscreening tool has been proven to improvethe rates of detection and treatment of PPDand should be implemented in obstetricians’and pediatricians’ offices and in primary caresettings by RNs and NPs.1 Evidence showsthat the EPDS is the best screening toolfor identifying women at risk for PPD; con-sequently, it should be used for the massscreening.1 A decision tree (Figure 1) was de-veloped to help the RN or NP understand thebest clinical practice guidelines regarding theEPDS screening tool that identifies PPD,the points during the postpartum periodwhen it should be used, and management ofpatients identified with or at risk for postpar-tum depression.

REFERENCES

1. Gjerdingen D, Yawn B. Postpartum depression

screening: importance, methods, barriers, and rec-

ommendations for practice. J Am Board Fam Pract.2007;20(3):280-288.

2. Cole C. Screening for postpartum depression. JNurse Pract. 2009;5(6):460-461.

3. Mancini F, Carlson C, Albers L. Use of the Post-

partum Depression screening Scale in a collabora-

tive obstetric practice. J Midwifery Womens Health.2004;52(5):429-434.

4. American Congress of Obstetricians and Gynecolo-

gists. Postpartum depression. http://www.acog.org/

publications/patient education/bp091.cfm.

5. Munoz C, Agruss J, Haeger A, Sivertsen L. Postpartum

218 CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2010

depression: detection and treatment in the primary

care setting. J Nurse Pract. 2006;2(4):247-253.

6. National Women’s Health Information Center. De-

pression during and after pregnancy. http://www.

womenshealth.gov/faq/depression-pregnancy.cfm#d.

7. Leigh B, Milgrom J. Risk factors for antenatal depres-

sion, postnatal depression and parenting stress. BMCPsychiatry. 2008;8(24):1-11.

8. Robertson E, Grace S, Wallington T, Stewart DE.

Antenatal risk factors for postpartum depression: a

synthesis of recent literature. Gen Hosp Psychiatry.2004;26:289-295.

9. McCoy SJB, Beal M, Shipman SBM, Payton ME, Wat-

son GH. Risk factors for postpartum depression:

a retrospective investigation at 4-weeks postnatal

and a review of literature. J Am Osteopath Assoc.2006;106:193-198.

10. McQueen K, Montgomery P, Lappan-Gracon S, Evans

M, Hunter J. Evidence-based recommendations for

depressive symptoms in postpartum women. JOGNNurs. 2008;37(2):127-136.

11. Delatte R, Cao H, Meltzer-Brody S, Menard MK. Uni-

versal screening for postpartum depression: an in-

quiry into provider attitudes and practice. Am J Ob-stet Gynecol. 2009;200(5):63-64.

12. McLearn KT, Minkovitz CS, Strobino DM, Marks E,

Hou W. Maternal depressive symptoms at 2 to 4

months postpartum and early parenting practices.

Arch Pediatr Adolesc Med. 2006;160(3):279-284.

13. Pawlby S, Sharp D, Hay D, O’Keane V. Postnatal de-

pression and child outcome at 11 years: the impor-

tance of accurate diagnosis. J Affect Disord. 2008;

107(1-3):241-245.

14. American Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorders: Text Revi-sion. 4th ed. Washington, DC: American Psychiatric

Association; 2000.

15. Fergerson S, Jamieson D, Lindsay M. Diagnosing post-

partum depression: can we do better? Am J ObstetGynecol. 2002;186(5):899-902.

16. Schumacher M, Zubaran C. Screening tools for post-

partum depression: validity and cultural dimensions.

Int J Psychiatr Nurs Res. 2008;14(1):1752-1756.

17. Pogany A, Petersen M. What are the best screening

instruments for PPD? J Am Acad Physician Assist.2007;20(7):34-38.

18. Agency for Healthcare Research and Quality. Perina-

tal depression: prevalence, screening accuracy, and

screening outcomes. http://www.ahrq.gov/clinic/

epcsums/peridepsum.htm.

19. Edwards B, Galletly C, Semmler-Booth T, Dekker G.

Does antenatal screening for psychosocial risk fac-

tors predict postnatal depression? Aust N Z J Psychi-atry. 2008;42(1):51-55.

20. Austin MP, Lumley J. Antenatal screening for postna-

tal depression: a systematic review. Acta PsychiatrScand. 2003;107(1):10-17.

21. Teissedre F, Chabrol H. Detecting women at risk for

postpartum depression using the Edinburgh Postna-

tal Depression Scale at 2 to 3 days postpartum. CanJ Psychiatry. 2004;49(1):51-54.

22. Jardri R, Pelta J, Maron M, et al. Predictive validation

study of the Edinburgh Postnatal Depression Scale in

the first week after delivery and risk analysis for post-

natal depression. J Affect Disord. 2006;93(2006):169-

176.

23. Dennis CL, Creedy DK. Psychosocial and psycho-

logical interventions for preventing postpartum

depression. Cochrane Database Syst Rev. 2004;(4):

CD001134. doi:10.1002/14651858.CD001134.pub2.

24. Dennis CL, Ross LE, Herxheimer A. Oestrogens and

progestins for preventing and treating postpartum

depression. Cochrane Database Syst Rev. 2008;(4):

CD001690. doi:10.1002/14651858.CD001690.pub2.