Postnatal depression

Research shows postnatal depression (PND) to be a relatively common problem often missed by health professionals which if undiagnosed can lead to greater problems in the future (Atkinson & Richel 1994, Cox 1989, Seeley 1996)

As part of the audit cycle started in December 1996 we set ourselves a task of establishing a practice protocol to make sure that all professionals in the PHCT are working towards the same standards of care. We felt it was important that the whole PHCT was involved and committed to the idea of identification of PND. Following the completion of the audit cycle started on Dec 1st 1998 a full protocol will be drawn up involving other professionals.

Antenatal

It is planned to introduce the topic of PND at the Health Visitors first contact with the mother-to-be. This may be at the early bird session at about 20 weeks, at parentcraft sessions and/or the home visit at 30-36 weeks.

During this antenatal period the HVs will be working with the midwives when discussing:

experiences and images of motherhood regarding realistic parenting
encouraging supportive relationship
education about postnatal disorder
introduction of EPDS as a tool for the early identification of PND. It shows women that I-IVs are interested in them and their well being not just the baby, and enables them to raise other topics not otherwise discussed
promoting continuity of care important

Home Visit

HV to visit mother antenatally at home 30 -36 weeks
introduction of EPDS (or reiteration for those who have attended parentcraft)
extra support visits if identified
risk assessment

This preparatory work in the antenatal period is followed up at the primary visit or during the visits in the first 6 weeks.
One of the HV aims will be to create a time which is mother-centred when the mother can talk about her own physical, emotional, psychological and social health

5-6 weeks postnatal

At a home visit 5-6 weeks postnatally the Edinburgh Postnatal Depression Scale will be given to the mother for her to complete. The score will be recorded on the sheet itself and a summary sheet kept by the HV.
The score is discussed by the mother and for HV intervention

See flow chart

10-16 weeks postnatal

EPDS will be repeated in the Child Health Clinic or at home. The score will be discussed with the mother and health visitor intervention as recommended in the flow chart

20-26 weeks postnatal

20-26 weeks postnatal HV will only use the scale opportunistically

Question 10 self harm - if score 1-3 some follow up to discuss in more depth the woman's response.
If there are concerns the GP to be informed especially if over a weekend.

Antenatal visit Discuss the realities of parenthood including the possibility of postnatal depression Explain the role of the HV and the EPDS Give PND handout, your telephone number and contact times
First postnatal visit Demonstrate interest in her emotional response to the birth experience and to motherhood Give info about EPDS, your telephone number and contact times
5-6 WEEKS: EPDS 1 ALL MOTHERS Home
Under 12 No action required		12 + discuss; if depressed offer a set number of weekly visits. Repeat EPDS after 2 wks Inform GP
10-16 WEEKS: EPDS 2 ALL MOTHERS Home or clinic
Under 12 No action required	12+ for 1st time: Discuss: if depressed offer set number of visits Inform GP	12+ after minimum of 4 extra visits Inform GP consider referral
20-26 WEEKS: EPDS 3 Opportunistically Home or clinic
Under 12 No action required	12+ for !st time: Discuss: if depressed offer set number of visits Inform GP	12+ after minimum of 4 extra visits Inform GP consider referral

EPDS is only a tool and is only as good as the people who use it. It should never override professional judgement

References

Atkinson A and Richel A (1984) Post partum depression in primiparous parents J of Abnormal Psychology 93 12 1-130
Cox J (1989) Can postnatal depression be prevented? Midwife Health Visitor and Community Nurse 25 8 326-9
Seeley S, Murray L, Cooper P, (1996) The outcome for mothers and babies of health visitor intervention Health Visitor 69 4 135-138

Links

Postnatal depression proforma

N.A.P.I. Guidelines for Post Natal Depression (Northumberland guidelines)

Management of postnatal depression