corrected NRS 452

Running head: THE USE OF SCREENING TOOLS 1

The Use of Screening Tools to Identify Risk for Developing Postpartum Depression in

Postpartum Women

Jazmine Randolph, Andrea Ritchie, & Jelena Tomljenovic

Oakland University

THE USE OF SCREENING TOOLS 2

The Use of Screening Tools to Identify Risk for Developing Postpartum Depression in

Postpartum Women

Nurses hold a key role in identifying the risk for developing postpartum depression

(PPD) in postpartum women. However, the role of nurses in effectively serving pregnant and

postpartum women with the aim of reducing the prevalence of PPD is not yet fully integrated in

clinical environments. PPD is a significant health issue for postpartum women, affecting

approximately 13% of women and their families (Horowitz, Murphy, Gregory, & Wojcik, 2011).

PPD is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a

major depressive disorder that occurs during pregnancy or within four-weeks of childbirth (Iwata

et al., 2015). According to other medical experts, minor or major depression occurs within 12

months of childbirth may be considered as having PPD (Mitchell, Mittelstaedt, & Schott-Baer,

2006). Therefore, PPD can be thought of as depression that may occur for several months after

childbirth, even up to one year (Iwata et al., 2015). The significance of PPD to the nursing

profession is reflected not only in the fact that it affects roughly 13% of women, but also because

there is significant opportunity for improving nursing practice in the screening and caring for

women with PPD (Horowitz et al., 2011). Therefore, the ability of nurses to effectively screen

for risk factors and signs of depression among women within the first year after childbirth could

have a significant impact on the lives of women affected by PPD and their families. The impact

of PPD on infants is also significant, since it unfavorably impacts the mother's cognitive,

emotional, and communication abilities that lead to the inability to appropriately interact with

their child (Horowitz et al., 2011). Studies show that simple screening techniques when used by

nurses, such as telephone calls and mail surveys, may effectively identify women at risk for PPD,

yet these practices are not standard nursing practice (Iwata et al., 2015). The purpose of this


paper is to write an empirically based literature review related to the use of screening

tools/techniques by nurses caring for pregnant and postpartum women and its effects on the

incidence of PPD.

Review of the Literature

In a study by Mitchell et al. (2006), the purpose of the study was to assess the reliability

of telephone follow-up screening in identifying symptoms associated with PPD in women eight

weeks postpartum. Initially, 126 women provided consent to participate in the study before being

discharged from a Midwestern community hospital. However, after two months, the sample

consisted of 106 women, denoting a response rate of 84%. The study participants had to be at

least 18 years of age or an emancipated minor, able to be reached via telephone for follow up six

to eight weeks after hospital discharge, and English speaking. The study design was descriptive

correlational. Nurses obtained data during the postpartum hospital stay and eight weeks

following discharge. The initial data collection effort used a self-report demographic form

completed by the mother before leaving the hospital. The self-report form asked for the mother’s

age, marital status, employment information, number of prior pregnancies, personal and family

history of depression, and current medications. The mothers were also asked whether or not they

were experiencing an increase in anxiety during the postpartum period prior to hospital

discharge. There are two forms of the PDSS, a short-form consisting of seven-items and a long-

form with 35-items (inclusive of the seven-item short form), that utilized the Likert scale to

measure seven-subscales: sleeping/eating disturbances, anxiety/insecurity, emotional liability,

cognitive impairment, loss of self, guilt/shame, and contemplating harming oneself. Clients then

received follow-up phone calls at eight weeks postpartum; at this time nurses assessed the

mothers for symptoms of PPD using the long-form of PDSS. The full 35-item scale yielded an


overall severity score that fell into one of three categories. A score below 59 was deemed as

being negative for symptoms of PPD and also was considered to be an indicator of normal

postpartum adjustment (Mitchell et al., 2006). Scores of 60 or greater suggest a risk for minor or

major depression, and scores of 80 or greater confirm a high probability of major depressive

symptoms (Mitchell et al., 2006). The results indicated that 77 participants (73%) demonstrated

normal postpartum adjustment with a mean PDSS score of 44.1 (SD=6.5). 18 participants (15%)

had moderate depression with a mean of score of 70.0 (SD=6.2). 11 (9%) of the women screened

positive for severe depressive symptoms with a mean score of 97.1 (SD=14.6). Interestingly,

27% of well-educated and married women were identified as having symptoms of PPD. Overall,

27% of the 106 women studied had scores ranging from 60 to 128, which identified them as

having symptoms of moderate-to-severe depression. Participants who screened positive for

depressive symptomatology on the PDSS were given a referral to a mental health clinician and

urged to notify their current health care provider of the screening results. The study determined a

correlational value of r=.91 (p=<0.1) when comparing the first seven-items of the PDSS to the

remaining 28-items of the long-form (Mitchell et al., 2006). Mitchell et al. (2006) concluded that

telephone screening for symptoms of PPD is reliable mechanism to identify mothers at risk.

Mothers that have received previous treatment or are currently being treated for depression

should be screened for PPD.

In a study by Dindar and Erdogan (2007), the purpose was to evaluate the Turkish

women for the presence of PPD along with potential risk factors for symptoms of PPD. The final

sample consisted of 679 postpartum women in their first postpartum year from nine different

public health centers in Turkey. In total, 622 participants (97.5%) were married, and the

remaining 2.5% were divorced. The mean age of the sample was 26.7 years (SD=5.4) with


maternal ages ranging from 16 to 47 years of age. The study sample was made up of

predominantly unemployed, low-educated mothers, representative of the Turkish population

(Dindar & Erdogan, 2007). The study design used a descriptive random survey method. The

Edinburgh Postpartum Depression Scale (EPDS) is a self-report assessment tool that uses 10-

items to identify symptoms of depression, and then scores individual responses for a possible

score of 0-30. The participants of this study completed all questions in the EPDS in private and

without assistance. A risk factor questionnaire was used during home visits to obtain the

women’s PPD risk histories and detailed socioeconomic background data. The researchers

established an EPDS score of 12 as the cut-off point, detecting a sensitivity score of 0.84 from

screening and psychiatric interviews, along with a specificity of 0.88. Higher scores, those

greater than 12.0, are attributed to higher levels of distress. The results indicated high rates of

depression were identified at two months, eight months, 10 months and then again at 12 months

postpartum. Specifically, 41 or 6% of the women at one month postpartum reported depression

on the EDPS; 309 or 45.5% had depressive symptoms between two and six months; and 329 or

48.5% of women reported depression symptoms at seven to 12 months postpartum. Of the 679

women in the sample, 174 (25.6%) reported high levels of depression (e.g. scores of 12 or

greater on the EPDS). Only 29 of the women (4.5%) reported a score of zero on the EDPS,

whereas 53.3% (n = 362) had EDPS scores > 9. Several variables were identified as being

predictors for future depression: prior psychiatric illness, women who had lost a past baby,

lower-income women, and marital problems. The study identified a statistically significant

relationship (p = < .01) among women who had an unplanned pregnancy, women that used

tobacco while pregnant, or women unsatisfied with their physical appearance, and the scores

obtained from the EPDS assessment. Dindar and Erdogan (2007) concluded that a high


prevalence of PPD was found in Turkish postpartum women, indicating a significant need to

educate these women in both private and public health care environments regarding symptoms of

PPD.

Summary

In Summary, the literature reviewed indicated that nursing use of postpartum depression

screening tools is beneficial in identifying risk for the development of postpartum depression.

The Edinburgh Postpartum Depression Scale and the Postpartum Depression Screening Scale are

two reliable methods to screen for postpartum symptomatology.

Nursing Implications

The nursing implications related to the use of screening tools to identify risk for

developing postpartum depression in postpartum women are numerous. Women are often

hesitant to seek help for postpartum depression for numerous reasons and some may even ignore

and/or deny the signs (Dindar & Erdogan, 2007; Mitchell et al., 2006). The use of PPD screening

tools identifies risk factors for PPD in postpartum women without much effort on the patient’s

part. Nurses need to be advocates for postpartum women at risk for PPD by screening for PPD

and doing a thorough assessment of risk factors associated with PPD. When nurses identify risk

factors associated with PPD or PPD symptoms early, they can assist the women in getting the

appropriate care they need in a timely manner (Segre, O’Hara, Arndt, & Beck, 2010). However

this is not routine nursing care in the intra-partum setting (Mitchell et al., 2006). In order to

effectively screen postpartum women for risk of PPD it is vital to develop all labor and delivery

nurses’/midwives’ skills in identifying PPD in the use of screening tools, such as EPDS and the

PDSS (Dindar & Erdogan, 2007). The option of face-to-face screening, screening via-mail, or


telephone screening makes the screening processes more convenient for the patient (Mitchell et

al., 2006; Serge et al., 2010). Postpartum women who have a history of depression or abuse, or

are experiencing an increase in anxiety or irritability should be screened multiple times during

the first year, as should all postpartum women who are on medication for depression. All

postpartum women with a positive screen for symptoms of PPD should be referred for a

diagnostic interview and should be monitored for worsening of symptoms (Mitchell et al., 2006).

Nurses have the advantage of providing a continuum of care due to frequent contact with

postpartum women, so nursing interventions should include educating the patient about PPD,

providing instructions on what to do if their symptoms get worse, making referrals, and

providing counseling (Segre et al., 2010). More nursing research is needed to explore the use of

PPD screening tools on vulnerable populations in the United States, such as women in prison,

and women of diverse ethnicities and socioeconomic status (Mitchell et al., 2006).

Conclusion

In conclusion, the use of screening tools by registered nurses to identify risk for

developing PPD among postpartum women is effective and allows the patient to be diagnosed

early and receive necessary treatment in a timely manner. While nurses in the intrapartum setting

do not routinely use PPD screening tools, in order to provide evidence-based care to postpartum

women, nurses should receive proper training to develop the skills and knowledge necessary to

use PPD screening tools and accurately identify PPD. As patient advocates it is important that

nurses implement PPD screening into prenatal and postnatal care and provide postpartum women

with education, referrals, and counseling for PPD.


References

Dindar, I., & Erdogan, S. (2007). Screening of Turkish women for postpartum depression within

the first postpartum year: The risk profile of a community sample. Public Health

Nursing, 42(2), 297-308. doi:10.1111/j.1525-1446.2007.00622.x

Horowitz, J. A., Murphy, C. A., Gregory, K. E., & Wojcik, J. (2011). A community-based

screening initiative to identify mothers at risk for postpartum depression. Journal of

Obstetric, Gynecology & Neonatal Nursing, 40(1), 52-61. doi:10.1111/j.1552-

6909.2010.01199.x

Iwata, H., Mori, E., Tsuchiya, M., Sakajo, A., Maehara, K., Ozawa, H., … Tamakoshi, K.

(2015). Predicting early post-partum depressive symptoms among older primiparous

Japanese mothers. Japan Journal of Nursing Science, 12(4), 297-308. doi:10.111/

jjns.12069

Mitchell, A. M., Mittelstadet, M. E., & Schott-Baer, D. (2006). Postpartum depression: The

reliability of telephone screening. The American Journal of Maternal/Child Nursing,

31(6), 382-387.

Segre, L. S., O’Hara, M. W., Arndt, S., & Beck, C. T. (2010a). Nursing care of postpartum

depression, part 1: Do nurses think they should offer both screening and counseling?.

The American Journal of Maternal/Child Nursing, 35(4), 220-225.

doi:10.1097/NMC.0b013e3181dd9d81

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