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Screening for Depression and Help-Seeking in Postpartum Women During Well-Baby Pediatric Visits: An Integrated Review

Published:August 12, 2010DOI:https://doi.org/10.1016/j.pedhc.2010.06.012

      Abstract

      Purpose

      The purposes of this integrated review are to examine the literature on screening for depression and help-seeking behaviors by postpartum women during pediatric well-baby visits; to identify gaps in the literature relating to depression and help-seeking behaviors; and to discuss implications for practice and future research.

      Method

      An extensive search of primary source documents was conducted in Academic Search Premier, CINAHL, MEDLINE, Mental Measurements Yearbook, PsycINFO, PsycARTICLES, and Women's Studies International using the key words postpartum, postpartum depression (PPD), help seeking, and pediatric setting or pediatrician. Thirty-five articles relevant to help seeking, PPD, and screening in the pediatric setting were included in this review. Research studies included both quantitative and qualitative articles.

      Results

      PPD affects 10% to 15% of all women after birth. Postpartum women generally do not seek help for depression. Untreated PPD has significant adverse affects on parenting, maternal bonding, and the infant's emotional and behavioral development. Interaction with the woman's obstetric provider ends shortly after the baby's birth. However, interactions with the pediatric office are initiated and continue throughout the infant's first two years of life.

      Discussion

      Early recognition of PPD and appropriate treatment are imperative for positive maternal-infant outcomes. A majority of women do not seek help for depression from any source. Because mothers have routine interactions with pediatric office staff during the first few years after giving birth, pediatric nurse practitioners and pediatricians have the perfect opportunity to screen and educate women regarding symptoms, treatment, and available resources for PPD.

      Key Words

      Postpartum depression (PPD) affects 10% to 15% of all women after childbirth. The symptoms usually occur after discharge from the hospital. Women often lack the knowledge to recognize the symptoms of depression and fail to seek help for the condition (
      • Holopainen D.
      The experience of seeking help for postnatal depression.
      ). A majority of women with PPD symptoms do not seek help from any source (
      • McGarry J.
      • Kim H.
      • Sheng X.
      • Egger M.
      • Baksh L.
      Postpartum depression and help-seeking behavior.
      ). Help-seeking behavior for PPD is influenced by a variety of factors including recognition of the problem, available resources, adequate social support, and perceived stigma (
      • Goodman J.H.
      Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression.
      ,
      • McCarthy M.
      • McMahon C.
      Acceptance and experience of treatment for postnatal depression in a community mental health setting.
      ,
      • Riecher-Rossler A.
      • Hofecker Fallahpour M.
      Postpartum depression: Do we still need this diagnostic term?.
      ,
      • Whitton A.
      • Warner R.
      • Appleby L.
      The pathway to care in post-natal depression: Women's attitudes to post-natal depression and its treatment.
      ). Untreated PPD is associated with maternal distress and childhood emotional, behavioral, and developmental problems. Therefore, early recognition and treatment are imperative (
      • Righetti-Veltema M.
      • Bousquet A.
      • Manzano J.
      Impact of postpartum depressive symptoms on mother and her 18-month-old infant.
      ). Pediatric well-baby visits are the only consistent health care contact encountered routinely by new mothers during the first 2 years after giving birth (
      • Chaudron L.H.
      • Szilagyi P.G.
      • Kitzman H.J.
      • Wadkins H.I.M.
      • Cornwell Y.
      Detection of postpartum depressive symptoms by screening at well-child visits.
      ,
      • Perfetti J.
      • Clark R.
      • Fillmore C.
      Postpartum depression: Identification, screening, and treatment.
      ). Thus pediatric nurse practitioners (PNPs) can make repeated observations of behavior changes in women and their infants and have a unique opportunity to detect PPD and recommend appropriate treatment. The purposes of this integrated review are to examine the literature on screening for depression and help-seeking behaviors by postpartum women during pediatric visits, identify gaps in the literature relative to depression and help-seeking behaviors, and discuss implications for practice and future research.
      Untreated PPD is associated with maternal distress and childhood emotional, behavioral, and developmental problems.

      Methods

      An integrated review methodology by
      • Whittemore R.
      • Knafl K.
      The integrative review: Updated methodology.
      was utilized to examine experimental and non-experimental research to fully comprehend the phenomenon of help-seeking behavior in postpartum women. This method provides a framework that guides the integrated review process to enhance the rigor of the review. Each article was evaluated for issues related to specifying the review purpose, searching the literature, evaluating data from primary sources, analyzing data, and presenting results. Quantitative, qualitative, and mixed method research studies were included in this review.
      An extensive search involved review of published peer review articles from 1995 to 2009. The key words postpartum, postpartum depression, help seeking, and pediatric setting/pediatrician were used when searching the databases. The databases searched included Academic Search Premier, CINAHL, MEDLINE, Mental Measurements Yearbook, PsycINFO, PsycARTICLES, and Women's Studies International. Inclusion criteria focused on research articles and integrated reviews, in English, that were published in the past 15 years. Research articles that examined women during the first 2 years after giving birth were included. Research articles focusing on women who experienced other psychological disorders or high-risk situations, such as domestic violence, were not included. Research that focused on postpartum women with infants diagnosed with high-risk conditions or disorders and studies focusing on foreign-born postpartum women in the United States also were excluded from this review. The search yielded 311 articles, of which 276 did not meet the inclusion criteria for this review and therefore were not considered. The remaining 35 articles that focused on help seeking, PPD, and screening for PPD in the pediatric setting were included in this review.
      Relevant information was extracted from the eligible articles and grouped into the three major categories of PPD, PPD and help seeking, and PPD identification in pediatric settings. Research articles are presented according to problem identification, author, date, purpose, design, sample, methods, and research findings.

      Results

      Postpartum Depression

      Normal postpartum adjustment is represented by the lack of significant symptoms of PPD. PPD is a major depressive disorder with possible long-term implications for the mother and her infant. The criteria for a major depressive disorder includes five or more symptoms, including depressed mood, markedly diminished interest or pleasure in an activity, appetite disturbance, sleep disturbance, physical agitation or psychomotor retardation, fatigue, feelings of worthlessness, diminished concern or inability to make decisions, and recurrent thoughts of death or suicide (
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      ). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revision (DSM-IV-TR) (2000), specifies onset of PPD within 4 weeks after birth, but most clinicians agree that PPD can occur up to a year after childbirth. Minor depression also causes impairment but is less severe than PPD, with fewer depressive symptoms reported (
      • Gaynes B.N.
      • Gavin N.
      • Meltzer-Brody S.
      • Lohr K.N.
      • Swinson T.
      • Gartlehner G.
      • Miller W.C.
      • et al.
      Perinatal depression: Prevalence, screening, accuracy, and screening outcomes summary.
      ).
      In this review, two qualitative studies explored the personal experience of PPD. Transcripts were checked with random participants for consistency, and inter-subjective agreement was accomplished by the researcher and the research assistant. Data were extracted and analyzed using a phenomenological research approach. Participants were purposely selected from a local community or support group. Twelve postpartum women with PPD reported their experience as an intense emotional response, which they described as an overwhelming feeling of doom. Nine themes emerged when the transcripts were analyzed and organized into categories: depression taking over mind and body, overwhelming responsibilities in caring for children, emotional and physical separation from their children, decreased desire to interact with children, guilt and irrational thinking, uncontrollable anger, depression limiting the ability to have relationships with other children, feelings of loss, and striving to minimize the negative effects of depression (
      • Beck C.T.
      Postpartum depressed mother's experiences interacting with their children.
      ).
      In a similar study in British Columbia, eight women who had recovered from PPD were interviewed about their experience with depression after birth. Three stages or themes emerged from the transcripts of these women. They include “why did this happen,” “spiraling downward,” and “getting to the other side.” Women began by trying to make sense about why they experienced PPD. As the depression continued, women described shattered dreams and loss of control. Getting to the other side involved recovery, which involved surrendering control, creating hope, and rebuilding of self (
      • Beck C.T.
      • Indman P.
      The many faces of postpartum depression.
      ,
      • Berggren-Clive K.
      Out of the darkness and into the light: Women's experiences with depression after childbirth.
      ). Women in both studies described incongruence between the visions of what motherhood would be like and the actual responsibilities and adaptations required of the new mother. As women describe their experiences, it becomes clear that many factors contribute to the difference in their expectations and the reality of motherhood. The sample participants were mostly married and White, which limits the ability to generalize the results. Only women with PPD were interviewed. A control group or comparison group was not utilized. Both studies were clear about the purpose of the study, had well-defined literature reviews, extracted and analyzed data appropriately, and presented results in a clear, comprehensive manner.
      Several research studies examined the incidence and prevalence of PPD. Three quantitative studies and four literature reviews or syntheses were identified.
      • Eberhard-Gran M.
      • Eskild A.
      • Tambs K.
      • Samuelsen S.O.
      • Opjordsmoen S.
      Depression in postpartum and non-postpartum women: Prevalence and risk factors.
      conducted a study to examine depression in postpartum and non-postpartum women in two municipalities in Norway. Women were recruited from community-based child health clinics and surveys were randomly mailed to all women aged 18 to 40 years from the registry. Two thousand five hundred seventy-seven non-postpartum women and 467 postpartum women returned questionnaires for a response rate of 63% and 89%, respectively. Depression was measured by the Edinburgh Postnatal Depression Scale (EPDS) and a cut-off score of 10 or more was used to determine a positive screen for depression. The postpartum group demonstrated an 8.9% prevalence rate for depression, while the non-postpartum group demonstrated a prevalence rate of 13.6%. A majority of women were married (98%), with no mention of ethnic or racial demographics (
      • Eberhard-Gran M.
      • Eskild A.
      • Tambs K.
      • Samuelsen S.O.
      • Opjordsmoen S.
      Depression in postpartum and non-postpartum women: Prevalence and risk factors.
      ).
      In a longitudinal study of PPD symptoms over time, postpartum women with increased depression scores on the EPDS were recruited from a large hospital in Boston to examine depression symptoms over time (4-8 weeks, 10-14 weeks, 14-18 weeks, and 2 years after birth) (
      • Horowitz J.A.
      • Goodman J.
      A longitudinal study of maternal postpartum depression symptoms.
      ). One hundred twenty-three postpartum women agreed to participate in the first two time periods, 117 continued to participate at time 3, and 62 of these postpartum women were located and participated at the final data collection point. The Beck Depression Inventory was administered at each time period after the initial recruitment. The percentage of women who scored positive for depression symptoms was 41.9% at 4 to 8 weeks, 35.5% at 10 to 14 weeks, 27.4% at 14 to 18 weeks, and 30.6% at 2 years. In this sample of women who scored positive for depression screening at 2 weeks postpartum, 30.6% were still experiencing symptoms of depression approximately 2 years after birth. A majority of participants were married (87%), and 74.2% were White. This study is limited by the high attrition rate of participants from time one to time four and the lack of consistent measures of depressive symptoms. The EPDS was used as a baseline screening for depression, and the Beck Depression Inventory was used for each data point throughout the study. Participants were not randomly selected and represented a small geographic area in the Northeast United States (
      • Horowitz J.A.
      • Goodman J.
      A longitudinal study of maternal postpartum depression symptoms.
      ).
      • Mayberry L.J.
      • Horowitz J.A.
      • Declercq E.
      Depression symptom prevalence and demographic risk factors among U.S. women during the first 2 years postpartum.
      examined PPD symptom prevalence rates among women in the United States during the first 2 years after giving birth. A large cross-sectional sample of postpartum women was drawn from an online poll site. Women were grouped into four categories: 0 to 6 months, 7 to 12 months, 13 to 18 months, and 19 to 24 months after birth. Depression symptoms were measured with use of the EPDS, and the cut-off scores of 10 to 12 for mild depression and 13 or more for moderate to severe depression were used. Mild depression rates across the four cohorts were 11% to 15.1%, with no significant differences across the groups. Moderate to severe depression ranges were 17.1% to 23.1% and also demonstrated no significant differences among groups. In terms of age, the highest rates of both mild (16.4%) and moderate to severe (29.9%) EPDS depression scores were among the youngest mothers (18 to 24 years of age). Compared with other income groups, women in the lowest income bracket had the highest rates of mild depression (18.9%) and moderate to severe depression (31%). A majority of the participants were White (81.8%), and there was no mention of marital status. Demographics including age, income, education, parity, employment, and race were not evenly distributed among the four groups of participants. The study was limited by the self-report of depression symptoms with no diagnostic criteria comparison and a sampling bias through an Internet-based survey (
      • Mayberry L.J.
      • Horowitz J.A.
      • Declercq E.
      Depression symptom prevalence and demographic risk factors among U.S. women during the first 2 years postpartum.
      ).
      Four of the research studies are literature reviews or syntheses examining the incidence or prevalence of PPD. The literature reviews reported an incidence of major depression from 1% to 5.9% in the first year after birth. The incidence of minor and major depression ranges from 6.5% to 12.9% in the same period. Overall averages of depression vary according to major depression, minor depression, or both. The overall incidence of major depression is reported as being 12%, minor depression is reported as being 19%, and both minor and major depression are reported as being 13%, or a range of 3% to 30%. The highest prevalence rate for major depression occurs at 2 and 6 months after birth, while the highest prevalence rate for both minor and major depression occurs at 3 months after birth, with a slight decrease in the fourth through seventh postpartum months (
      • Beck C.T.
      State of the science on postpartum depression, part 1.
      ,
      • Gaynes B.N.
      • Gavin N.
      • Meltzer-Brody S.
      • Lohr K.N.
      • Swinson T.
      • Gartlehner G.
      • Miller W.C.
      • et al.
      Perinatal depression: Prevalence, screening, accuracy, and screening outcomes summary.
      ,
      • O'Hara M.W.
      • Swain A.M.
      Rates and risk of postpartum depression: A meta-analysis.
      ,
      • Ugarriza D.N.
      • Robinson M.K.
      Assessment of postpartum depression: A review of the research.
      ). All of these reviews report the method of categorizing and analyzing the results in each of the studies and report limitations, including lack of a standardized screening method for depression, lack of consistent cut-off scores on instruments, inconsistent data collection points, and lack of formal diagnosis based on diagnostic criteria.
      Several studies describe the negative impact of PPD on maternal-infant interactions. Two quantitative studies and three integrated reviews focus on infant outcomes of maternal PPD.
      • Dawson G.
      • Frey K.
      • Panagiotides H.
      • Yamada E.
      • Hessl D.
      • Osterling J.
      Infants of depressed mothers exhibit atypical frontal electrical brain activity during interactions with mother and with a familiar, nondepressed adult.
      evaluated expressive and communicative abilities, temperament, and electroencephalogram results for infants 13 to 15 months of age. Ninety-nine postpartum women were recruited for the study by newspaper ads, community groups, and individual medical offices. Within this group, 59 women (70%) screened positive for depression symptoms on a self-report scale. Infants were evaluated using the MacArthur Communication Development Inventory for expressive and communicative child abilities and the Colorado Child Temperament Inventory for child temperament.
      Electroencephalography also was performed on each of the toddlers. Toddlers were evaluated during five conditions including baseline calm environment, mother play, stranger approach, experimenter play, and maternal separation. Infants of depressed women exhibited reduced relative left frontal brain activity in baseline conditions, mother play, and experimenter play. These infants also demonstrated atypical brain patterns in playful interactions and non-social situations. The study had a few limitations, including self-report of depressive symptoms and no control for risk factors of depression. A strength of the study includes the comparison of a non-depressed group of women and their 13- to 15-month-old infants (
      • Dawson G.
      • Frey K.
      • Panagiotides H.
      • Yamada E.
      • Hessl D.
      • Osterling J.
      Infants of depressed mothers exhibit atypical frontal electrical brain activity during interactions with mother and with a familiar, nondepressed adult.
      ).
      In a large study of 570 pregnant women, researchers examined PPD and child development during the last trimester of pregnancy, three months after birth, and 18 months after birth. At three months after birth, 58 of the 570 women (10.2%) scored above 12 on the EPDS for depression symptoms. At 18 months after birth, 12 (17.1%) obtained a score above 12 on the EPDS. The following scales and tests were used to evaluate the infants in this study: Guaraldi's test assessing mother-child interactions, the Bur Scale evaluating mother-infant relationships, The Denver Developmental Screening Test for infant development, The Bayley Scale for infant development, the Strange Situation test assessing infant attachment to mother, and the Object Concept Task, which assessed the infant concept of object permanence. At 18 months, infants of depressed mothers demonstrated less verbal interaction (22.9% versus 0%, p < .05) and more time playing alone (78.8% versus 51.4%, p < .05) than did infants of non-depressed mothers. The Denver Developmental Screening Test demonstrated minor differences in both groups. The Bayley scale showed significant differences in responsiveness to the mother, fear of the examiner, degree of happiness, attention span, endurance, and level of energy between infants of depressed and non-depressed mothers. In the Strange Situation test, infants of depressed mothers searched much less for their mothers during separation episodes and demonstrated more avoidance behaviors during reunions with their mothers. During the object permanence task, only 42.9% of infants of depressed mothers achieved the level corresponding to their age compared with 77.1% of infants of non-depressed mothers (p < .001). A limitation of this study includes the small sample size of participants. A strength of this study includes the use of a control or maternal group with no reported depressive symptoms for comparison (
      • Righetti-Veltema M.
      • Bousquet A.
      • Manzano J.
      Impact of postpartum depressive symptoms on mother and her 18-month-old infant.
      ).
      Three literature reviews summarize the effects of PPD on infant emotional, cognitive, and behavioral development.
      • Beck C.T.
      State of the science on postpartum depression, part 2.
      reports that PPD has a moderate to large effect on mother-infant interactions and a small but significant effect on child cognitive and emotional development. Limitations of these studies include no control for current level of depression and no formal diagnostic screening for PPD (
      • Beck C.T.
      State of the science on postpartum depression, part 2.
      ).
      • Murray L.
      • Cooper P.J.
      Effects of postnatal depression on infant development.
      reported delayed motor and mental development among 12- to 18-month-old infants of mothers with depression. Overall, these infants also demonstrated a lower rate of interactive behavior, less concentration, more negative responses, insecure attachment behavior, and more behavioral difficulties than did infants of non-depressed mothers. Overall limitations include a lack of a formal rating system for quality of some infant behaviors and a small sample size (
      • Murray L.
      • Cooper P.J.
      Effects of postnatal depression on infant development.
      ).
      • Weinberg M.K.
      • Tronick E.Z.
      Emotional characteristics of infants associated with maternal depression and anxiety.
      conducted an integrated review of studies that examined infant emotional characteristics associated with maternal depression and anxiety. As early as 2 months, infants demonstrated less engagement in object and social interactions, less eye contact, and more negative affect than did infants of non-depressed mothers. At 1 year of age, infants demonstrated poorer performance on developmental tasks and inconsistent attachment behaviors. Children later in age demonstrated difficulties in school, poor modulation of affect, conflict with parents and peers, and increased rates of psychiatric problems including depression. Overall, the researchers reported several methodologic problems with these studies including small sample size, no comparison groups, and the maternal report of infant characteristics as opposed to direct observations (
      • Weinberg M.K.
      • Tronick E.Z.
      Emotional characteristics of infants associated with maternal depression and anxiety.
      ).

      Postpartum Depression and Help Seeking

      Help seeking is defined as the process of initiating an interaction with another individual to obtain support, information, advice, assistance, or treatment (
      • Broadhurst K.
      Engaging parents and carers with family support services: What can be learned from research on help-seeking?.
      ,
      • Gourash N.
      Help seeking: A review of the literature.
      ). In this review of the literature, women with PPD demonstrated low rates of help seeking (
      • McGarry J.
      • Kim H.
      • Sheng X.
      • Egger M.
      • Baksh L.
      Postpartum depression and help-seeking behavior.
      ,
      • Riecher-Rossler A.
      • Hofecker Fallahpour M.
      Postpartum depression: Do we still need this diagnostic term?.
      ,
      • Whitton A.
      • Warner R.
      • Appleby L.
      The pathway to care in post-natal depression: Women's attitudes to post-natal depression and its treatment.
      ). The literature supports the concern that women who may need help for PPD often do not seek help from available resources (
      • Broadhurst K.
      Engaging parents and carers with family support services: What can be learned from research on help-seeking?.
      ).
      Low help-seeking rates affect maternal-infant outcomes and therefore are relevant to examine in the population of postpartum women. A quantitative, retrospective study of a dataset from the Utah Pregnancy Risk Assessment Monitoring System (PRAMS) survey demonstrated an overall rate of 14.7% (N = 337) of women who reported depressive symptoms (
      • McGarry J.
      • Kim H.
      • Sheng X.
      • Egger M.
      • Baksh L.
      Postpartum depression and help-seeking behavior.
      ). In this sample of 337 women between 2 and 6 months after birth, 60.5% (n = 213) did not seek help for their depressive symptoms. Postpartum women who did not seek help were younger, less educated, of non-White race, and more likely to be enrolled in the Women's, Infants, and Children program. This study relied on a self-report of depressive symptoms without any formal screening tool or diagnostic criteria, which limits the strength of this study (
      • McGarry J.
      • Kim H.
      • Sheng X.
      • Egger M.
      • Baksh L.
      Postpartum depression and help-seeking behavior.
      ).
      An Australian study of 571 postpartum women between 0 and 4 months after birth reported an incidence of depressive symptoms of 20.7% (n = 118) (
      • Webster J.
      • Pritchard M.A.
      • Linnane J.W.J.
      • Roberts J.A.
      • Hinson J.K.
      • Starrenburg S.E.
      Postnatal depression: Use of health services and satisfaction with health-care providers.
      ). Depressive symptoms were measured by the EPDS, and a cut-off score of more than 12 was used for this study. Women with high depression scores stated that they were not coping well with parenting and were three times more likely to describe their infant as difficult (24.3%) compared with mothers without depressive symptoms (7.2%). Among the participants, 521 (91%) of women saw their general practitioner (GP) at least once in 4 months, 117 (20%) saw their GP five or more times, and 55 (11%) reported that depression was the reason for their visits. Women with depressive symptoms were more likely to visit a psychiatrist (odds ratio [OR], 9.2; 95% confidence interval [CI], 4.3-19.6), social worker (OR, 6.1; 95% CI, 3.3-11.1), postpartum support group (OR, 4.0; 95% CI, 1.3-12.6), pediatrician (OR, 2.5; 95% CI, 1.6-3.9), or GP (OR, 2.1; 95% CI, 1.4-3.2) than were women without depressive symptoms. Overall, women with depressive symptoms were less satisfied with health care services despite their increased use of health care services in comparison with women who did not report depressive symptoms (
      • Webster J.
      • Pritchard M.A.
      • Linnane J.W.J.
      • Roberts J.A.
      • Hinson J.K.
      • Starrenburg S.E.
      Postnatal depression: Use of health services and satisfaction with health-care providers.
      ).
      In a similar study in Australia, pregnant women were recruited from the Maternal Health Study from early pregnancy to 18 months after birth (
      • Woolhouse H.
      • Brown S.
      • Krastev A.
      • Perlen S.
      • Gunn J.
      Seeking help for anxiety and depression after childbirth: Results of the Maternal Health Study.
      ). Overall, 1385 women were included in the study, which examined help-seeking attitudes and barriers. The EPDS was again utilized to screen for depression, using a cut-off score of 13 or more for major depression and 10 or more for minor to moderate depression. Results for major depression demonstrated that 7.3% of women scored 13 or higher at 3 months after birth and 9.1% at 6 months after birth. Results for minor to moderate depression demonstrated that 14.5% of women scored 10 or higher at 3 months after birth and 18.2% at 6 months after birth. Only 121 (59%) of the women with depression symptoms spoke to a health care professional by 9 months after birth. Most women who sought health care services talked to their GP (42%) or maternal and child health care nurse (20.6%). For the 41% of women who did not seek help for their symptoms, reported barriers included a preference to deal with the symptoms on their own, too busy, too embarrassed/stigma, and a belief that their feelings were normal and would go away. The use of a large sample of postpartum women strengthened the methodology of this study. Limitations included a high attrition rate among the various postpartum periods, no standardized measurement of depression before and after pregnancy, and no comparison groups (
      • Woolhouse H.
      • Brown S.
      • Krastev A.
      • Perlen S.
      • Gunn J.
      Seeking help for anxiety and depression after childbirth: Results of the Maternal Health Study.
      ).
      Most of the literature on help seeking addresses problem identification as a major factor in help-seeking delays. In a convenience sample of 78 postpartum women scoring positive for PPD, 76 (97%) reported that they had been feeling worse than usual but only 25 (32%) believed they had PPD at 6 to 8 weeks after birth (
      • Whitton A.
      • Warner R.
      • Appleby L.
      The pathway to care in post-natal depression: Women's attitudes to post-natal depression and its treatment.
      ). These women had difficulties in distinguishing between normal postpartum adjustment and impairment in their ability to function. Only 9 (12%) of these women had spoken to a health care professional. These findings are consistent with the literature, which demonstrates low rates of help seeking in the population of postpartum women. In a qualitative study of 15 mothers diagnosed with depression and receiving treatment, women reported a reluctance to identify themselves as having PPD. Many of these women revealed a perceived stigma associated with depression. Depression was viewed as a failure in the transition to being a new mother (
      • McCarthy M.
      • McMahon C.
      Acceptance and experience of treatment for postnatal depression in a community mental health setting.
      ). Most postpartum women do not recognize or understand the symptoms they are experiencing. Most women are unable to differentiate between normal transitions to motherhood and PPD symptoms (
      • McCarthy M.
      • McMahon C.
      Acceptance and experience of treatment for postnatal depression in a community mental health setting.
      ,
      • McGarry J.
      • Kim H.
      • Sheng X.
      • Egger M.
      • Baksh L.
      Postpartum depression and help-seeking behavior.
      ,
      • Riecher-Rossler A.
      • Hofecker Fallahpour M.
      Postpartum depression: Do we still need this diagnostic term?.
      ,
      • Whitton A.
      • Warner R.
      • Appleby L.
      The pathway to care in post-natal depression: Women's attitudes to post-natal depression and its treatment.
      ).
      Women who did recognize the symptoms of PPD were not aware of the available resources for help. When PPD symptoms reached a crisis level, women sought help from several sources. In a qualitative study of seven postpartum women, the most common source of help reported was the support network of the spouse or partner, family, and friends (
      • Holopainen D.
      The experience of seeking help for postnatal depression.
      ). Some women discussed their symptoms with maternal health nurses. Some women perceived their help seeking as supportive and some did not, but a majority of women were referred to a psychiatrist by the health care nurses. Women were dissatisfied with hospital doctors and GPs, claiming that they had limited time and compassion (
      • Holopainen D.
      The experience of seeking help for postnatal depression.
      ).
      Many studies addressed the reasons that postpartum women did not seek help for depression. In a comprehensive review of the literature,
      • Riecher-Rossler A.
      • Hofecker Fallahpour M.
      Postpartum depression: Do we still need this diagnostic term?.
      reported reasons for treatment delay including shame or stigma, fear of separation from infant, lack of knowledge regarding treatment, and misinterpretation of symptoms. Health care services often failed to meet the needs of newly postpartum women and did not consider specific situations, perceptions, problems, and fears of these women.
      • McCarthy M.
      • McMahon C.
      Acceptance and experience of treatment for postnatal depression in a community mental health setting.
      conducted a qualitative study to investigate the experience and treatment of PPD in a community mental health setting. A majority of these women reported feelings of being a “bad mother,” shame and guilt, and an inability to cope with motherhood as reasons in delaying help seeking. Similar findings were cited in a study with a convenience sample of 509 pregnant women in their last trimester of pregnancy. A majority of women (92%) reported that they would participate in therapy if needed but only 35% would likely take medication and only 14% would participate in group therapy. These women were not screened for depression, only their perceptions and attitudes toward treatment of depression. The greatest perceived barriers to help seeking were reported as lack of time, stigma, and fear (
      • Goodman J.H.
      Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression.
      ).
      Overall, limited research has been conducted on help-seeking behavior in postpartum women with depression. Well-established data exist on rates of help seeking and barriers to help seeking in this population. A majority of research studies used an interview or question method to obtain information on help seeking. Very few studies have investigated interventions to increase help seeking in postpartum women with depression. Few research studies examine help seeking among comparison groups for control purposes.

      Postpartum Depression Screening in Pediatric Settings

      Screening women for PPD is a challenge in the weeks after childbirth. Screening done in the hospital immediately after birth is often performed too early to make a diagnosis. The postpartum visit with the obstetric provider, at 6 weeks, is an opportunity for screening for depressive symptoms and is an appointment focused on the woman's well-being. The interaction with the obstetric health professional is often terminated after this follow-up visit. However, the new mother encounters a pediatric health care professional at least eight times in her infant's first 2 years of life. Screening can be implemented easily in this setting (
      • Perfetti J.
      • Clark R.
      • Fillmore C.
      Postpartum depression: Identification, screening, and treatment.
      ).
      Screening for depression in the pediatric setting has been reported in the literature as reliable and feasible.
      Screening for depression in the pediatric setting has been reported in the literature as reliable and feasible. In a study of 110 infants, detection of PPD was compared before and after universal screening of postpartum women (
      • Chaudron L.H.
      • Szilagyi P.G.
      • Kitzman H.J.
      • Wadkins H.I.M.
      • Cornwell Y.
      Detection of postpartum depressive symptoms by screening at well-child visits.
      ). A statistically significant difference was reported between the before group (1.6%) and the after group (8.5%) in detecting PPD (p < .001). The screening tool was completed in a timely manner, was easy to score, and was accurate in detecting depression. In a similar study of 96 postpartum women at their infant's 8-week well-baby visit, 14.6% of women were found to have depression (
      • Freeman M.P.
      • Wright R.
      • Watchman M.
      • Wahl R.A.
      • Sisk D.J.
      • Fraleigh L.
      • Weibrecht J.M.
      • et al.
      Postpartum depression assessments at well-baby visits: Screening feasibility, prevalence, and risk factors.
      ). The screening in this pediatric setting was feasible and relatively well accepted by postpartum women. In both research studies, the EPDS was used to screen for depression. The EPDS is a 10-item self-administered questionnaire. Each item is scored from 0 to 3 with possible total scores of 0 to 30. It is recommended that scores greater than or equal to 13 be used to identify women with a major depressive episode that requires further assessment (
      • Cox J.L.
      • Holden J.M.
      • Sagovsky R.
      Detection of postpartum depression: Development of the 10-item Edinburgh Postnatal Depression Scale.
      ). Limitations include non-consistent cut-off scores of the same tool to screen for depression.
      Despite the significant negative impact of untreated PPD, many physicians fail to diagnose and treat maternal depression. One study examined physician knowledge, beliefs, and perceived barriers toward managing PPD (
      • Leiferman J.A.
      • Dauber S.E.
      • Heisler K.
      • Paulson J.F.
      Primary care physicians' beliefs and practices toward maternal depression.
      ). A total of 232 physicians—including obstetricians, pediatricians, and family practice practitioners—completed self-administered surveys. More than 90% reported that it was their responsibility to recognize PPD, but 84 (39.8%) of the physicians rarely or never assessed for depression. Additionally, 143 (66.2%) of these physicians rarely or never referred women for treatment of depression. Two research studies examined the beliefs and practices of pediatricians relative to screening for maternal depression. A national survey of randomly selected pediatricians yielded 508 completed surveys (
      • Olson A.L.
      • Kemper K.J.
      • Kelleher K.J.
      • Hammond C.S.
      • Zuckerman B.S.
      • Dietrich A.J.
      Primary care pediatricians' roles and perceived responsibilities in the identification and management of maternal depression.
      ). Of these pediatricians, more than half (57%) felt responsible for recognizing maternal depression. When depression was suspected, 48% completed additional assessment. Pediatricians indicated that they had an active role in 66% of the cases in which they provided one or more brief interventions. The major barriers that limited diagnosis and management were reported as insufficient time to obtain an adequate history, insufficient training on diagnosis and treatment, and lack of education or counseling. Similar findings were reported in a study of 389 randomly selected pediatricians who participated in a nationwide survey to assess pediatrician knowledge and views about PPD (
      • Wiley C.C.
      • Burke G.S.
      • Gill P.A.
      • Law N.E.
      Pediatricians views of postpartum depression: A self-administered survey.
      ). About half of the pediatricians surveyed reported little to no education about PPD, and few pediatricians felt confident in recognizing maternal depression.
      In a study of family nurse practitioners and screening practices used to identify PPD, fewer than half (42%) of the participating NPs ever screened for PPD in some manner (
      • Goldsmith A.E.
      Postpartum depression screening by family nurse practitioners.
      ). The nurse practitioners who were knowledgeable of the symptoms and management of PPD performed some formal or informal type of screening. A majority of nurse practitioners followed clinical practice guidelines of care. However, no current guidelines specifically address PPD (
      • Goldsmith A.E.
      Postpartum depression screening by family nurse practitioners.
      ).
      In a systematic review of the literature on the effectiveness of postpartum support to improve maternal outcomes, it was reported that educational visits in the pediatric office setting demonstrated statistically significant improvements in parenting skills in low-risk women (
      • Shaw E.
      • Levitt C.
      • Wong S.
      • Kaczorowski J.
      Systematic review of the literature on postpartum care: Effectiveness of postpartum support to improve maternal parenting, mental health, quality of life, and physical health.
      ). In women at high risk for PPD, home visitation or peer support produced a statistically significant reduction on depression scale scores. Maternal satisfaction was higher with the home visitation programs that were identified in these studies.
      • Feinberg E.
      • Smith M.V.
      • Morales M.J.
      • Claussen A.H.
      • Smith D.C.
      • Perou R.
      Improving women's health during internatal periods: Developing an evidenced-based approach to addressing maternal depression in pediatric settings.
      discuss the role of pediatric providers in improving women's health through detection and management of maternal depression. The Pediatric-Based Maternal Depression Detection and Management System was developed as a 3-year project to highlight the feasibility of an evidence-based approach to the detection and management of PPD in a pediatric setting. The system components include universal screening at well-child visits, assessment of additional symptoms, an educational discussion about PPD, and guidance regarding referrals. The model was developed for future research (
      • Feinberg E.
      • Smith M.V.
      • Morales M.J.
      • Claussen A.H.
      • Smith D.C.
      • Perou R.
      Improving women's health during internatal periods: Developing an evidenced-based approach to addressing maternal depression in pediatric settings.
      ).

      Discussion

      Strengths and Limitations

      The strengths of these studies included strong reliability and validity of the screening tools utilized to screen for PPD. The methods for screening were well documented for use in this population of women. There were also well-documented studies in various ethnic and minority populations for each of these screening tools, and some sample sizes represented a large, diverse population of postpartum women.
      Few randomized controlled studies had been conducted in all areas of screening and management of PPD. A majority of studies were limited to a convenience sample in a specific geographic area. Inconsistent cut-off scores were used for the EPDS, which makes it difficult to compare statistics among each of the studies that utilized the tool. Even fewer research studies examined help seeking in postpartum women. Some limited longitudinal studies addressed prevalence rates of depression at various postpartum periods. Finally, numerous studies examined attitudes of help seeking and intentions and willingness to seek help, but few studies were conducted on actual help-seeking behavior.
      As the literature suggests, screening for PPD with use of a standardized screening tool is rarely accomplished in any health care setting after birth. In addition, health care providers have a lack of knowledge related to the screening tools and the diagnosis and treatment of PPD. A majority of pediatricians believe that it is their responsibility to recognize PPD; however, most do not screen, diagnose, or treat women experiencing PPD. A lack of clinical practice guidelines for advanced nurse practitioners regarding PPD assessment, diagnosis, and treatment also exists.

      Implications for Practice and Research

      Training and education on the detection, management, support, and prompt referral of women with PPD is necessary to improve maternal and infant outcomes.
      Given the significant impact of PPD on maternal and infant outcomes, it is imperative to be consistent and thorough in detecting and treating PPD. Detection and management involves increasing awareness of the screening methods, symptoms, and management of PPD by all health care providers whom the new mother encounters. PNPs can improve maternal-infant outcomes through consistent PPD screening, education, and prompt referral. New mothers and advanced nurse practitioners have frequent encounters at well-baby visits during the first few years after birth. The pediatric setting is an optimal place for screening and education about PPD. The EPDS could be administered with the required paperwork in the waiting room or in the examination room prior to the visit with the nurse practitioner. The EPDS is a short, self-administered, 10-item questionnaire that takes only 10 to 15 minutes to complete. The questionnaire is easily scored and interpreted, so training would require very little time and effort. The EPDS should not override clinical judgment and should be utilized to enhance clinical assessment. PNPs interact with new mothers and infants on a regular basis. Any changes in maternal mood or behavior indicative of possible depression would be evident during these frequent routine interactions with a practitioner. Women report ease in discussing their concerns with the health care nurse, and the PNP is often the health care provider whom the mother sees on a regular basis. Training and education on the detection, management, support, and prompt referral of women with PPD is necessary to improve maternal and infant outcomes.
      Given the magnitude of PPD and the reluctance of women to seek help for this disorder, future research should focus on consistent screening methods and educational effectiveness in the pediatric setting. Very little research regarding help seeking is conducted with postpartum women. It is important to understand attitudes and perceptions toward help seeking in postpartum women. Identifying barriers and facilitators to help seeking could increase help-seeking rates and improve maternal-infant outcomes.

      Conclusion

      PPD is the most common complication of the postpartum period. A majority of women do not recognize the symptoms of depression and fail to seek help for PPD. Untreated PPD may cause maternal distress and infant emotional, cognitive, and developmental problems during childhood. Limited research is available on help seeking in postpartum women, and most of the help-seeking screening tools have not been used in this population of women. Screening tools focus on attitudes, intentions, and willingness to seek help rather than the actual help-seeking behavior. A majority of the research studies focused on women in the immediate weeks after birth with little to no longitudinal research in the first 2 years after birth. Efforts to increase routine screening for PPD in the pediatric setting should involve adequate training and education in the identification, management, and support of this disorder in postpartum women.

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      Biography

      Terri L. Liberto, Assistant Professor and Chairperson for the Associate of Science in Nursing Program, La Roche College, Pittsburgh, PA.