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Review of Screening Tools

Self-report questionnaires have been used successfully to detect depression during and after pregnancy and may be helpful in increasing our ability to recognize this disabling illness (Gise, 1992). Professor Brice Pitt in Great Britain was the first researcher to devise a specific self-report measure of postpartum depression in 1968. This was a 24 item scale designed to be given before and after delivery and used in Pitt's study of depression. It was established to check for changing scores and not for absolute scores of the mothers (Cox, 1986). A simple, accurate and practical devise was designed in 1978 for detecting the woman at risk for postpartum emotional disorders. This Canadian model found six of 19 items to be of predictive value.

These were:

    A. admission of often feeling unloved by the husband
    B. admission of feeling that pregnancy is undesired
    C. past history of postpartum depression
    D. being single or separated
    E. admission of marital problems
    F. admission that pregnancy was unplanned
    (Braverman and Roux, 1978)

The Braverman and Roux study inferred that these six basic questions as part of a routine written prenatal yes-no history could provide a window of opportunity for early intervention. During the 1980's, the research of John Cox and Jeni Holden began on the development of a Postnatal Depression Scale. Since the work was being conducted near Edinburgh, Scotland to became known as the Edinburgh Postnatal Depression Scale (EPDS). The research came from recognizing the limitations of existing self-report scales as screening instruments for postpartum depression. The 1978 Anxiety and Depression Scale (SAD) was insensitive to changes in mood after childbirth and was not valid for use during pregnancy (Cox, 1986). The Beck Depression Inventory (BDI) which had been written in 1961, had limitations for use in this population and was not always acceptable to many field workers (O'Hara, 1984). The EPDS has been designed for u se specifically with this population.
It is :

    A. to identify postpartum depression
    B. simple to complete
    C. acceptable to the mothers
    D. acceptable to professional health workers

Since health care visitors are part of the standard of maternal care in the United Kingdom, the scale is given to the mothers in the privacy of their own homes. This factor is considered important to accurately reflect a mother's current mood when she is not being observed and judged by others as she completes the assessment. This scale has been validated for use by:

    A. general practitioners
    B. health visitors
    C. midwives
    (Cox 1986)

Literature reviews in the United States state that the EPDS has been recommended for use to aid the primary care diagnosis since it is a simple, self-rated, screening inventory that can be administered to the patient at the time of her postpartum checkup (Wohlreich and Lydiard, 1994, Kendall-Tackett, 1994). A copy of the Edinburgh Postnatal Depression Scale is included in this study (Appendix C). It has now been translated into eleven languages (Cox and Holden, 1994).

It was recommended in a 1986 exploratory study that a methodological approach be implemented which redefined postpartum care in America.

This involved six dimensions of human functioning related to childbearing:

    A. biochemical
    B. structural
    C. social
    D. interpersonal
    E. cognitive
    F. affective changes
    (Affonso, Arizmendi, 1986) An example of one such approach was instituted by the State of California, Department of Health Services, Maternal and Child Health Branch in 1987. They have a Comprehensive Perinatal Services Program (CPSP) (Appendix D)> In its Guidelines to the Provider, it states that the scope of services is based on the recognition that coordination of obstetric, nutrition, psychosocial, and health education services during the course of perinatal care contributes significantly to improved pregnancy outcome. The psychosocial component of the CPSP requires:

    A. a complete initial assessment
    B. trimester reassessments by 26, 39 weeks gestation
    C. a care plan
    D. psychosocial treatment, intervention, and referral services
    E. postpartum assessment, care plan, and interventions

The CPSP screen assesses the patient's risk status. The minimum requirements of regulations for the initial psychosocial assessment include:

    A. a social support system
    B. a personal adjustment to pregnancy
    C. a history of previous pregnancies
    D. a current emotional status and history
    E. wanted or unwanted pregnancy
    F. acceptance of this pregnancy
    G. substance use and abuse
    H. housing and household needs
    I. education and employment
    J. financial and material resources
    K. a patient's goals in her current pregnancy

The health education component of the assessment requires an individualized care plan which addresses:

    A. health education strengths
    B. prevention and resolution of health education problems, needs and medical conditions, and health promotion and risk reduction behavior which can be ameliorated or resolved through education
    C. goals to be achieved via health education interventions
    D. health education interventions based on the patient's identified needs, interests and capabilities

These are particularly directed toward assisting the patient to make appropriate, well-informed decisions about her pregnancy, delivery and parenting. Referrals are made as recommended (California, 1990). This is an extensive screening model which was not designed solely to detect mood disorders. The population it has been serving are those women using the California Public Health Services System. Pregnant and postpartum women who are privately insured and utilizing other models of health care have not been participating in such an extensive screening process.

The literature review repeatedly affirmed a certain set of particular indicators which should be asked during pregnancy and after birth. These included:

    A. sleep disturbance
    B. changed eating habits
    C. prolonged or unusual fatigue
    D. drawn-out loss of interest in usual activities
    E. long mood depression or continued mood swings
    (Theesen et al, 1989)

Another screening list of nine items which could be used for diagnostic purposes includes:

    A. dysphoria
    B. loss of interest
    C. appetite
    D. sleep disturbance
    E. fatigue
    F. guilt
    G. problems in thinking
    H. suicidal ideation
    I agitation or retardation
    (O'Hara, 1990)

The prevailing opinion expressed in the studies is that self-report strategies should be followed by structured interview by trained clinicians or reports from significant others such as family, friends or work colleagues in order to destigmatize the childbirth mental health process. Careful screening of women before, during and after pregnancy should be conducted to distinguish between stress and clinical depression and will educate the family on the process of life changes related to childbearing (Affonso, Arizmendi, 1986). A 1990 Screening for Postpartum Depression study was conducted at The Mount Sinai School of Medicine. There were four trials on 1053 pregnant or postpartum women using three self-report tests for depression. The instruments were well tolerated and 25% of the women scored positive. A diagnosable mood disorder was found in 93% of these positive scores. The screening process also worked favorably to stimulate nurses to ask about postpartum depression, and educate the patients. Their Department of Social Work became involved by seeing all the patients who scored positive and they also started a support group (Gise, 1990)
It cannot be overly emphasized that there are distinguishing indicators of psychiatric illness for normal concomitants of this time period. The primary considerations are:

    A. worsening of sleep disturbances, and an inability to go back to sleep after feedings despite extreme fatigue
    B. eating problems expressed as hyper or hypophagia
    C. an increase in the intensity and duration of depressed feelings or irritability, particularly if unrelated to any specific event.

The mother's negative cognitive set frequently includes preoccupation with self-deprecatory thoughts. These may be about her conduct during childbirth, her competence as a mother, and her body image. She may express increasing discomfort with the maternal role, have fears for the child, self doubt, death wishes and sometimes, suicidal or infanticidal fantasies. The woman may lack compensatory measures to counteract the fatigue or exhaustion such as taking naps or mobilizing emotional support to the point that energy loss interferes with her functioning. Family and friends may notice that she withdraws and is socially isolated while complaining about lack of emotional support, particularly by the father of the child. In extreme situations, there is faulty interaction with the baby because of misinterpretation of its cues or evident disinterest in the baby (Herz, 1992). A growing body of research addresses the issues of how maternal depression impacts on the woman's child and the marital relationship (O'Hara, 1987, Marce Conference, 1994). The lack of detection and recognition of prenatal and postpartum disorders may lead to a host of personal psychological problems. Included in these are:

    A. a woman's shame for the feelings she is having
    B. fear of being judged a bad person
    C. fear of having the baby taken away
    D. being seen as having a weak character

These are magnified when she is not being acknowledged by professionals as having a real problem. The lack of psychosocial support may be complicated by the changing roles for women in our society and the conflict of the dual roles facing mothers today (Gise, 1992). The use of screening tools during pregnancy and following the baby's arrival would fit into a current system of primary care which is directed towards the baby and not towards the woman. This intentional attention shift would improve the chances of identifying a substantial group of childbearing women who have been overlooked by the present system (Affonso, et al, 1992)

One of three popular books published during the summer of 1994 includes in the appendix a Postpartum Depression and Anxiety Assessment. This is an evaluation tool designed and used by the authors to help provide a comprehensive history to assess current functioning. It is recommended that the woman bring this form to her first appointment with a professional in order to assist the evaluation process. The instructions include the statement that "if you do not intend to seek professional help, this appendix will not be useful to you" (Raskin and Kleiman, 1994, p. 269). In the foreword to the newest volume written by Michael O'Hara, Postpartum Depression, Causes and Consequences, Dr. Lee Cohen writes "perhaps the most compelling aspect....is the implied mandate.... to screen for so prevalent a disorder" (O'Hara, 1995), p. viii).