• Registered Nurses Association of Ontario (RNAO). Interventions for postpartum depression. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Apr. 92 p. [231 references]

This is the current release of the guideline.

Postpartum depression

Counseling
Evaluation
Management
Prevention
Risk Assessment
Treatment

Family Practice
Internal Medicine
Nursing
Obstetrics and Gynecology
Psychiatry
Psychology

Advanced Practice Nurses
Nurses

To present nursing best practice guidelines for the confirmation, prevention, and treatment of mothers with depressive symptoms in the first postpartum year

Women with or at risk of postpartum depression

Evaluation/Risk Assessment

1. Edinburgh Postnatal Depression Scale (EPDS)
2. Assessment for self harm ideation/behaviour

Prevention

1. Psychosocial and psychological interventions including supportive home visits, antenatal and postnatal classes, lay home visits, early postpartum follow-up by family physicians, midwifery-led debriefing, and continuity of care provided by midwives.

Management/Treatment

1. Provide supportive weekly interactions, using non-directive counseling
2. Facilitate peer support
3. Facilitate family involvement in care
4. Promote self-care activities

• Risk and rates of postpartum depression
• Morbidity associated with postpartum depression
• Reliability of the Edinburgh Postnatal Depression Scale (EPDS) at identifying women with depressive symptoms
• Effectiveness of interventions at reducing or preventing symptoms of postpartum depression

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

A database search for existing postpartum guidelines was conducted by a university health sciences library. An initial search of the MEDLINE, Embase, and CINAHL databases for guidelines and articles published from January 1985 to July 2004 was conducted using the following search terms: "practice guideline(s)," "clinical practice guideline(s)," "standards," "consensus statement(s)," "consensus," "evidence based guidelines," and "best practice guidelines." After the scope of the guideline was established, a search was guided by the identified clinical questions and using the following search terms: "Postpartum depression, postnatal depression, puerperal depression, post-partum depression, post-natal depression. Combined with search strings using 'maximum sensitivity' approach for aetiology and therapy".

One individual searched an established list of Web sites for content related to the topic area. This list of sites, reviewed and updated in July 2004, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The Web sites at times did not house a guideline but directed to another website or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/email.

A Web site search for existing postpartum depression guidelines was conducted via the search engine "Google," using the search terms identified above. One individual conducted this search, noting the search term results, the Web sites reviewed, date, and a summary of the findings. The search results were further critiqued by a second individual who identified guidelines and literature not previously retrieved.

Additionally, panel members were already in possession of a few of the identified guidelines as well as literature on the topic area.

This above search method revealed two guidelines, several systematic reviews, and numerous articles related to postpartum depression.

The final step in determining whether the clinical practice guideline would be critically appraised was to have panel members screen the guidelines based on the following criteria. These criteria were determined by panel consensus:

• Guideline is in English
• Guideline is dated no earlier than 1999
• Guideline is strictly about the topic area
• Guideline was evidence-based, e.g., contained references, description of evidence, sources of evidence
• Guideline is available and accessible for retrieval

Two guidelines met the screening criteria and were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE Collaboration, 2001) instrument.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Not stated

Expert Consensus

In June of 2004, a multidisciplinary panel with expertise in practice, education, and research from hospital, community, and academic settings was convened under the auspices of the Registered Nurses Association of Ontario (RNAO). At the outset, the panel established the scope of the guideline through a process of discussion and consensus. It was decided to focus on the confirmation of depressive symptoms among postpartum women and the implementation of effective prevention and treatment interventions.

Through a structured literature search, guidelines related to postpartum depression were identified and critically appraised. Following the review of these identified guidelines, a search for existing literature on the identified clinical questions was conducted, details of which are found in Appendix B in the original guideline document. A Master's prepared nurse with expertise in critical appraisal completed a preliminary quality appraisal of the literature for each delineated question. With guidance by the Team Leader, the panel members then divided into subgroups to address one question, and the preliminary critical appraisal was used to focus the literature review. Based on the evidence available, draft recommendations were developed. The development panel as a whole reviewed the recommendations and, through discussion and consensus, presented a draft guideline.

Not applicable

A published cost analysis was reviewed.

External Peer Review
Internal Peer Review

A draft of the original guideline document was distributed to external stakeholders for review. As noted in the acknowledgment section, the stakeholders represented various healthcare professionals as well as clients. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel -- further discussion and consensus resulted in revisions to the draft document prior to publication.

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.

Practice Recommendations

Prevention

Recommendation 1.0

Nurses provide individualized, flexible postpartum care based on the identification of depressive symptoms and maternal preference.

(Level of Evidence = Ia)

Recommendation 2.0

Nurses initiate preventive strategies in the early postpartum period.

(Level of Evidence = Ia)

Confirming Depressive Symptoms

Recommendation 3.0

The Edinburgh Postnatal Depression Scale (EPDS) is the recommended self-report tool to confirm depressive symptoms in postpartum mothers.

(Level of Evidence = III)

Recommendation 4.0

The EPDS can be administered anytime throughout the postpartum period (birth to 12 months) to confirm depressive symptoms.

(Level of Evidence = III)

Recommendation 5.0

Nurses encourage postpartum mothers to complete the EPDS by themselves in privacy.

(Level of Evidence = III)

Recommendation 6.0

An EPDS cut-off score greater than 12 may be used to determine depressive symptoms among English-speaking women in the postpartum period. This cut-off criterion should be interpreted cautiously with mothers who 1) are non-English speaking; 2) use English as a second language, and/or 3) are from diverse cultures.

(Level of Evidence = III)

Recommendation 7.0

The EPDS must be interpreted in combination with clinical judgment to confirm postpartum mothers with depressive symptoms.

(Level of Evidence = III)

Recommendation 8.0

Nurses should provide immediate assessment for self harm ideation/behaviour when a mother scores positive (e.g., from 1 to 3) on the EPDS self-harm item number 10.

(Level of Evidence = IV)

Treatment

Recommendation 9.0

Nurses provide supportive weekly interactions and ongoing assessment focusing on mental health needs of postpartum mothers experiencing depressive symptoms.

(Level of Evidence = Ib)

Recommendation 10.0

Nurses facilitate opportunities for the provision of peer support for postpartum mothers with depressive symptoms.

(Level of Evidence = IIb)

General

Recommendation 11.0

Nurses facilitate the involvement of partners and family members in the provision of care for postpartum mothers experiencing depressive symptoms, as appropriate.

(Level of Evidence = Ib)

Recommendation 12.0

Nurses promote self-care activities among new mothers to assist in alleviating depressive symptoms during the postpartum period.

(Level of Evidence = IV)

Recommendation 13.0

Nurses consult appropriate resources for current and accurate information before educating mothers with depressive symptoms about psychotropic medications.

(Level of Evidence = IV)

Education Recommendations

Recommendation 14.0

Nurses providing care to new mothers should receive education on postpartum depression to assist with the confirmation of depressive symptoms and prevention and treatment interventions.

(Level of Evidence = III)

Organization and Policy Recommendations

Recommendation 15.0

Practice settings establish local care pathways and protocols to guide practice and to ensure postpartum mothers with depressive symptoms have access to safe and effective treatment.

(Level of Evidence = III)

Recommendation 16.0

Practice settings provide orientation and continuing education related to the care of postpartum mothers experiencing depressive symptoms.

(Level of Evidence = IV)

Recommendation 17.0

Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:

• An assessment of organizational readiness and barriers to education.
• Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
• Dedication of a qualified individual to provide the support needed for the education and implementation process.
• Ongoing opportunities for discussion and education to reinforce the importance of best practices.
• Opportunities for reflection on personal and organizational experience in implementing guidelines.

In this regard, Registered Nurses Association of Ontario (RNAO) (through a panel of nurses, researchers, and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the Registered Nurses Association of Ontario guideline Interventions for Postpartum Depression.

(Level of Evidence = IV)

Definitions:

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

A clinical algorithm is provided in the original guideline document for a sample care pathway.

The type of evidence is provided for each recommendation (see "Major Recommendations" field).

• Nurses, educators, administrators, and other health care professionals who are leading and facilitating practice change will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment, and documentation tools.
• Flexible, supportive home visits provided by a health professional postnatally is a promising intervention that may have a preventive effect
• The Edinburgh Postnatal Depression Scale (EPDS) has been shown to reliably identify women with depressive symptoms.
• The Edinburgh Postnatal Depression Scale has good sensitivity and specificity as an indicator of depressive symptoms when the recommended cut-off score greater than 12 is used in the postpartum period.
• Support provided by lay people who have experienced a similar health problem or stressor has been shown to have a positive effect on psychological well-being.

Not stated

• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability or discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them, nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• It is acknowledged that the individual competencies of nurses vary across categories of nursing professionals and depends upon their scope of practice. Knowledge, skills, attitudes, critical analysis, and decision making are enhanced over time through education and experience. It is expected that individual nurses will perform only those assessments and interventions for which they have the appropriate knowledge and skill set. Furthermore, it is imperative that nursing professionals seek appropriate consultation in instances where the mother's care needs require a multidisciplinary approach. It is also important to note that a diagnosis of postpartum depression can only be established by a clinical diagnostic interview completed by a trained mental health specialist. This guideline has been conceptualized within the scope of nursing practice. As the etiology of postpartum depression is multifactorial, diverse interventions provided by other health professionals may also be required. As such, it is acknowledged that effective healthcare depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and mothers while including maternal preferences and needs. Furthermore, postpartum care in Ontario varies across geographical locations and the provider of services. Currently, women who have given birth vaginally are typically discharged from hospital within 48-hours of delivery. Due to shorter length of stay, much of the responsibility of care in the postpartum period is delivered by community health providers in a variety of settings (e.g., clinics, family practice, community facilities, and client's home).

Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. In this light, Registered Nurses Association of Ontario (RNAO), through a panel of nurses, researchers and administrators has developed the Toolkit for Implementation of Clinical Practice Guidelines (2002) based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a healthcare organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment, and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

Evaluation and Monitoring

It is recommended that organizations implementing this nursing best practice guideline consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on a framework outlined in the Registered Nurses Association of Ontario Toolkit: Implementation of Clinical Practice Guidelines (2002d) illustrates some indicators for monitoring and evaluation.

Implementation Strategies

The RNAO and the guideline development panel have compiled a list of implementation strategies to assist healthcare organizations or healthcare disciplines who are interested in implementing this guideline. A summary of these strategies can be found in the original guideline document.

Getting Better
Staying Healthy

Effectiveness
Patient-centeredness

• Registered Nurses Association of Ontario (RNAO). Interventions for postpartum depression. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Apr. 92 p. [231 references]

The Registered Nurses Association of Ontario (RNAO) panel selected the following guidelines to adapt and modify for the current guideline:

• British Columbia Reproductive Care Program (2003). Reproductive mental illness during the perinatal period. British Columbia Care Program [Electronic version].
• Scottish Intercollegiate Guidelines Network (2002). Postnatal depression and puerperal psychosis. Scottish Intercollegiate Guidelines Network [Electronic version].

2005 Apr

Registered Nurses' Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Guideline Development Panel Members:

Cindy-Lee Dennis, RN, MScN, PhD
Team Leader
Assistant Professor
Faculty of Nursing
University of Toronto
Toronto, Ontario

Sue Bookey-Bassett, RN, BScN, MEd
Project Manager
Near Miss Study, University of Toronto and Independent Consultant
Oakville, Ontario

Donna Bottomley, BA, MSW, RSW
Perinatal, Obstetrical & NICU Social Worker
Ottawa Hospital
General Campus
Ottawa, Ontario

Barbara Aileen Bowles, RN, BSN, PNC(C)
Staff Nurse
Maternal Child Family Centre
St. Catharines General Site
Niagara Health System
St. Catharines, Ontario

Judi DeBoeck, RN, BA CHPE
Public Health Nurse
Mother Reach Program
County of Oxford
Public Health & Emergency Services
Woodstock, Ontario

Marilyn Evans, RN, PhD
Assistant Professor
School of Nursing
University of Western Ontario
London, Ontario

Denise Hébert, RN, BScN, MSc
Family Health Specialist
Healthy Babies, Healthy Children Program
Ottawa Public Health
Ottawa, Ontario

JoAnne Hunter, BScN, MHSc, RN(EC)
Primary Care Nurse Practitioner
Family Health Centre
University Health Network
Toronto, Ontario

Stephanie Lappan-Gracon, RN, MN
RNAO Program Staff
Facilitator, Program Coordinator
Nursing Best Practice Guidelines Program
Registered Nurses Association of Ontario
Toronto, Ontario

Elizabeth McGroarty, RN, COHN(C) COHN-S, CRSP, Cert HRM
Occupational Health Consultant
Myriad Services
Toronto, Ontario

Karen McQueen, RN, BScN, MA(N)
Assistant Professor
Faculty of Nursing
Lakehead University
Thunder Bay, Ontario

Phyllis Montgomery, RN, MScN, PhD
Associate Professor
School of Nursing
Laurentian University
Sudbury, Ontario

Lori Ross, PhD
Research Scientist
Women's Mental Health & Addiction Research Section
Centre for Addiction & Mental Health
Toronto, Ontario

Marcia Starkman, MSN, RN, CS
Nurse Psychotherapist
Postpartum Partnership
Richmond Hill, Ontario

Sharon Thompson, RN, BScN
Nurse -- Counsellor
Women's Health Centre
St. Joseph's Health Centre
Toronto, Ontario

Ulla Wise, RN, MN
Public Health Nurse -- Mental Health Specialist
Toronto Public Health
Toronto, Ontario

Bonnie Wooten, RN, MPA
Program Manager
Family Health Services
Middlesex-London Health Unit
London, Ontario

Declarations of interest and confidentiality were made by all members of the guidelines development panel. Further details are available from the Registered Nurses Association of Ontario (RNAO).

This is the current release of the guideline.

None available

This summary was completed by ECRI on July 12, 2005. The information was verified by the guideline developer on July 18, 2005.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses Association of Ontario (2005). Interventions for postpartum depression. Toronto, Canada: Registered Nurses Association of Ontario.