How to improve?
How can we make better use of this scarce resource —
our time — with the postnatal population? The misuse
of the EPDS, the reliance on the score to the exclusion
of clinical judgement, is not helpful to our depressed mothers.
We also know that reliance on clinical judgement alone
doesn't work either: this is the misdiagnosis problem I
pointed out earlier(1). We need a reliable way
of systematically assessing maternal mood for every woman.
Evidence from Tessa Leverton and Sandra Elliott's study(7)
suggests that the systematic assessment by a health visitor
at six weeks, of a fed-up or depressed woman was a better
predictor of depression than the EPDS alone. But the combination
of the EPDS (at a 9/10 cut-off) together with systematic
assessment produced the highest sensitivity rating.
Given the right training and support I see no reason why
health visitors cannot use clinical judgement about mental
health in the way that other health professionals do. By
that I mean, in addition to the EPDS, making a systematic
clinical enquiry of every postnatal woman.
Clinical interview
In practical terms this means, in addition to preparing
the mother and ensuring privacy, allowing at least 10 minutes
for feedback from the EPDS and subsequent systematic augmentation
of it.
I have been helping health visitors over the past two to
three years to augment the EPDS by use of a clinical interview.
This involves going through the nine symptoms from DSM IV
to tease out more of the woman's experience and the effect
on her life, in particular the persistency and pervasiveness
of the depressive symptoms. This approach can easily dovetail
into the routine feedback from the EPDS and from this an
assessment of the mother's mood can be made.
Anecdotal evidence shows this has proved helpful. Depressed
women scoring under cut-off are being assessed as in need
of contracted support visits. Non-depressed women scoring
over cut-off have negotiated whatever help they find they
need. The health visitors using this approach are enthusiastic.
I am not knocking the EPDS. I find it a superb facilitator
for discussion at the emotional level. Where would we be
without it? I suspect still at the stage of believing that
only those in psychiatry can deal with PND.
Holden(4) et al have proved that we health visitors
can deliver the intervention effectively. But we need a
coordinated approach at primary level: not just management,
but detection, of PND. It is only right that this is rolled
out equitably across the country. Hopefully, the CPHVA's
Postnatal Depression and Maternal Mental Health Network
will make a substantial contribution to this end.
Sheelah Seeley
First published: CPHVA Conference Proceedings, October
2001; 16-19
References
1 Briscoe M Identification of emotional
problems in postpartum women by health visitors. British
Medical Journal 1986; 292 1245-1247
2 Seeley S, Murray L, Cooper PJ. The
outcome for mothers of babies of health visitor intervention.
The Health Visitor 1996; 69, 4, 135-138
3 Hearn G, Iliff A et al. Postnatal
depression in the community. British Journal of General
Practice 1998; 48, 1064-1066
4 Cox J, Holden J, Sagovsky R. Detection
of postnatal depression. Development of the ten-item Edinburgh,
Postnatal Depression Scale British Journal of Psychiatry
1987; 150, 182-186
5 Murray D, Cox JL. Screening for depression
during pregnancy with the Edinburgh Postnatal Depression
Scale (EPDS) Journal of Reproductive and Infant Psychology
1990; 8, 99-107
6 Murray L, Carothers AD. The validation
of the Edinburgh Postnatal Depression Scale on a community
sample. British Journal of Psychiatry 1990; 157,
288-290
7 Leverton T,Elliott S. Is the EPDS
a magic wand? Journal of Reproduc!ive and Infant Psychology
2000; 18, 4, 279-295
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