Recognizing and Screening for Postpartum Depression in Mothers of NICU Infants

Adv Neonatal Care. 2003;3(1)

Predictors of PPD

Identifying reliable predictors of PPD is a critical step in early detection, support, referral, and appropriate treatment for this devastating disorder. Beck conducted a meta-analysis of 84 studies published in the 1990s to identify significant risk factors of PPD and recently updated this list of predictors.^[17] Thirteen significant predictors (P < 0.001) for PPD were identified ( Table 1 ).

Based on this meta-analysis, the PPD Predictors Inventory (PDPI)^[18] was developed and recently up-dated and published in the form of the PDPI-Revised.^[19] For a complete copy of the instrument, see the related Family Screening Tool, "Screening for PPD," in this issue. The PDPI-Revised is an inventory of 13 predictors, in the form of questions, that is designed to be used as a screening tool in a guided interview format.

The PDPI-Revised tool can help evaluate the pre-existing risks for PPD and can be used during pregnancy and in the postpartum period. This inventory was not designed and has not been tested as a self-report checklist. It is designed to be administered during an interview with a clinician. Once complete, the inventory can serve as a basis for both referral and interventions. It identifies individual vulnerabilities for which specific interventions can be initiated.

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Table 1. Significant predictors for PPD
Prenatal depression Low self-esteem Childcare stress Prenatal anxiety Life stress Low social support Poor marital relationship History of previous depression Difficult infant temperament Maternity blues Single marital status Unplanned/unwanted pregnancy Low socioeconomic status

Table 2. Interpretation of the PDSS total score
PDSS Total Score Range	Interpretation	Implications for Practice
35-59	Normal adjustment	Women who score in this range generally do not need to be referred for psychiatric evaluation, unless there is a strong indication of significant depression or other psychopathology from another source of information. Provide basic information about PPD and postpartum adjustment, perhaps in the context of explaining the purpose of PDSS. It is also advisable to readminister the PDSS every 3 months during the first 12 months after delivery to provide continued screening for PPD.
60-79	Significant symptoms of PPD	Some, though not all, of the women scoring in this range are in need of formal psychiatric evaluation. In deciding whether to refer a woman in this range for further evaluation consider the following: The woman's medical and psychiatric history. Feedback from significant others. Assess for evidence that the woman poses a danger to herself or to others, and refer immediately for psychiatric evaluation. Discuss your assessment with the multidisciplinary team. Good clinical judgment will dictate whether a psychiatric referral is appropriate for a woman in this range. Other useful interventions that may reduce the risk for exacerbation of depression include the following: Education and anticipatory guidance regarding PPD. Review treatments for depression (eg, psychotherapy, medication). Provide practical advice on what the woman should do if she feels her mood worsen (eg, how to access specialists in the treatment of PPD). Provide a list of local new-mother and PPD support groups. It is advisable to readminister the PDSS to the woman at all of her subsequent contacts with the health care system during the first 12 months after delivery.
80-175	Positive screen for major PPD	Although this is not equivalent to a DSM-IV diagnosis of Major Depressive Disorder With Postpartum Onset, it does indicate a high probability that the woman has this disorder. Refer to the mental health team for further assessment and treatment as soon as possible. Refer immediately to the emergency psychiatric services if there is indication of danger to self (eg, elevation of the PDSS Suicidal Thoughts scale) or to others. Note: Whenever the PDSS Total score is elevated above the range of normal adjustment, it is useful to examine the scores for the symptom content scales to characterize the pattern of symptoms for an individual respondent.

Table 3. Web resource list for postpartum depression
Web Site	Internet Address	Description of Contents
Depression After Delivery (D.A.D.)	www.depressionafterdelivery.com Depression After Delivery, Inc. 91 East Somerset Street Raritan, NJ 08869 1-800-944-4773 (4PPD) (Information Request Line)	Depression After Delivery, Inc. (D.A.D.) is a national nonprofit organization founded in 1985 by Nancy Berchtold after experiencing her own postpartum complications. It was formed to provide support for women with PPD, postpartum psychosis, and the baby blues. The organizations' focus includes education, information, and referral for women and families coping with mental health issues associated with child bearing, both during pregnancy, postpartum, and beyond. D.A.D. provides information on pregnancy and postpartum disorders, a professional referral list, a list of volunteer telephone contacts, and support groups.
PSI: Postpartum Support International	www.postpartum.net Postpartum Support, International 927 North Kellogg Avenue Santa Barbara, CA 93111 USA (805) 967-7636 jhonikman@earthlink.net	The purpose of this non-profit organization is to increase awareness among public and professional communities about the emotional changes that women often experience during pregnancy and after the birth of a baby. They provide current information on the diagnosis and treatment of postpartum mood and anxiety disorders; advocate research into etiology, diagnosis, and treatment of postpartum mood and anxiety disorders; provide education about mental health issues of childbearing; address legal and insurance coverage issues; encourage collaboration with related organizations; encourage health care professional participation in PSI; encourage the formation of new groups and strengthen existing support groups; and sponsor an annual PSI conference to review progress in achieving these objectives.
Symptoms of Depression.com	www.symptoms-of-depression.com	A comprehensive Web site dedicated to the topic of depression including postpartum depression.
The Online PPD Support Group	www.ppdsupportpage.com	The Online PPD Support Group offers information, support, and assistance to those dealing with postpartum mood disorders, their families, friends, physicians, and counselors

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Recognizing and Screening for Postpartum Depression in Mothers of NICU Infants

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