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THE DEVELOPMENT OF A SCREENING PROTOCOL TO DETECT
POSTPARTUM DEPRESSION IN THE PRIMARY CARE POPULATION

By

Judith P. Brady

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT

THE DEVELOPMENT OF A TELEPHONE SCREENING PROTOCOL TO DETECT
DEPRESSION IN THE PRIMARY CARE POPULATION

By

Judith P. Brady

Postpartum depression adversely affects approximately fifteen percent of women
who have given birth in the past year. Screening tools to detect depressive
symptomatology in the primary care environment are available, however these
instruments are underutilized. The implementation of a telephone screening protocol for
use during the first ten days of the postpartum period, enhances the ability of the primary
care provider to detect depression within a given patient population. Appropriate
intervention to ensure the continued functional ability of the mother, optimal growth and
development of the infant and maintenance of family fimction can then be implemented.
Using Dorthea Orem’s Self-Care Deficit Theory of Nursing as a fi'amework, this project
outlines the development of a telephone screening protocol to detect depressive
symptomatology in postpartum women in the primary care environment. Implications for

practice, education and research are presented.

DEDICATION

I would like to dedicate this scholarly project to my husband, Bob, for words
cannot express the love and unwavering support he has shown me throughout the last
three years. Also to our three daughters Megan, Lauren and Allison for being my ever
present cheering section and for helping me to truly understand the joy it is to be a mother

and what precious gifts fiom God babies truly are.

iii

ACKNOWLEDGMENTS

I would like to thank my scholarly project committee for their expertise, support
and creative ideas which helped to bring this project to fi'uition.

Katherine Dontje, RN, MSN, CS, my committee chair, for her undivided
attention, her practical, clinical knowledge and her ability to keep me focused on the job
at hand.

Celia Wills, RN, Ph.D., for her expertise in the area of depression and her ability
to help me locate information, just when I needed it most.

Joan Wood, RN, Ph.D., for her help in clarifying the conceptual details and edit
my writing in a scholarly form.

I would also like to thank my colleagues at the University of Michigan’s Brighton
Health Center for their clinical expertise and support throughout my education.

Finally, I would like to express my sincere gratitude to my closest colleagues,
Karen and Ellie. Thank you for sharing a laugh or a shoulder to cry on; your fi’iendship

was a refuge in this time of chaos.

iv

TABLE OF CONTENTS

List of Figures ............................................................................................... vi
Introduction .................................................................................................... 1

Problems Statement ........................................................................................ 3
Project Goal .................................................................................................... 3
Conceptual Definitions .................................................................................. .4
Conceptual Framework .................................................................................. .6
Figure 1 ......................................................................................................... .7
Figure 2 ........................................................................................................ .8
Literature Review ........................................................................................... 9

Project Plan ................................................................................................. .26
Implications for Advanced Practice ............................................................. 38
Conclusion .................................................................................................... 42
Appendix A ................................................................................................. .44
Appendix B .................................................................................................. 48
Bibliography ............................................................................................... .50

LIST OF FIGURES

Figure 1: Orem’s Conceptual Model for Nursing
Figure 2: Application of Orem’s Conceptual Model for Nursing to the Development of a

Telephone Screening Protocol to Detect Postpartum Depression in the Primary
Care Population

vi

Introduction

The birth of a baby and the year that follows is a joyous occasion for many
women and their families, however, for the approximately nine to sixteen percent of
women that suffer from postpartum depression (PPD), the period following this joyous
event can become a nightmare filled with anxious thought and overwhelming fear (Beck,
1995). Postpartum depression negatively impacts the well-being of the mother, the
ability of the mother to care for her child, the emotional and cognitive development of the
infant and places stress on the broader relationships within the family structure. Due to
the far reaching effects of PPD, universal screening for the detection of women at risk for
the development of PPD is imperative (O’Hara, 1995).

Change in the health care delivery system is one factor fueling the need to screen
women for the development of PPD. Fragmentation of prenatal, antepartum, postpartum
and well-child care are common. Women receive prenatal care in one setting, deliver
their baby in another setting and are usually discharged from the hospital in twenty-four
hours. These factors increase the likelihood that the earliest signs of PPD will remain
unnoticed (Beck, 1992). The first six weeks of the postpartum period is focused on the
health of the infant and commence with the infant’s two week well-child check up. Little
emphasis is placed on the well-being of the mother at this time, even though the mother is
experiencing many physiologic changes and adjusting to meet the demands of a major
change in roles as well. By the time the mother returns to her obstetric care provider for
her postpartum check-up, it is possible that a depressive disorder may be inhibiting her

ability to care for herself and her infant (Stowe & Nemeroff, 1995).

Changes in insurance coverage have also made it difficult for clients to receive
mental health services in a timely manner. This fact also points to the need of effective
screening methods in the primary care setting (O’Hara, 1995). Frequently it is the
primary care provider who is responsible for detecting changes in health status.
Therefore, the primary care provider must be educated regarding the etiology and onset of
PPD, be equipped to make the initial diagnosis, begin treatment when necessary and
make a referral to a mental health specialist if needed (Mulrow, et al., 1995).

Since health care providers cannot accurately predict who will develop PPD,
primary care providers must facilitate the screening of all prenatal clients for detection
and diagnosis of PPD (Beck, 1992). Various screening tools have been developed to
accurately detect depressive symptomatology in the primary care population. Studies
have also indicated that a variety of screening methods may be employed (AHCPR,
1993). Once collected, the screening information can be validated with physical exam
findings and a structured interview conducted to ensure an accurate diagnosis. Early
detection and treatment leads to more rapid elimination of symptoms therefore enhancing
the return of function to the mother.

As a product of the screening process, the primary care provider has the
opportunity to educate childbearing women and their families regarding the normal
physiologic adjustment inherent in the postpartum period, as well as the warning signs
which may point to the risk of later development of depression (Knops, 1993). The
education process enables the primary care provider along with the woman and her family
to quickly and accurately identify those women who are suffering from depression and

also to deal effectively with normal postpartum adjustment issues. Studies have shown

that the simple act of providing information and reassurance, may be enough to help the
new mother form appropriate expectations of herself and her family during this time of
transition without falling into depression (Gruen, 1990). The implementation of a
screening protocol to detect depressive symptomatology in postpartum women, as well as
the provision of an intervention when appropriate, is a practical and holistic model for
primary health care.
Problem Statement

The number of women suffering from postpartum depression (PPD) varies from
nine to sixteen percent (Beck, 1996). Although the majority of these women obtain
obstetric and postnatal care in the primary care environment, little is done in the way of
screening to detect the onset of PPD (O’Hara, 1995). PPD inhibits the functional ability
of the mother, and decreases the ability of the mother to perform self-care actions in the
care of herself and the dependent care of her infant. This lack of functional ability
impacts not only on the well-being of the mother, but impacts the psychological,
emotional and cognitive development of the infant ( O’Hara, 1995). According to Beck it
is critical for nurses to intervene as early as possible to prevent long-term effects on
children of mothers who suffer severe depression.
Project Goal

The goal of this project was to provide, through the process of a telephone
screening protocol, the identification of clients exhibiting warning signs for the
development of postpartum depression. Once identified, appropriate intervention may be
instituted prior to the development of functional limitations associated with PPD. If

depressive symptomatology does develop, the disease may be quickly and accurately

diagnosed, thus ensuring the continued functional integrity of the mother. The screening
process also facilitates the education of postpartum women regarding the normal and
expected changes of the postpartum period. This enables the women to better cope with
self-care demands. The screening process also promotes the well-being of the mother, by
providing support and information and fostering a relationship with the primary care
provider. This process enhances the mother’s ability to perform self-care activities
needed to maintain her own health, the health of the infant and ultimately the health of
her family unit.
Conceptual Definitions

For the purposes of this project the following definitions were utilized to clarify
the principal concepts. The key concepts are postpartum depression, protocol, health
screening, primary care, and primary care providers.
Postpartum depression (PPD): Depressive symptomatology as outlined in the Diagnostic
and Statistical Manual of Mental Disorders (1994), presenting anytime within the
postpartum period, to one year post delivery defines PPD.
m: The use of an organized, systematic, research based, line of questioning to
assess the severity of a problem and help the provider and the client make informed
health care decisions (Briggs, 1997). The protocol is designed to provide consistency,
while minimizing subjectivity and to gather needed information related to the problem at
hand. A protocol is not designed to diagnose, but to detect changes in health status that
may require additional follow-up or referral.
Health screening: Last (1980), describes health screening as the examination by a single

test or procedure of a well population for the purpose of detecting those who may have

unrecognized disease. The Clinician’s Handbook of Preventive Services (U SPSTF)
(1996), outlines conditions which must exist for screening tests to be useful. The
conditions include: 1) the condition must have significant effect on quality of life, and 2)
the availability of acceptable treatment and the incidence of the condition must be
sufficient to justify the cost. Although USPSTF does not endorse routine screening of all
individuals in primary care for depression, the universal screening of postpartum women
for depression is heartily endorsed in the literature (O’Hara, 1995; Beck, 1992; Affonso
et al., 1990).

Primm care: According to Starfield (1992), primary care is difficult to define and one
must look at its characteristics to understand its function. Orem (1995) describes primary
care services as geographically and financially available, providing periodic examinations
to detect change in the health status of an individual or family. Primary care also
involves the participation of individuals in their own care and developing individual
programs of care. The purpose of primary care services as the individual or families first
contact with the health care system (Starfield, 1995). Services provided in primary care
settings include health maintenance, health promotion, as well as primary, secondary and
tertiary prevention (Orem,1995).

Marv Care Providers (PCP): Primary care services may be provided by a number of
individuals, singly or in teams to provide health services in a supportive, caring manner.
It is the responsibility of the primary care provided (PCP) to be accountable for the
coordination, integration and management of the client’s total health care and services

(Starfield, 1992). PCPs include medical and osteopathic physicians in the areas of

pediatrics, internal medicine and obstetrics and gynecology, as well as advance practice
nurses (APN), who function in these clinical settings.
Conceptual Framework

A screening protocol developed to detect warning signs associated with the onset
of PPD may be viewed as a tool to prevent illness and promote the health and well-being
of the new mother, her infant, and the family unit. Dorthea Orem’s Self-Care Deficit
Theory of Nursing has been selected as the framework to facilitate the process.

Dorthea Orem’s Self-Care Deficit Theory of Nursing is composed of three
interrelated theories: the theory of self-care, self-care deficit theory and the theory of
nursing systems. The system of theories defines self-care and its properties, delineates
when nursing is needed and discusses how nursing care is delivered. The application of
Orem’s theory to the health screening process helps to explain how nursing can impact
the ability of the new mother in order to provide continuous therapeutic self-care to meet
her own needs as well as the needs of her infant. Figure 1 and Figure 2 help to
conceptualize this relationship.

Self-care Theory

Self-Care Theory relates what elements are inherent in the performance of self-
care activities. Orem (1995), defines self-care as “ a human regulatory function that
individuals must with deliberation, perform for themselves...to supply and maintain a
supply of materials and conditions to maintain life; keep physical and psychic
functioning and development within norms compatible with conditions essential for

life...” (1.1 172).

Figure l: A conceptual model for nursing.

 

 

  
 
 
 

 

 

    
 

 

  

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From Dorthea Orem (1995), Nursing concepts of practice, p. 435

Figure 2: The application of Orem’s conceptual model for nursing to the Development of
a Screening Protocol to Detect Postpartum Depression in the Primary Care Population

1. Deliberate actions to maintain
health of self and dependent

 
   
   

  

Self-care
Agency

 

age, race, gender, depressive symptoms,
education, socio-economic status
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1. Ability to provide Self-care l. Bio/psycho changes
continuous therapeu Deficit place new/different
self-care demands on the mother

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symptoms

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1. Application of telephone screening protocol
2. Development of nursing care based on client needs
3. Implementation and evaluation of nursing interventions

Adapted from Dorthea Orem (1995), Nursing concepts of practice, p. 435.

Orem (1995), further describes self-care as a learned activity, a right as well as a
responsibility in which adults engage. Self-care also involves the giving or supervising
of the self-care of another, as a component of infant and adolescent care, in the
maintenance of health and life function.

The concept of health is viewed from a global perspective. Health is defined as
the state of physical, mental and social well-being, not merely the absence of disease
(Foster & Bennett, 1995). Orem (1995), fithher states that the above components are
inseparable in the individual. In order to maintain health, health care must include the
promotion of physical, emotional and spiritual components, not just the treatment of
disease or injury.

Self-care Agency

The ability of an individual to perform self-care is known as an individual’s self-
care agency. Orem (1995), defines self-care agency as the intrinsic motivation through
which self-care is accomplished. It is the complex acquired ability to know and meet
continuing requirements for deliberate, purposive action to regulate their own functioning
and development (Orem, 1995). The individual’s ability to engage in self-care is affected
by basic conditioning factors including: age, gender, developmental state, family system
characteristics, socioeconomic factors and interaction with the health care system. An
individual’s self-care agency is influenced by the therapeutic self-care demand or the
“totality of self-care actions to be performed for some duration to meet known self-care

requisites” (Orem, 1995, p. 82 ).

10

Self-care Deficit

When an individual’s therapeutic self-care demand is greater than their ability to
perform self-care, a self-care deficit exists. Self-care deficit theory defines when nursing
is needed. Orem (1995), states that nursing is required when an adult, or child under the
care of the adult, is limited or incapable of continuous, effective self-care.

Theory of Nursimg Svstem_s_

Orem’s theory of nursing systems discusses how nursing care will be delivered. If
an individual is unable to meet self-care demands, a nursing system is designed by the
professional nurse which aides the ability of the client to perform effective self-care. The
APN in the primary care setting will employ the “supportive-educative” system to help
clients and their families meet self-care demands. Orem (1995), states that under this
system the client is able to perform and should learn to perform required measures of
externally or internally oriented therapeutic self-care, but cannot do so without assistance.
Orem states the ability to help others meet their therapeutic self-care demand is termed
nursing agency (Foster & Bennett, 1996).

Nursing Agency

Nursing agency can be broken down into three components: 1) the ability to help
the client meet their own and dependent others needs, 2) assistance for the client, and 3)
assistance for members of the client’s family which fosters competence in care (Fawcett,
1995). The APN uses the body of knowledge gained through training and practice as a
professional nurse to recognize potential self-care deficits. The ability to design nursing
strategies to help clients perform self-care actions helps the client to maintain health, but

also enables a higher level of well-being to be obtained.

11

A screening protocol to detect PPD in the primary care population is an act of
nursing agency when clients at risk for the development of illness and a potential self-
care deficit are identified. Through the assessment of basic conditioning factors, such as
a previous history of depression, the lack of social support and previous life events, the
professional nurse may identify factors which may predispose a woman to the
development of PPD. As a women moves from the pregnant state to the postpartum
period, the nurse will assess changes in the woman’s therapeutic self-care demand.
Symptoms such as anxiety, fatigue and child-care stress, may make it difficult for a
woman to provide herself and her infant continuous, effective self-care. The screening
process provides a tool for the professional nurse to utilize when assessing these changes
and providing support, education and intervention as appropriate. Through the process of
screening for warning signs predictive of PPD, the nurse can assist the client in regaining
her ability to meet her therapeutic self-care demand, enhance self-care agency, which
enables the client to perform continuous, effective self-care, for herself, as well as, her
infant. This process ultimately enhances the health of the client and her family system as
a whole.

Review of the Literature

The review of the literature defines the problem of postpartum depression (PPD),
addresses the impact of this disorder on the mother, the infant and the family structure,
and supports the need to screen women in the primary care setting for symptoms of
depression. The review also explores the screening tools available to the primary care
clinician to detect depressive symptomatology and the methods employed to implement

these tools in the primary care population.

12

Postpartum Affective Disorders

There are three affective disorders which may present during the postpartum
period. In order of severity they are: maternity blues, postpartum depression and
postpartum psychosis. It has been proposed that postpartum mood disorders range along
a continuum of severity from little to no disturbance to severe disturbance in functioning
(O’Hara, 1995). There are no natural dividing points to separate these disorders and
women at the boundaries will be similar to each other (O’Hara, 1995).

The maternity blues commonly referred to as the blues is the most common and
least debilitating of the postpartum affective disorders. This disorder has shown a
consistent, positive correlation with the later development of postpartum depression.
Approximately fifty to eighty percent of postpartum women develop symptoms
associated with the blues (O’Hara, 1995). It is generally a self-limiting condition of the
early postpartum period, with symptoms consisting of labile mood, tearfulness and
irritability (Millis & Komblith, 1992). The onset of the blues usually begins on the third
or fourth day and peaks on the fifth through the tenth day of the postpartum period. The
blues rarely cause disability and are best treated with support and reassurance (Millis &
Komblith, 1992). Women who develop severe cases of the blues should be closely
monitored for the later development of depressive symptomatology (Beck, 1992).

At the opposite end of the spectrum of postpartum affective disorders lies
postpartum psychosis. This is a rare disease entity with rapid onset, presenting with
significant reality impairment, rendering the woman unable to care for herself or her
infant (Beck, 1993). These women may experience suicidal and/or homicidal ideation,

impaired reality testing and the physical symptoms of inability to eat or sleep. The onset

13

of any of these symptoms requires immediate intervention. Postpartum psychosis is
considered a medical emergency and hospitalization with medication and intensive
therapy are generally required (Stowe & Nemeroff, 1995). Women who experience one
episode of postpartum psychosis have a four-fold chance of a repeat episode. Therefore,
assessment for history of psychiatric episodes is essential during the prenatal history and
assessment visits (O’Hara, 1995).

A postpartum depression episode may encompass features found in both the blues
and postpartum psychosis and present with varying levels of impairment of maternal
fimction. The disorder may strike women regardless of age, race or socioeconomic
status, anytime within the first postpartum year (O’Hara, 1995). Left untreated, PPD has
the potential to become a chronic, disabling entity, impacting the function of not only the
woman herself, but her family as well (Beck, 1995).

Pitt (1968), first described depression after childbirth as “atypic ” or different
than the normally held construct of depression. Pitt’s (1968) definition included
emphasis on anxiety, not generally found in diagnostic criteria for a major depressive
episode. The DSM-IV (1994), the standard by which psychological disease is measured,
defines the symptoms of a major depressive episode as:

“changes in appetite or weight, sleep or psychomotor activity, decrease in energy,
feelings of worthlessness or guilt; difficulty thinking, concentrating, or making
decisions; recurrent thoughts of death, suicidal ideation, plans or attempts” (p. 320).

Beck’s (1992) phenomenological study describes the experiences of women
suffering from PPD. It addresses the components included in this definition, and
provides further insight into the disorder from the mother’s perspective. According to

Beck (1992), the experience of PPD can be described as revolving around eleven specific

14

themes. The themes include: unbearable loneliness, contemplation of death, fear of
harming their infants and obsession with being a bad mother. These mothers described
periods of “being in a fog”, being unable to think, concentrate, feel emotion or enjoy
previous interests (Beck, 1992). Panic attacks and lack of control over what is occurring
in their lives completes the list. Although components of the DSM-IV definition are
apparent, anxiety is the prevailing symptom, concurring with earlier findings that PPD is
a distinct affective disorder.

While recognition of postpartum depressive symptoms is significant, not all
authors agree that PPD is a distinct depressive entity. Gotlib and Whiffen (1991), found
very few differences in depressive symptomatology between samples of depressed
childbearing women and matched controls of non-childbearing women. O’Hara et al.,
(1991), also found little difference between samples of depressed women, with different
childbearing status. However, there have been too few controlled studies to be confident
that PPD does not present in a distinct fashion (O’Hara, 1995). These findings have lead
the DSM-IV to label depression in the postpartum period, “Postpartum onset major
depression” (1994). The acknowledgment of the presentation of a distinct depressive
disorder supports the need to develop methods of detecting PPD.

Symptoms of PPD

The literature explores warning signs and symptoms which may herald the onset
of a depressive episode in the postpartum period. According to Beck (1992), PPD may
present with symptoms which include: low mood, crying, increased level of fatigue, lack

of sleep, increased level of anxiety, the inability to enjoy previous activities and obsessive

15

thoughts. Other signs such as over concern for the baby’s welfare, anger and irritability
and excessive anger may be present (Affonso etal., 1990; Knops, 1993).

It is also important to note that although women may display the signs and
symptoms of PPD, it may be impossible to predict which women will actually go on to
develop the disorder. Normal postpartum physiologic symptoms may camouflage the
depression (Whiffen, 1988). Primary care providers need to be aware of the symptoms of
PPD when interacting with a new mother. PPD has been described as “mercurial”, as the
symptoms wax and wane over time and may be different on a daily basis. It is for this
reason mothers and their families may not recognize the problem.

The onset of PPD may be gradual, therefore evaluation for the disorder should
continue if the client presents for multiple somatic complaints during the first postpartum
year (Stowe & Nemroff, 1995). O’Hara (1995), states although it is common for PPD to
be detected in the first six weeks to six months following delivery, the disorder may
strike anytime within the first year.

Causes of Postpartum Depression

Research has also focused on uncovering the factors which may predispose a
woman to the development of PPD. Studies have explored the physical, emotional and
cultural factors which may contribute to the development of PPD.

Some authors contend that PPD is a “hormonally mediated” depression.
Although neuroendocrine changes which take place during the postpartum period are
likely markers in the development of mood disorders, research in this area has been
unable to make a direct link between a specific hormone or change in hormonal level and

the onset of PPD (O’Hara, Schlechte, Lewis & Varner, 1991).

16

The etiology of PPD appears to stem from not only physiological factors, but also
is combined with psychological and cultural factors as well. For many women the birth
of a child signifies a developmental milestone. According to Gruen (1990), the birth of a
child can be viewed through the framework of loss. The new mother’s coping skills are
no longer sufficient to meet the demands of her multiple roles of wife and mother, while
still attempting to continue to provide for own needs. A loss of the established couple
relationship is realized, as well as loss of personal freedom. These factors coupled with
the inability of the mother to express negative emotions surrounding the birth of typically
a healthy infant may cause women to experience shame and fear when negative emotions
are experienced (Gruen, 1990). Popular media portrays a smiling new mother, playing
with her cuddly newborn infant, while juggling the demands of a spouse, job and a
family. For many women this scenario is a myth, quickly turning the bliss of coming
home with a new baby to feelings of overwhelming concern (Unterman, Posner &
Williams, 1990). According to Affonso (1990), the role of mother is not innate, but
acquired over time. Health care providers should work to support mothers in this process
of role attainment, while providing a supportive environment to express their concerns.

Relationships within the family structure are important factors which impact the
development of PPD. Studies have consistently linked women’s dissatisfaction with the
primary intimate relationship with the development of PPD (O’Hara, 1995; Whiffen,
1988; Beck, 1996).

Other studies have explored the relationship of the woman with her own parents
as an indicator of the development of PPD (Knop, 1993). A distant relationship with

ones’ own mother, the perception that the mother did not enjoy the mothering role and

17

lack of involvement of the father all correlate with the predisposition to the development
of PPD (Holden, 1991). Genetic factors may also help explain an increase in PPD in
women who have a first degree relative with a history of depression (O’Hara, 1995).
Predictor Variables of the Development of PPD

Through the analysis of the causative factors associated with PPD, a set of risk
factors which may predict the development of PPD has been validated by Beck (1996)
through meta-analysis. Eight categories of predictor variables were identified as being
positively correlated to the development of depressive symptoms postpartum. The cited
variables include: prenatal depression, child care stress, life stress, lack of social support,
prenatal anxiety, maternity blues, lack of marital satisfaction and history of previous
depression. The above variables can be utilized as an initial screen to “flag” those
women who may be at risk of development of PPD in the primary care setting.
Cgsequences of PPD

The development of PPD has negative consequences for the woman, her children
and the family unit as a whole. The literature points to an increased incidence of repeated
depressive episodes in women who suffer fi'om PPD. A woman who suffers from a
depressive episode postpartum is 30% more likely to suffer fi'om subsequent depressive
episodes than a non-depressed woman postpartum (O’Hara, 1995). Research has
indicated that depressed women have a difficult time relating to their babies and may
develop negative attitudes toward their children (Susman, 1996). Beck (1995), describes
the feelings of loss experienced by women who are recovering from PPD. Mothers are
left feeling angry, as though their child’s infancy was wasted, as they were unable to

enjoy so many of the changes that take place during the baby’s first year of life.

18

Due to the finding that PPD can result in significant impairment of the function of
the mother to care for her child, studies have investigated the effect of PPD on the
cognitive and emotional development of the child. PPD adversely impacts
maternal/infant bonding which fosters cognitive and behavioral deficits in the infant
(Affonso et al., 1990). Unterrnan, Posner and Williams (1990) describe the withdrawal,
irritability and fatigue of the depressed mother, as limiting and distorting healthy
interaction with the infant; this causes emotional deprivation in the child. This factor
encourages the child to fall into the depressed mood of the mother, thus responding to the
affective climate in the home.

Even as the mother recovers from a depressive episode, the impact of the
depression persists as the child becomes older. Children of depressed mothers have been
found to be more temperamental, have more negative impressions of their mothers and
possess more cognitive and behavioral deficits when compared to children of non-
depressed mothers
(Susman, 1996).

Although little research has been done on the impact of PPD on the family as a
unit, there is evidence that the stability of the couple’s relationship is affected by maternal
depression. Depressive symptomatology in the mother may leave her significant other
feeling distraught and confused (Gruen, 1990). The partner feels powerless to control the
situation. This feeling of powerlessness may lead to overt or covert anger expressed
toward the mother or the child for disrupting the couple’s life (Gruen, 1990). Anger may
also be expressed at health care providers for failure to inform the father regarding the

potential for the development of PPD or for not curing the illness (Gruen, 1990).

19

Current Screening Recommendations

Current screening recommendations include, detecting risk factors through a
prenatal history assessment, as well as screening for depressive symptomatology during
the postpartum period. O’Hara (1995), states that risk factors associated with the
development of PPD can be detected early in pregnancy. Thus, prenatal history questions
should include information regarding risk factors such as treatment for a current
depressive episode, prenatal anxiety, history of depressive episode, lack of social support
or financial resources. These risk factors may help the clinician identify women at risk to
develop depression in the postpartum period.

Some authors have devised prenatal screening tools to detect risk factors
associated with the development of PPD during the prenatal period. Posner, Unterman,
Williams and Williams (1997), constructed the Antepartum Questionnaire. This tool was
developed in the interest of identifying those women at risk for PPD in the prenatal
period in order to prevent PPD or at least institute early treatment of the disorder.
Likewise, Stamp, Williams and Crowther (1996), present an antenatal screening tool to
predict the likelihood of the development of PPD. As these tools are newly developed,
no controlled studies have been done to date to test their validity and reliability of such
screening tools. Further study is needed to determine if these screening measures
improve the rate of detection of PPD, therefore improving the outcome of treatment for
the disorder.

The detection of depressive symptomatology during the postpartum period is
perhaps the most prevalent method to screen for the disorder. The literature documents

numerous screening tools to detect depression during the postpartum period.

20

Unfortunately, no systematic guidelines for the assessment of depression in postpartum
women have been evaluated to standardize the screening process.
Tools to Screen Depression in Primm

Various screening tools are available to primary care clinicians to detect
depressive symptomatology in postpartum women. Brief paper and pencil questionnaires
have been specifically constructed to assess stressors that may indicate risk factors for
adverse mental health outcomes (Hall, et al., 1996). According to AHCPR (1993)
guidelines, patient self-report tools are a low cost, valuable method of depression case-
fmding in the primary care setting. Although these tools are sensitive, an accurate
diagnosis cannot be made on the basis of patient self-report alone. Results of screening
tools must be verified through physical exam findings to rule out physical disease, as well
as psychological assessment based on DSMIV criteria to accurately diagnose depression
and comparison to DSM-IV criteria (Stowe & Nemeroff, 1995).

The most frequently mentioned self-report tools noted in the literature include, the
Beck Depression Inventory (BDI) (Beck et al., 1960) and the Edinburgh Postnatal
Depression Screen (EPDS) (Cox et al., 1987). The BDI is an accurate, reliable and valid
self-report tool that has been reported as effective in the primary care setting (Mulrow
et al., 1995). The BDI is a depression specific tool consisting of twenty-one items, with
easy readability and an administration time of two to five minutes. Many early studies
exploring PPD used the BDI to assess depressive symptoms (O’Hara, Neunaber &
Zekoski, 1984; O’Hara et al., 1991). As research progressed, it was found that the
instrument did not necessarily predict the onset of PPD (O’Hara, 1988; Gotlib et al.,

1991). It was hypothesized that the somatic nature of the depressive symptoms assessed

21

by the BDI were overlapping normal physiologic changes associated with the postpartum
period. Fatigue, difficulty sleeping and change in appetite are all normal physiologic
complaints of postpartum mothers which are also predictors of depression as assessed by
screening tools (Affonso et al., 1990). This overlap in physical symptoms led researchers
to develop a tool which would control for normal physiologic changes, while still
assessing for the emotional components of depression.

The development of the EPDS, was an attempt to construct a screening tool that
could detect the emotional changes inherent in PPD. The tool was developed with the
goal of being acceptable to both the provider and the woman, and easily incorporated into
the primary care setting (Holden, 1991). Several studies have shown the EPDS to be a
valid and reliable screen in detection of PPD in the primary care population (Holden,
1991; Cox, 1996).

The tool is a ten item questionnaire which takes a few minutes to complete and
focuses on the psychological, emotional and physical manifestations inherent in PPD.
Items include the assessment of the ability to laugh, the ability to enjoy activities, feeling
panicky or scared, the ability to sleep, feelings of sadness, and the inability to accomplish
tasks. The mother must indicate if she has encountered the concern listed and then
quantify the response. The tool has been recently validated for use in pregnant woman,
and in women with older children (Cox et al., 1996). The criticism of the EPDS, as well
as other self-report tools, is the fact that the tool does not give the woman the opportunity
to fully describe their depressive symptoms (Beck, 1996).

Semi-structured questionnaires are another method of detecting depressive

symptomatology in the primary care environment. An example of a semi-structured

22

questionnaire used to detect PPD is known as Schedule of Affective Disorders and
Schizophrenia (SADS)(Affonso et al., 1990). The SADS questionnaire has been most
frequently used to validate symptoms found on self-report measures. Semi-structured
questionnaires give the provider more information regarding the history and course of
symptoms by allowing the patient to fully explain symptoms. However, these tools are
costly to administer and may be difficult to integrate into a busy office practice (Affonso
et al., 1990; AHCPR, 1993).

Newer studies are focusing on the variety of case-finding instruments available to
detect depression in the primary care setting. Recently developed tools are shorter,
focusing primarily on the psychogenic properties noted in depression: low mood and
anhedonia, or the loss of pleasure in usual activities. Whooley, Avins and Browner
(1997) evaluated a tool limited to two questions: “Are you bothered by feeling down,
depressed or hopeless?” and “Have you been bothered by little interest or pleasure in
doing things?” The performance of these two questions in detecting depression in the
outpatient setting was similar to valid, reliable measures in this particular study.
Implementation of Screening_'_l‘o_ol§

Although research studies have focused on screening tools to detect PPD, little
work has been done to explore the efficacy of the variety of methods available to
administer these tools (Mulrow et al., 1995). Available literature discusses the
application of screening tools in a variety of environments. Screening tools can be
completed in the primary care provider’s waiting room, during an examination, over the

telephone, or in the client’s home (AHCPR, 1993). The population being screened and

23

resources available within the health care system appear to dictate the method of
administration of these tools.

Changes in the health care arena have impacted the way the medical community,
particularly in primary care, provides, manages and evaluates its service (Starfield, 1992).
Primary care providers are responsible for detecting and managing changes in the client’s
health status (Stowe & Nemeroff, 1995). In order to detect and monitor these changes,
alternate methods of assessment have been developed. The use of the telephone to
manage clients has become an important aspect in the provision of primary care services
(Studdiford et al., 1996).

The Use of the Telephone in Primgy Care

The use of the telephone to keep in contact with clients during vulnerable times, is
a valuable, cost-effective assessment tool. The telephone has been used to monitor the
elderly, the chronically ill, and the matemal-child population (Studdiford et al., 1996;
Stover & Marnej on, 1995). The result has been increased support for clients, providing
“extension of the stethoscope” in making decisions to clinically manage clients, and
saving time and health care dollars by assessing and managing the client outside the
hospital or clinic setting when possible (Studdiford et al., 1996).

Early hospital discharge for matemal-child clients has shifted the responsibility
back to the primary care provider for the of care for the early postpartum periods for both
the mother and the baby (Stover & Marnej on, 1995). It is now more important for
primary care providers to stay in close contact with new mothers during this time of

transition.

24

According to Stover and Marnejon (1995), a follow-up phone call within the first
week of the postpartum period is an opportunity to exchange valuable information
regarding the progress of the mother and the new infant. The use of the telephone,
employing supportive listening, helps to allay concerns, provides anticipatory guidance,
and helps the new mother to develop realistic expectations of herself and the infant in the
early postpartum period. Questions such as, “How is it going at home?”, can give the
new mother an opportunity to discuss her experience and give the nurse an opportunity to
pick up on cues that concerns are present and need to be addressed. Perhaps a follow-up
appointment to evaluate concerns or a phone call to provide anticipatory guidance is
appropriate.

The support provided by a postpartum phone call also gives new mothers the
invitation to call the primary care provider back if unexpected concerns arise. The
support provided is important when dealing with a mother who may be depressed. Often
times women do not feel that others can associate with their experience nor do they feel
they can share their negative feelings (Beck, 1995 ). A provider/client relationship built
on trust will facilitate positive health outcomes for the mother and her infant.

Other questions to accurately assess the adjustment of the mother and her infant in
the early postpartum period may include: “Do you have any concerns regarding your own
health?” and “What are you doing to meet those needs?” A question phrased as, “Do you
have any concerns about how your baby is doing?”, may open the door to discuss with
the new mother concerns related to the health of the infant as well as assess the mother’s

knowledge of newborn care (Stover & Marnejon, 1995, p. 1467).

25

The Use of Telephone Protocols in Pimgrv Cafi

Telephone protocols are one way to gain and document information to aid in
clinical decision making in the primary care setting (Studdiford et al., 1995). In order to
accurately obtain information regarding the adjustment of the postpartum women, the
primary care provider must delegate telephone duties to a professional prepared in art of
telephone assessment, who possesses good interpersonal skills and has the ability to
detect affective nuances which indicate a possible adjustment problem. Telephone
protocols enable the caller to obtain the desired information in an organized, consistent
fashion, and enables health care providers and consumers to make decisions related to the
severity of a medical disorder (Briggs, 1997).

According to Briggs (1997), telephone protocols help to guide a line of
questioning to aid in health care decision making, but do not make a medical diagnosis.
Telephone protocols help the health care professional to respond to a call with confidence
and consistency, while minimizing subjectivity (Briggs, 1997). Although protocols aid in
decision making, they do not take the place of sound clinical knowledge and experience,
therefore, RN 5 must gather information and refer to primary care providers when
indicated. Studdiford (1995), states that only personnel trained specifically in the use of
the telephone, who have excellent assessment skills and clinical knowledge base should
be responsible for answering and documenting medically related telephone calls
(Studdiford et al., 1995).

The review of the literature summarizes the symptoms associated with PPD, the
causes of PPD as well as the effects of PPD on the mother, the child and the family. The

impact of this disorder points to the need to increase the use of screening measures to

26

detect PPD in the primary care setting. The literature also reviews a variety of tools to
and methodology to implement the screening process, not only to detect depressive
symptomatology, but to provide education regarding the normal and expected changes

encountered in the postpartum period as well.

Project Plan

Target Population

A screening protocol to detect the warning signs associated with the onset of
postpartum depression will be developed for use within a primary care clinic which
provides obstetrics and gynecology services. The office practice serves, Midwestern,
white, women, aged eighteen through forty five, with on average an eighth grade
education or above. The practice supports between fifteen and twenty deliveries a month.
Various health insurance plans are represented in this population: Medicaid, private
health maintenance organizations, commercial insurers and private payers.
Development of the Protocol

The protocol will be framed as a postpartum follow-up phone call, consisting of a
semi-structured questionnaire based on the work of Stover and Marenjon (1995), Cox et
al. (1987), and Whooley et a1. (1997). The use of a semi-structured questionnaire,
although time consuming, has the advantage of allowing the mother to describe her
postpartum experience and ask questions when indicated (Beck,l995). The interview
format allows the RN opportunity gather needed information from the client, provide
valuable education to the new mother, and provide a supportive environment to facilitate

the building of a trusting relationship with the client.

27

In order to make the protocol easy to understand and administer, the project will
consists of two separate instruments. The first instrument, the telephone screening
protocol, will discuss the information needed to be collected to complete the screen, will
provide the rationale for the inclusion of each question in the protocol and discuss the
appropriate follow-up action based on the client’s response to the protocol. This
document can be used as a reference guide should questions arise during the
administration the protocol and can also be used to educate the staff regarding the
implementation of the protocol. Appendix A outlines the telephone screening protocol.

In order to provide a format that is quick and easy for the clinician to administer and
provide a mechanism to document the client encounter, a second format was developed.
The tool is comprised of the list of questions needed to administer the protocol, with
diagnostic criteria to aid in formulating an individual plan of care for each new mother.
Appendix B outlines the tool labeled, Initial Postpartum Contact.

The RN is chosen to administer the screening protocol as the literature discusses the
need to delegate telephone management of patients by protocol only to those personnel
with clinical knowledge and effective communication skills (Studdiford et al., 1996).

The RN will administer the screening protocol to all women who deliver infants while
under care of the clinic’s primary care providers (PCPs), within ten days of the infant’s
birth. This time-frame is chosen as up to 80% of women suffer some symptoms of the
maternity blues during this period of time (O’Hara, 1995). Women who experience a
severe case of maternity blues are at increased risk for the later development of PPD

(Beck, 1992). Postpartum psychosis, a rare and severe condition may also present during

28

this time-frame. Therefore, assessment of maternal adjustment at this time interval may
be helpful in detecting a range of postpartum affective disorders.

Subjective data

The telephone screening protocol will open with the RN introducing herself, stating
the purpose of the call will state that she is phoning from the primary care clinic to see
how the mother is doing since she has been home fiom the hospital with her new baby
(Stover & Marnejon, 1995). The mother will be informed the length of the call will be
approximately ten minutes. If the mother consents to the call, the protocol will be opened
with the questions regarding the mother’s physical condition since hospital discharge.
Concerns related to the care of the episiotomy, the breasts, the ability to maintain
adequate rest, nutrition and fluid status will be assessed by the nurse. The nurse will
inquire as to whether the mother has specific concerns related to physical changes. A
mother who has multiple physical concerns, is unable to obtain adequate nutrition due to
decreased appetite or is fatigued due to the inability to obtain adequate rest due to anxiety
or demands of child-care is at greater risk for the development of PPD (Beck, 1996).

Questions regarding physical concerns are placed first in the protocol as many new
mothers have questions related to the physical changes associated with the postpartum
period. Most mothers are comfortable discussing these concerns with the nurse, this
comfort level helps to foster a trusting relationship between the nurse and the client. This
trust facilitates later discussion regarding emotional concerns common to the postpartum
period, as the literature shows many postpartum women have difficulty discussing

negative emotional concerns related to the birth of a healthy baby (Beck, 1992).

29

The nurse will then inquire regarding the physical status of the infant. Does the
mother have any concerns regarding the infant’s feeding, elimination, sleep pattern or
temperament? Many new mothers have questions regarding the routine infant care. The
RN will have the opportunity to assess the mother’s level of knowledge in this area and
provide education as appropriate. The mother will also be asked if she feels she is able to
meet the needs of her infant. A mother who verbalizes difficulty meeting baby’s needs,
shows over-concem for the health of her infant, as well as an infant who is overly fussy
or fails to thrive may indicate depression in the mother (Knops, 1993).

Social support is the second topic addressed by the protocol. “How is your family
adjusting to life with baby?”, may open the discussion of spousal support as well as
support of extended family and friends. Is the spouse willing and able to take part in
child care activities? Is the couple able to integrate the baby into the established family
structure? Women with an unstable primary relationship or lack social support are at risk
for the development of PPD (Whiffen, 1988). This may also be a good time to provide
the new mother education regarding the normal and expected transition of the roles for
both spouses during the postpartum period. This information may help both spouses
form realistic expectations of both mother and infant during the postpartum period
(Gruen, 1990). The RN may also be able to help the mother tap into available
community resources for use during this time of transition if indicated.

Once physical and support issues are explored, the nurse may then proceed to assess
the emotional issues which may be apparent during the early postpartum period. The
mother will be asked to answer “yes” or “no” to the following questions. Is the mother

suffering fi'om mood swings, crying spells or increased anxiety level which interferes

30

with her normal activities? Does the mother feel she is unable to think clearly and has the
inability to think clearly impaired the mother’s ability to make decisions? Is the mother
experiencing feelings of increased anxiety or guilt? Is the mother suffering from low
mood or the inability to experience pleasure in the activities she once enjoyed? If the
mother answers any of the above questions in the affirmative, then the perceived level of
distress must be quantified. The mother will then be asked how may days in the last
week the symptoms have been present. The response options will include 1-2 days, 3-4
days or 5-7 days. Grading the endorsement of a symptom in this manner allows the RN to
quantify the level of distress in the new mother and assess these feelings may impact the
level of the mother’s functioning. By quantifying the response the RN is able to provide
nursing interventions based on the client perceived level of distress (Cox et al., 1987).

If the mother responds positively to only mood swings and irritability, lasting for only
several days, the RN may suspect that the mother is suffering from maternity blues. As
the blues are transient in nature, the RN may simply provide a listening ear and offer the
new mother community support systems to help her better cope with the situation (Millis
& Komblith, 1992). As the onset of maternity blues is a risk factor for the later
development of PPD, the RN should plan a follow-up phone call within the next week or
so to assess the mother’s level of fimction (Beck, 1992).

If the mother gives an affirrnative response to the questions relating to low mood and
lack of ability to experience pleasure, quantifying the emotion as most days of the week,
the nurse may suspect the client is depressed (Whooley et al., 1997). These two factors
were found to be reliable indicators of depression in the primary care population. Other

indicators of depression as outlined in the DSM-IV (1994) include: anxiety, guilt,

31

hopelessness, as well as low or sad mood and inability to experience pleasure and
recurrent thoughts of death. The greater the number of symptoms endorsed by the client,
the greater the chance a diagnosis of depression will be made (AHCPR, 1993).

The endorsement of symptoms associated with depression indicates the nurse must
address the concept of suicidality with the mother. Again, the mother will be asked to
answer “yes” or “no” to the following questions. Has the mother considered the act of
harming herself or her infant? If she has considered this thought, has the mother
formulated a plan to carry out this consideration? The ability of the mother to formulate a
plan to harm herself or her baby is a medical emergency, indicating immediate
intervention by the client’s PCP or the referral to a mental health specialist when
indicated.

During this line of questioning the nurse may pick up on cues that the mother has
impaired reality testing. Irrational behavior, with impaired cognition resulting an
inability to eat, sleep or care for herself or her child should lead the nurse to consider the
onset of postpartum psychosis (Stowe & Nemeroff, 1995). Postpartum psychosis
presents in a sudden fashion, generally within the first two postpartum weeks. Should the
RN suspect any the symptoms consistent with the development of postpartum psychosis,
immediate intervention by the PCP is indicated.

Objective data

Prior to the completion of the screening protocol, the RN must review the clients
prenatal and hospital record for pertinent history information, which will aid in planning
of needed follow-up care (O’Hara, 1995). Risk factors such as treatment for current

depressive episode, past history of psychiatric disorder, the lack of support systems and

32

the occurrence of stressful life events are all predictor variables which may increase the
risk of the development of PPD (Gotlib et al., 1991). It is also important for the nurse to
note a less than optimal birth outcome. Women who have given birth to a stillborn
infant, an infant with a birth defect or had a traumatic birth experience may also be at risk
for the development of PPD (Beck, 1995).

If the client has pertinent risk factors, these must be taken into consideration along
with subjective findings when planning appropriate follow-up care. In some instances,
providing reassurance by means of a phone call to the new mother will be adequate
(Gruen, 1990). For women with extensive risk factors, such as treatment of current
depressive disorder or who experience the delivery of an infant with a birth defect, an
early follow-up appointment may be indicated with the client’s PCP (O’Hara, 1995).

Clinical decision making

The analysis of the gathered subjective and objective data will guide the RN in the
clinical decision making process. Women who exhibit the warning signs of PPD, as
assessed by the tool, will need appropriate follow-up. Appropriate follow-up care is
determined by the number of risk factors present for the development of PPD and the
level of distress displayed by the mother during the interview process.

Women who present with moderate to severe levels of low mood, lack of interest in
usual activities, or exhibit greater than three emotional or multiple somatic complaints
will require early office follow-up. The time-frame of the follow-up will be determined
upon consultation with the client’s PCP, as follow-up must be tailored to the client’s
symptoms. According to DSM-IV (1994) criteria, depressive symptomatology must be

present for at least two weeks to diagnose a depressive disorder. For women with more

33

mild symptoms, or for those women with multiple risk factors, but no perception of
distress during the interview, a follow-up phone call in one to two weeks by the clinic RN
to assess continued maternal adjustment is indicated. Should changes in maternal health
status occur, the RN will discuss the change with the client’s PCP and a further plan of
care will be formulated.

Plan of care

After the questionnaire is completed, the RN will ask if the mother has any further
questions and inquire regarding the scheduled date of the infant’s well-child check and
the mother’s six week postpartum check. The RN will develop an initial plan of care
based on the outcome of the assessment interview and any present risk factors. If
scheduled appointment dates are deemed inappropriate after the interview, the RN will
make adjustment in the appointments based on the guidelines stated in the protocol.
The RN will complete the documentation of the encounter tool labeled, Initial Postpartum
Contact and add the document to the client’s record for review of the primary care
provider prior to the mother’s six week postpartum check.
Implementation of the Protocol

Before the protocol can be effectively implemented, all clinic staff must be
adequately trained regarding the purpose of the protocol, have sufficient knowledge to
administer the protocol and understand the collaborative nature of the protocol. The APN
would be responsible for the training of the clerical, RN and provider staff, ensuring a
smooth implementation of the screening protocol.

In order to competently perform the screening protocol, the RN should be properly

educated in the normal postpartum changes experienced by women and their families.

34

The RN should be able to supply practical advice regarding infant care concerns, the
normal and expected course of postpartum symptoms such as fatigue, care of the
perineum or cesarean section incision, appropriate nutrition, as well as, guidelines for
activity and adequate rest. The RN should also have adequate knowledge of normal
newborn feeding, sleeping and elimination patterns, as well, as normal infant behavior to
answer questions the mother may have.

The APN will facilitate the assessment of the RN’s knowledge base through a pre-
test prior to the implementation of the protocol. The APN would then provide education
to the RN staff based on the areas of demonstrated weakness. A post-test would then be
provided to ensure adequate learning has occurred to facilitate successful completion the
protocol.

In order to implement the telephone screening protocol, the RN must also have the
ability to pick up verbal cues which may give valuable information regarding the
mother’s adjustment during the postpartum period. The RN needs to note the mothers
affect. Does she sound anxious and overwhelmed or content and in control? Is she
comfortable with answering the questions or does she seem preoccupied? These are the
affective nuances that the RN must be in tune with when questioning the mother
regarding her postpartum experience.

To ensure the RN staff is able to detect affective nuances and is able to provide a
line of questioning to obtain needed information from the client, the APN will institute a
role-playing exercise. The RN staff will take turns playing the role of the client and the
interviewer in a variety of hypothetical situations. This exercise would sharpen the RN’s

interviewing skills and provide a forum for discussion of how to best handle various

35

client interactions. Education on this topic is mandatory as the literature shows that many
women have difficulty verbalizing their concerns and do not feel they can express
negative emotion associated with their childbirth experience. Therefore, it is important
for the RN to pick up on cues which may signal a concern on the part of the mother
(Beck, 1995; Gruen, 1990).

The PCPs working within the clinic must also be trained as to the intent of the
protocol, their role in the care of patient based on the findings of the protocol and the
process by which the protocol will be implemented. The literature discusses the reality
that not all PCPs are aware of the problem of PPD or how to diagnose and manage the
disorder (Knops, 1993). PCPs should be familiar with the risk factors which may
predispose a client to the development of PPD, the presenting signs which may herald the
onset of the disorder as well as diagnosis and treatment strategies (O’Hara, 1995). The
APN may play a role in educating the clinic PCPs regarding the topic of PPD and act in
the role of consultant when needed.

The clerical staff must also be trained regarding the proper implementation of the
protocol from a process standpoint. The clerical staff will prompt the RN to complete the
follow-up call when the mother phones the clinic to schedule follow-up appointments for
her six-week postpartum check-up and the baby’s newborn check. The mothers are
informed at discharge from the hospital to contact their primary care provider within 24-
48 hours of arriving home (Stover and Marnejon, 1995). The clinic receptionist
scheduling the appointment will alert the RN of the mother’s contact. The receptionist
will complete the demographic data on the Initial Postpartum Contact tool and forward it

to the RN to implement the screening protocol.

36

The clerical staff will also monitor the number of clients who receive the telephone
screening protocol. At the end of each month the clerical staff will check the list of
clients who have delivered and do a chart audit to ensure that all eligible clients have
received the screen. This method of case management may also be used as a quality
assurance tool, to assess whether the system in place to notify the RN of the need to
implement the screen is reaching all eligible clients.

ELaluation of the Protocol

To evaluate the effectiveness of this screening protocol, a pilot study of the protocol
will be undertaken. According to Polit & Hungler (1995), it is important to test the
validity of the screening tool, ensuring the ability of the tool to measure what it is
designed to measure. As the use of screening tools in the primary care setting may help
to detect disease and provide early intervention, the efficacy of the screening tool must
first be tested in order to ensure the ability of the protocol to screen for a given disorder.
If screening tools are not valid, frequent false-positive responses will result in expensive
clinical work-up, wasting health care dollars (U SPSTF, 1996).

A pilot study of ten client encounters will be analyzed. The responses provided to
various questions of the screening protocol and the plans of care derived from the
encounter, based on the criteria set forth in the protocol would be monitored. Polit and
Hungler (1995), state that a pilot study will help assess the feasibility of a protocol and
determine if the questions are able to obtain needed information as written. Adjustments
to the protocol would be made on the basis of the information collected during the pilot

study.

37

The second aspect of the pilot study would be to gather information from the
individuals implementing the protocol, which may help to improve one or more aspects
of the project (Polit & Hungler, 1995). The RN administering the tool would be surveyed
to inquire about the ease of administration of the tool. Inquiry would be made as to
whether the questions were grouped in logical order and if the protocol flowed easily
from one topic to the next. The RN would also be questioned regarding the receptivity of
the mother to phone call. From the RN ’3 perspective, was the mother receptive to the
phone call or did she find the call intrusive?

Input should be received from the primary care providers to assess if the tool is able
to detect those women with depressive symptomatology. This feedback would provide
information regarding the reliability of the protocol, or the ability of the tool to detect the
physical and emotional components inherent in the development of PPD. Feedback
would also be elicited as to the quality of the information obtained as a result of the
screening questions asked of the client. Overall, information would be obtained from the
PCP’s perspective, to identify whether or not the tool was useful in making a diagnosis of
depression.

Finally, a patient satisfaction survey would be generated to assess the client’s
reaction to the phone call. Information would be elicited regarding the ability of the
client to understand the questions which were asked and feedback regarding the quality of
the information received would be obtained. Other survey questions would inquire
regarding the ability of the nurse to provide the new mother adequate education and

support related to adjustment issues of the early postpartum period.

38

Implications for the Advanced Practice Nurse
Implications for Practice

The development of a screening protocol to detect PPD in the primary care
population has important clinical implications for the practice of APN in the primary care
environment. The APN as a clinician in the primary care setting, must assess changes in
the status of his/her clients. As PPD has been described “mercurial”, making it difficult
for the mother to relay her symptoms, the protocol will allow the APN a basis of
comparison for future interactions with the client by providing a quantitative assessment
of the mother’s emotional concerns. The protocol will also assist the APN in formulating
an individualized plan of care according to the information obtained during the screen.
The implementation of the screening protocol will enhance the ability of the APN to
detect and diagnose PPD, ensuring early treatment for the client. Early treatment of
depressive symptomatology may help to decrease the functional limitations of the mother
associated with PPD and lessen the impact of the mother’s depression on the child.

The APN will also function in the role of consultant during the process of
implementation of the protocol. The literature shows that not all PCPs in the primary
care environment are aware of the incidence PPD or of the methods available to
effectively screen for the disorder (O’Hara, 1995). By acting as a consultant to other
PCPs, both within their own environment, as well as in other practice settings, an increase
in the incidence of screening for PPD may take place.

Implications for Education
The protocol can be also utilized as a tool to educate primary care staff regarding the

incidence, detection and treatment of postpartum affective disorders. The APN can

39

functions as a resource clinician for both primary care providers and ancillary clinic staff
in this endeavor. As overall rates of detection of PPD in the primary care setting are low,
the introduction of this screening protocol will help to heighten awareness of the
problem among a multi-specialty primary care staff.

Within the pediatric environment, the APN could educate staff regarding detection of
PPD in that setting. The pediatric PCP has the opportunity to periodically evaluate the
adjustment of the mother and family at designated well child check-ups. The pediatrician
may detect changes in the mother ability to perform care for herself or the ability of the
mother to care for her infant. Mothers may be noted as tearful, anxious or may be
sensitive to comments made by the provider that is perceived as “critical” of their
mothering skills. If these symptoms are present and PPD is suspected, the pediatric
department must have information regarding appropriate community resources to help the
mother cope and referral information to mental health specialists available within the
community.

Members of the internal medicine practice must be made aware of the incidence and
presenting factors associated with PPD. As the symptoms associated with PPD can
manifest anytime in the first postpartum year, affected women may present to internal
medicine practitioners with vague physical symptoms which may be difficult to
substantiate clinically. Common physical complaints of mothers who are suffering from
PPD include: headaches, gastrointestinal symptoms, as well as fatigue (Stowe &
Nemeroff, 1995).

As the incidence of screening for PPD needs improvement in the primary care

environment, the protocol could be used as a tool to educate both nursing and medical

40

students to increase their awareness of the problem of PPD. Future primary care
clinicians must understand the risk factors associated with the development of PPD.
Students must also have knowledge of the symptoms which herald the onset of the
disorder and the impact of the disorder on both the mother and child. Integration of the
information found in this protocol into the student’s coursework, would help to ensure a
solid knowledge base for the next generation of PCPs when screening women for PPD in
the primary care setting.

Finally, the information contained in the screening protocol could be a starting point
for the development of a prenatal classes to educate expectant parents regarding
adjustment issues during the postpartum period and the signs and symptoms associated
with the development of PPD. Expectant parents would be made aware of community
services available to help meet adjustment needs and become familiar with mental
services for reference if later issues develop. The prenatal classes would also serve as a
support group for new mothers in the community during the postpartum period.
Implications for Research

The development and implementation of a telephone screening protocol to detect
PPD in the primary care environment provides an opportunity for continued research on
the topic of the screening of postpartum women for depression. The APN would have the
opportunity to participate in the collecting of data to analyze research questions generated
by this protocol.

Once the validity and reliability of the protocol were established, the next step to
further test the protocol would be to pilot the tool in an alternate practice setting.

Validation of the protocol would take place in an urban and/or rural setting serving an

41

alternate population. Data collected would be analyzed to determine if the information
gathered by the protocol was able to detect depressive symptomatology in alternate
settings. The testing of the protocol with different client populations would increase the
ability to generalize the use of the tool to other practice environments, with varied
populations (Polit & Hungler, 1995). The ability to generalize the use of the tool to
alternate populations would enhance the utility of the tool for APNs who primary care
practice includes different client populations.

The second topic of investigation would focus on the rate of screening for PPD in the
primary care environment. Through the implementation of the protocol, the APN has
taken the opportunity to educate the clinic staff regarding PPD. A research study could
be undertaken to determine if the education provided to the staff PCPs regarding the
incidence, risk factors and the impact of disorder on the mother and the child, would lead
to an increase in the screening rate of postpartum women for depression in that particular
primary care environment. Detection rates of PPD by using this protocol could then be
tracked and compared to rates noted in the current literature. This study would help to
determine if the use of the protocol impacts the rate of depression detected in the primary
care setting.

Finally, the APN could participate in studies to assess the client outcomes associated
with the early telephone screening and detection of PPD in the primary care environment.
Longitudinal studies would be undertaken to investigate the course of those women who
receive screening and are ultimately diagnosed with PPD. Information would be gathered
to analyze the relationship between screening and early detection of depression and the

impact of depressive symptomatology on the mother and her family. Did the incidence of

42

early screening for PPD lead to the early treatment of depression in the mother? Did the
early treatment of PPD lead to an increase in the functional ability of the mother,
increasing the ability of the mother to perform continued self-care actions to meet her
own needs and dependent-care functions to meet the needs of her infant? Studies could
then be implemented to investigate whether early treatment for depression in the mother
decreases the cognitive and behavioral deficits in children that are associated with
maternal depression.

In summary, the development of a screening protocol to detect depression in the
postpartum women and the research questions generated by this protocol will enhance the
body of knowledge available to APNs in the primary care community related to the

screening and detection of PPD.

Conclusion

Due to the far reaching effects of PPD and the low rate of screening for this disorder,
the APN in the primary care setting needs a concise, reliable method to approach this
problem in daily practice. The development of a telephone screening protocol to detect
postpartum depression in the primary care population facilitates the ability of the APN to
detect depressive symptomatology and provide early treatment for this disorder during a
vulnerable time in a woman’s life. The protocol also provides an opportunity to facilitate
needed education for colleagues in the primary care environment regarding PPD, as well
as providing education to postpartum women and their families through the
implementation of the protocol. Finally, the telephone screening protocol is a means to

collect data to further add to the body of knowledge regarding PPD. Together these

43

factors ensure a holistic, client-centered, research based approach to the screening of

postpartum women for depression in the primary care setting.

APPENDIX A

44

APPENDIX A

Telephone Screening Protocol to Detect Postpartum Depression
(PPD) in the Primary Care Population

PURPOSE: To provide a mechanism to screen for symptoms associated with the
development of postpartum depression and provide the new mother with information
regarding normal adjustment issues inherent in the postpartum period.

GOAL: Through the process of screening, identify those mothers who may be at risk for
the development of PPD, to ensure early treatment of the disorder, decreasing the
matemal/infant functional limitations associated with depression.

FORMAT: Framed as a postpartum follow-up phone call, the protocol will be
administered by the clinic RN per phone, during the first ten days of the postpartum
period.

Introduction: I’m calling to see how you and your family are doing since you’ve
been home from the hospital with your new baby. I would like to ask you a series of
questions related to common concerns experienced by new mothers in the early
postpartum period and then answer any questions you may have. The interview
will take approximately ten minutes to complete.

Consent to participate: Is this a good time to talk? Confirm alternate date/time if
necessary.

SUBJECTIVE:

1. The first question will relate to physical concerns common to new mothers and
their babies during this time. Please answer “yes” or “no” to the following
questions:

Rationale: Increase somatic complaints, inability to rest related to anxiety, weight loss
or gain or multiple somatic complaints may indicate depressive symptomatology in the
mother.

The RN will inquire regarding the symptoms listed below. If the answer is positive the
RN will clarify the response in the comment section.

-<

N COMMENT
a. Do you have any concerns how your bottom is healing?
b. Is your baby breastfed?

c. Do you have any concerns regarding your breasts?

d. Are you able to eat three nutritious meals daily?

e. Are you able to obtain rest each day to avoid fatigue?

DElElElEl
DEIDDD

45

2. Do you have any concerns regarding the baby’s health?

Rationale: Over concern for the health of the infant/failure to thrive/ increased
fussiness may indicate risk A temperamental baby who is difficult to console may
increase perceived childcare stress in the mother, also increasing risk for PPD.

Y N COMMENT

a. Is your baby having difficulty feeding? Cl C]
b. Does your baby have 6-8 wet diapers daily? El Cl
C. Does your baby have difficulty sleeping? El El
d. Are you able to effectively calm baby? El El

11. The next section will focus on how you and your family are adjusting to the
addition of your baby in your family. Please answer “yes” or “no” to the
following questions:

Rationale: Lack of adequate social support or lack of spousal support, dissatisfaction
with primary intimate relationship and/or inappropriate expectations of mother may
indicate risk for the development of PPD.

Y N COMMENT

a. Is your partner willing and able to help

with child care and household duties ? D D
b. Does your partner have appropriate expectations

of mother/infant during postpartum period? D D
c. Are family members available to provide support? El El
d. Do you know two persons you can call upon

if help is needed? D E

III. Next, I would like to discuss some emotional concerns that new mothers may
have after they come home from the hospital. Please answer “yes” or “no”.
If the response is “yes”, please note the number of days in the last week the
feeling has been experienced: 1-2, 3-4 or 5-7 days.

Rationale: five or more symptoms, lasting 2 or more weeks, which are a change in
previous function such as increased fatigued, labile mood, anger, excessive guilt,
feeling anxious or overwhelmed, inability to concentrate, and/or lack of interest in
previously enjoyed activities may indicate depression per DSM-IV criteria.

1. Emotional concerns: # of days

a. Have you had crying spells or mood swings?
b. Have you been more irritable or more angry than usual?
c. Have you had feelings of anxiety or being overwhelmed?

 

ElElEJ "<
EIEIEI 2

46

Y N # of days
d. Have you had difficulty making decisions, concentrating,
thinking or getting things done? D D
e. Have you feelings of guilt or hopelessness? El El
f. Have you experienced low mood or the inability
to enjoy your previous activities? [3 El

A positive response to items c-f, indicates the need to assess the concept of suicidality.
Feelings of anxiety, difficulty concentrating, making decisions, experiencing feelings of
hopelessness or guilt are included in the diagnostic criteria for depression. Item f, has
been shown to be a reliable indicator of depression in the primary care population.

MSometimes when women feel depressed, they may have considered no longer
wanting to live.

Y N # days

a. Have you considered this thought in the last week? [II D

b. Have you ever considered harming your baby? E] El

c. Have you considered a plan to carry out these thoughts? El El

"If the mother answers yes to any of the above, immediate intervention by the PCP is
indicated.

Upon this line of questioning, does the mother exhibit signs of impaired reality testing or
appear unable to care for herself or her infant? If these elements of present, the nurse
must suspect the onset of postpartum psychosis. Again, immediate intervention is
indicated.

At the other end of the spectrum, should the mother only endorse mood swings and
increased irritability without associated physical, support or historical symptoms, the RN
may suspect maternity blues. The blues is best treated with support and reassurance.

OBJECTIVE:

Prior to the implementation of the screening tool, the RN must review the client’s
medical record for risk factors noted in prenatal history.

Rationale: History variables may predict those at risk for PPD: Current depression,
history of depression, first degree relative with depression, current stressful life events or
poor birth outcome (the birth of a still born infant, infant with a birth defect, or a
traumatic birth) may indicate risk for the development of PPD.

Please circle the objective risk factors noted:

Current depressive episode, history of prior depression, Family history of depression,
Stressful life events or Poor birth outcome.

Describe:

47

CLINICAL IMPRESSION/PLAN:

Circle the statement that best describes the client’s behavior; indicate follow up
appointment.

1. Concerns re: ability to hurt self or baby:
*affirmative response requires immediate intervention from primary care
provider. Depending severity of the symptoms presented, the PCP will provide
assessment in the office setting or will refer to a mental health provider.

2. Emotional concerns endorsed:
*Endorsement of 111(1) or more than three emotional concerns for greater than 3
days in the past week will require an office visit to assess the noted symptoms.
This appointment will be scheduled after consultation with the client’s PCP.

*Endorsement of 2 emotional concerns, or endorsement of multiple physical
concerns, lack of support or presence of other risk factors, require follow-up

phone call in one week per clinic RN.

3. No concerns noted:
*Six week postpartum visit as scheduled.

4. Education provided: List topics discussed.

RN SIGNATURE

APPENDIX B

48

APPENDIX B

INITIAL POSTPARTUM CONTACT

INTRODUCTION: I’m calling to see how you and your family are doing since you’ve
been home from the hospital with your new baby. 1 would like to ask you a series of
questions related to common concerns experienced by new mothers in the early
postpartum period and then answer any questions you may have. The interview will
take approximately ten minutes to complete.

SUBJECTIVE DATA:
1. The first questions relate to physical concerns common to new mothers and their babies
during this early postpartum period. Please answer “yes” or “no” to the following questions:

1. Do you have concerns related to your health?

Y N COMMENT
a. Do you have concerns how your bottom is healing? El El
b. Is your baby breastfed ? El Cl
C. Do you have concerns regarding your breasts? El El
(1. Are you able to eat three nutritious meals daily? El El
e. Are you able to obtain rest each day to avoid fatigue? El El
2. Do you have any concerns regarding your baby’s health?
Y N COMMENT
a. Is your baby having difficulty feeding? El El
b. Does your baby have 6-8 wet diapers per day? D El
c. Does you baby have difficulty sleeping? El El
d. Are you able to effectively calm baby? El El

11. The next section will focus on how you and your family are adjusting to life with
the addition of your baby, please answer “yes” or “no” to following questions:

Y N COMMENT
a. Is your partner willing and able to assist in childcare
and household duties?
b. Does your partner have appropriate expectations of
mom/infant in the postpartum period?
c. Are family members available to provide support?

d. Do you know two persons you can call upon to help
if needed?

DUDE]
DUDE!

111. Next, I would like to discuss some emotional concerns that new mothers may have
after they come home from the hospital. Please answer the questions “yes” or “no”.

49

If you respon “yes”, please note the number of days in the last week the feeling has been
experienced; 1-2, 3-4, or 5-7 days.

# of days
a. Have you had crying spells or mood swings?
b. Have you been more irritable or angry than usual?
0. Have you had feelings of anxiety/ feel overwhelmed?
d. Have you had difficulty thinking, making decisions
or getting things done?
e. Have you experienced feelings of hopelessness or guilt?
Have you experienced low mood or have you
lost interest in your previously enjoyed activities? D U
“Women who endorse a positive response to the above questions must answer :

EIIIIIIIEID"<
ElElEJElEIZ

2")

“Sometimes when women feel depressed, they may have considered no longer wanting

to live. Y N # of days
a. Have you considered this thought in the last week? El El
b. Have you considered a plan to carry out that thought? El Cl
C. Have you considered harming your baby? El El

OBJECTIVE DATA:

After review of the medical records; does the client have any risk factors related to the
development of PPD? Circle risk factor(s): History of prior depression, Family history of
depression, Stressfirl life events, Poor birth outcome

Describe:

CLINICAL DECISION MAKING/PLAN:
Circle the statement that best describes client’s behavior; indicate follow-up apmintment:

a. Concerns related to ability to harm self or baby?
*Immediate intervention by PCP indicated.

b. Emotional concerns related to increased risk for depression?
*Endorsement 111(1) or 3 or more emotional symptoms with or without other risk
factors require office evaluation after consultation with PCP.

*Endorsement of 2 emotional concerns, or endorsement of multiple physical
concerns, lack of support or presence of other risk factors, without emotional
distress require a follow-up phone call in one week per clinic RN.

c. No concerns noted at this time?
*Six week postpartum checkup as scheduled.

(1. Education Provided:
RN SIGNATURE

BIBLIOGRAPHY

50

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