What resources will need to be put in place to ensure that your change project is sustainable at the organization after you leave? Who should you leave in charge of the change after you

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Postpartum Depression Prevention

Jany Dominguez

West Coast University

NURS 691B: Culminating Experience II

Dr. Tracy Macdonald

November 26, 2023

Postpartum Depression Prevention

One issue that affects many women who have recently given birth is changes in their emotional state. Over 70 percent of women experience what is commonly referred as the “baby blues” (Centers for Disease Control, 2023), a term used to encompass a range of physical and psychological symptoms that frequently manifest after giving birth. Symptoms including worry, anxiety, tiredness, and sadness can occur within 1 day after giving birth and can last up to two weeks However, for a substantial portion of women, these symptoms endure, leading to a diagnosis of postpartum depression (PPD). The Centers for Disease Control (CDC) reports that approximately 10-15 percent of women are affected by PPD, a noteworthy statistic given its profound impact on both the mother and the child (2023). Furthermore, PPD has an economic impact on society from the added costs of providing care for women and offspring throughout their lives. Luca et al. (2020) estimates the current cost of treating women and their offspring from birth to 5 years postpartum to be around $14 billion.

Interventions aimed at reducing the incidence of PPD can have a far-reaching benefits for both mother and child. Preventing PPD can improve the emotional, social, and economic aspects of women and their families. Furthermore, prevention of PPD reduces the economic burden of health systems and enhances overall public health.

The purpose of this project is to provide a framework for a change project aimed at reducing PPD through cognitive behavioral therapy interventions to be implemented at a OB/GYN clinic in the South Florida region. This proposal will include the following: a PICOT question, a literature review, project aims, values, and desired outcomes, conceptual and/or theoretical framework, interventions, and finally recommendations.

Proposed Project and PICO(T) Question

Problem Identification and Description

Although giving birth has a negative psychological impact on many women, it is often mild and transient. In contrast, PPD is a more serious condition both in severity and duration. Currently, PPD is characterized by depressive symptoms that align with the criteria for major depression, with their onset occurring within four weeks of childbirth, as indicated by Moldenhauer (2023).When left untreated PPD has the potential to become disabling and could lead to postpartum psychosis. Although its etiology is unknown, it is thought that changes in hormone levels after childbirth alongside sleep deprivation and prior/familial history of depression play a role (Shuman et al., 2022) . There are also several identified factors which can lead to PPD. Social factors, such as inadequate social support, financial stress, and relationship difficulties, can further exacerbate the risk (Moldenhauer, 2023).

Once identified, treatment includes antidepressant drugs alongside psychotherapy. Additionally anxiolytics can be used if anxiety is a major symptom. Although treatments exist, prevention and early identification is key. At medical offices and clinics that provide OB/GYN care to women, the overall strategy is to identify PPD after onset and treat it accordingly (Johnson et al., 2018).

Currently there are non-pharmacological interventions that can be implemented and are effective at preventing and reducing PPD. One such intervention is the use of Cognitive Behavioral Therapy (CBT). CBT has been shown to be an effective intervention for PPD and its implementation can be done by nursing professionals (Moldenhauer, 2023). Using proactive methods that focus on prevention is a more sustainable healthcare approach that can lead to positive outcomes for patients.

One barrier to the use of CBT in its current form is its face-to-face or in person delivery mode. For many patients, this modality makes it less than optimal due to time constraints and economic barriers for some (Fonseca et al., 2019). Furthermore, Fonseca et al., argue many clinics and medical offices do not have the infrastructure and resources to implement an in-person CBT delivery model (2019). This project aims to provide an alternative through implementation of CBT through mobile health (mHealth), specifically video conferencing to ameliorate some of the current barriers to implementation.

PICO(T) Question

In women at risk for postpartum depression, does the implementation of a six-session Cognitive-Behavioral Therapy (CBT) program over Zoom©, compared to standard prenatal care, result in a reduction of postpartum depression symptoms within a 6-week period?

· Population – women at risk for postpartum depression

· Intervention – six-session Cognitive-Behavioral Therapy (CBT)

· Control – standard prenatal care

· Outcome – decreased symptoms of postpartum depression

· Timeline – 6 weeks

Significance of Evidence-Based Project

PPD is of high relevance to medical professionals working in clinical settings such as obstetrics and pediatrics where they are most likely to encounter women who are at risk for PPD or suffering from PPD. It is therefore important for them to understand how to prevent, identify and treat these patients.

PPD is of clinical importance due to the long-term effects. Even when treated, many women with PPD continue to suffer from depression for years as well as suffering from anxiety disorders (Abdollahi & Zarghami, 2018). Women who suffer from PPD can also exhibit social difficulties, especially in partner relationships with many describing their relationships as cold and distant (Slomian et al., 2019). PPD is not only detrimental for women as it also affects the offspring. Mother to infant bonding is impaired and a depressed mother might not be able to provide a nurturing environment for children to develop.

A systematic review by Slomian et al. (2019) discovered that infants of women with PPD exhibited a possibility of compromised motor development, encompassing both gross and fine motor skills. Furthermore, it showed the offspring of women with PPD suffer from behavioral and cognitive deficits well into their adolescent years. This underscores the fact of PPD’s negative and long lasting consequences for both mothers and their children making it necessary to find effective ways to prevent and manage it.

Currently, clinicians aim to diagnose and treat PPD after its onset with very few making use of preventive strategies (Johnson et al., 2018). Using strategies that identify women at risk and prevent the incidence of PPD can greatly improve patient outcomes. Nursing professionals can play a role in the prevention and management of PPD.

As direct care providers, nurses often have direct and consistent contact with expectant mothers during the prenatal and postpartum care periods. As such, they are uniquely positioned to identify women at risk for PPD and women who are exhibiting symptoms of PPD. Nurses can provide essential emotional support, education, and resources to mothers, helping them understand the potential risk factors and coping strategies for PPD. Moreover, nurses can facilitate implementation of interventions aimed at preventing and managing PPD.

Although mental health interventions have usually been delivered as part of a face-to-face individual or group session, the latest research has shown that “digital therapy,” is an effective means of delivering mental health interventions. Nursing professionals could make use of technology to implement CBT in a more efficient manner.

Interventions to prevent PPD have the potential to improve the quality of life of mothers and their children. Women who suffer from PPD have long lasting effects primarily detriment to their mental health. Children of women with PPD also experience mental health issues throughout their lives. In general, PPD places a strain on society through increased costs of caring for these women and their children.

At present, there is a recognized need for additional research concerning the efficacy of PPD prevention programs delivered through mHealth platforms (Sun et al., 2019). This project is designed to evaluate the viability of utilizing mHealth for the delivery of evidence-based PPD prevention programs. The outcomes of this project may serve as a roadmap for the expanded adoption of PPD prevention via mHealth, potentially expanding the reach of these interventions to a greater number of women and, in turn, diminishing the occurrence of PPD.

Literature Review

Symptoms of PPD are the same as those for major depressive disorder with the only differentiating factor being the onset after giving birth. The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) defines PPD as a major depressive episode which onset is within 4 weeks of giving birth while The International Classification of Diseases, Tenth Revision (ICD-10) increases the onset time to 6 weeks. Currently the causes of PPD are unknown but it is thought that changes in hormone levels, and genetics play a role (Shuman et al., 2022). Psychological factors such as history of mental illness, negative attitudes towards the baby as well as risky pregnancies increase the risk of PPD (Mughal, Azhar, & Siddiqui, 2022). Societal factors also play a role with a lack of social support and living in an abusive household being causative factors. PPD is most common in teenage adolescent females, and low income women have a 50% higher chance of developing PPD when compared to middle-class women (Moldenhauer, 2023).

First line treatment of PPD is psychotherapy with the addition of Selective Serotonin Reuptake Inhibitors (SSRIs) when symptoms are moderate to severe (Moldenhauer, 2023). SSRIs and other antidepressants are not always effective and also carry adverse effects making many women, especially those breastfeeding hesitant to take them. Two drugs are currently approved specifically for the treatment of PPD. In 2019, the FDA approved brexanolone injection, which can only be administered at a healthcare facility due to adverse effects such as excessive sedation and loss of consciousness. In August of 2023, the FDA approved zuranolone, a fast acting treatment taken daily for 2 weeks and it is expected to be available at the end of the year (FDA, 2023)

Impact of PPD

Although the CDC states the incidence of PPD to be around 10-15%, it is thought these statistics are much higher due to many women being undiagnosed. Many women are reluctant to discuss these symptoms and it is thought that around 50% of women go undiagnosed making the percentage of women who suffer from PPD around 20% (Mughal, Azhar, & Siddiqui, 2022). PPD incurs additional costs in the form of medical care, drug costs, and time loss from work. One U.S. study estimates the cost of mood and anxiety disorders in pregnant women including PPD from birth to 5 years postpartum is $14 billion (Luca et al., 2020). Newly released data has shown during the COVID-19 epidemic rates of PPD increased but there it is unknown whether these numbers remain now that the pandemic has officially ended.

Even when treated, women who experienced PPD have long lasting effects. Many women suffer from chronic depressive disorder and a minority can develop bipolar disorder, and/or substance abuse (Slomian et al., 2019). Suffering from mental illness leads to negative impacts in daily living and work. It also strains the relationships with family members, friends, and partners eroding the social support system these women need in their lives. PPD affects not just the mother but those around her, especially the newborn as multiple studies have shown these children are also affected throughout their lives.

There is a high degree of emotional distance that occurs between a depressed mother and her child which affects the mother-infant bonding leading to insecure attachment in the child (Slomian et al., 2019). It has been shown that children who exhibit insecure attachment patterns suffer from anxiety and have difficulties creating healthy relationships with others. During early childhood, children of mothers with PPD can develop behavioral problems and learning disabilities. The most common problem for these children is language development (Mughal, Azhar, & Siddiqui, 2022). Language development deficiencies impact a child’s performance while in school and into their adult lives.

PPD is a condition which effects are long lasting both for the mother and the child, causing a variety of hardships leading to a reduction in quality of life. As such, it is important to screen mothers for PPD and commence treatment as soon as possible. More importantly, an emphasis on prevention rather than treatment could have a meaningful impact for sufferers of PPD.

Screening

Prevention of PPD involves identifying women at risk. For this effort, screening tools must not only be effective but also easy to use by medical personnel who provide care during pregnancy. Although there are a number of screening methods, their effectiveness varies depending on factors such as the age of the person being screened, and their symptoms (Asgarlou, Arzanlou, & Mohseni, 2021). It is therefore important for healthcare providers to choose a screening tool carefully and choose more than one screening method to identify women at risk or suffering from PPD. Because PPD can manifest both emotionally and physically, screening for both symptoms can increase the ability to identify PPD. Currently the American College of Obstetricians and Gynecologists’ Committee recommends using two screening tools: the Edinburgh Postnatal Depression Scale (EDPDS) and the Patient Health Questionnaire-9 (PHQ-9). The EDPDS screens for psychological symptoms such as anxiety and feelings of sadness while PHQ-9 screen for fatigue, energy loss, and changes in sleep patterns (Asgarlou, Arzanlou, & Mohseni, 2021). Both tools are 10 item questionnaires that can be done quickly during office visits. Their effectiveness and ease of use make them appropriate tools in the medical office/clinic where time available for each patient is usually compromised.

Prevention

Interpersonal psychotherapy, SSRIs, and cognitive behavioral therapy (CBT) have been found effective in the prevention of PPD. Out of the three, CBT has been shown to be most effective (Sun et al., 2019). CBT teaches patients to identify and challenge dysfunctional thoughts and behaviors (Moldenhauer, 2023). The fact that CBT teaches a patient how to deal with their emotions gives them tools they can use in the future making it a valuable tool for healthcare professionals as patients learn self-regulatory skills that could be of help in future pregnancies and/or transferred to other problems in their daily lives.

One program that is effective in preventing PPD is the ROSE (Reach Out, Stay Strong, Essentials for new mothers). This evidence based program consists of four group sessions where women are taught about social support, relaxation techniques, psychoeducation on relationships, assertiveness, communication, and goal setting. A fifth individual session reviews symptoms of depression and identifies individual problems. Randomized clinical trials (RCTs) have shown ROSE to decrease rates of PPD by up to 50% (Johnson et al., 2018). This program is relatively easy to implement and it can be delivered by many professionals in the clinical setting including nursing professionals and medical assistants. This makes ROSE a valuable tool for providers who might not have access to an onsite therapist.

Although CBT has been proven to be effective, a face-to-face delivery creates barriers both for the patient and the provider making it less than optimal for many. For the provider, a face-to-face CBT model might be difficult to implement due to a lack of time and/or employees trained to deliver it (Fonseca et al., 2019). In the U.S., providers often care for many patients leaving them with very little time to implement CBT. Additionally, nursing professionals are also task with many responsibilities in their day-to-day schedule making the delivery of CBT difficult. A simple solution would be to hire a team to implement CBT but that might not be financially feasible for most providers.

On the patient’s part, barriers in accessing face-to-face CBT are other responsibilities such as family and work making it hard to attend scheduled sessions. There is also an economic component with many women not being able to afford insurance copays. Low income women are at highest risk for PPD yet they have the lowest rates of attendance to CBT programs when available (Johnson et al., 2018). The stigma around PPD and mental illness in general creates another difficult barrier as some women might be unwilling to attend sessions due to cultural beliefs and the societal expectation of motherhood as the happiest time in a woman’s life.

Over the last few years there has been a focus on delivering medical services using technology. The COVID-19 pandemic has only accelerated the delivery of healthcare services over phone apps, video conferencing, and texts. Mobile health (mHealth) has been successfully used to deliver a variety of healthcare services and many insurance companies currently offer mHealth as a cheaper alternative for doctor visits. mHealth is proven effective in the delivery of mental health visits and therapy (Fonseca et al., 2019). mHealth could be an effective strategy in overcoming the barriers that often lead to low compliance in face-to-face CBT. mHealth provides a flexible, convenient, and private option for women who might otherwise be unable to take part.

mHealth for PPD – Knowledge Gaps

Although CBT aimed at preventing PPD could be effectively delivered over mHealth, there is no concrete evidence that it is a viable alternative. It is generally assumed that because mHealth based CBT is effective for other mental health conditions, then it can be used for PPD prevention. Although there are some studies that have shown that CBT delivered over other means besides a face-to-face setting there is not enough evidence to fully support it. Sun et al., (2019) argued clinical effectiveness of using mHealth to deliver CBT must be better evaluated through RCTs.

Further research into this method is required to assess the effectiveness of alternative delivery of CBT in improving and preventing PPD in women. Validating this approach could help to care for a larger number of women who might otherwise not be willing to participate or who do not have the means due to financial instability or living in areas where prenatal care is limited. Nursing professionals are able to partake in this research and help to develop effective alternatives to improve patient outcomes.

PPD is a significant concern with far-reaching consequences for mothers, children, and society. Preventive strategies, such as effective screening and the use of interventions like CBT and innovative approaches like mHealth, hold promise in mitigating its impact. Nursing professionals play a crucial role in researching and implementing these strategies, ultimately improving patient outcomes and the overall quality of life for women facing PPD.

Project Aims, Values, and Desired Outcomes

This project aims to overcome barriers in delivering CBT for PPD by utilizing video conferencing. The focus is on accessibility, especially for high-risk groups and offering a low-cost tool for providers. The initiative seeks to assess the effectiveness of CBT over Zoom©, contributing to knowledge on mHealth interventions. It also aims to collect participant feedback to refine the intervention. The project values reducing PPD rates and facilitating women’s participation in CBT to diminish the risk for developing PPD.

Project Aims

Despite the fact that CBT has been proven effective in the treatment of PPD, barriers to delivery exist for both healthcare providers and patients. Sun et al.(2019), found many healthcare professionals lack the resources to deliver face-to-face CBT due to the time constraints. For patients, day-to-day responsibilities might cause them to miss CBT sessions diminishing the effects of these interventions. This is most evident for high risk patients like low income women and teenage mothers who could benefit the most but have the lowest rates of completion (Johnson et al., 2018). This project aims to ameliorate these barriers through implementation of CBT over a video conferencing setting making it more accessible to women.

Although the use of this technology, often termed mHealth, has been shown to be effective in delivering a variety of mental health interventions, its effect on the prevention of PPD has not been fully established. Current data is promising but further studies are needed to validate the clinical effectiveness of alternative methods of delivering CBT (Zhou et al., 2020). Another aim of this change project is to assess the viability and effectiveness of delivering CBT over Zoom©. This project aims to add to the current body of knowledge regarding the use of mHealth, specifically video conferencing in increasing participation in CBT and decreasing rates of PPD. This project also aims to collect subjective information from participants to improve future CBT sessions.

Because this project will take place over video conferencing means it could be delivered by one or two individuals and being only a six session intervention, it should not require long hours to complete. Many CBT programs for PPD prevention and treatment offer free training and materials making them easy to implement from an economic standpoint. For this project, major expected expenses are IBM SPSS statistics program and a paid Zoom subscription to conduct video conferencing. Benefits of this project is the availability of CBT for women whom might otherwise not be able to attend face-to-face sessions. For providers and health clinics, this project could provide a low cost intervention for decreasing PPD.

Values

The main value for this project is using CBT to decrease the rates of PPD by teaching women skills to deal with the physical and mental demands of pregnancy. Another value for the project is to facilitate the participation of women in CBT sessions. As previously discussed, some women find it difficult to attend face-to-face sessions and providing them with an alternative that works around their personal lives can increase the number of women who participate. Participating in CBT for PPD has the added effect of teaching women strategies they can apply to other problems in their lives and gives them tools to deal with stress in future pregnancies further preventing the incidence of PPD. For practitioners, the value of this project is the ability to improve the health of mothers and their children by improving their care to prevent incidence of PPD.

Desired Outcomes

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