Managing depression in the community

Mental Health Nursing,  Sep/Oct 2001  

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Maria Forrester won the first CPNA Organon award for the management of depression in the community. In her award-winning paper, she describes how, over the past seven years, mental health professionals in Foyle Trust in Northern Ireland have worked to meet the needs of women suffering from this illness, by facilitating a post natal depression (PND) therapy group

Mental Health Nursing Vol 21 No 5 pp 23-25

The Department of Health national service framework for mental health (1999) has highlighted PND as a priority area that needs to be addressed by a multi-disciplinary team of health professionals. O'Hara and Swain (1996) examined various studies of post natal mothers and reported the rate of depression within the first six months after childbirth to be 10-15 per cent.

In February 2000 finance was allocated to Foyle Trust through primary care development funding for a two year project on PND. A health visitor and a CPN (the author) were appointed, part-time, to evaluate current service provision and identify gaps in service.

McCarthy (1998) highlights that 75 per cent of mothers with post natal depression will be managed in primary care. Our overall aim was, therefore, to increase awareness and develop an integrated care pathway for post natal depression.

Our objectives were:

* Raise awareness of post natal depression among the general public, health professionals, statutory agencies, community and voluntary groups.

* Training and on-going supervision of health professionals (e.g. health visitors, midwives) in the detection of and management of post natal depression.

* To increase the detection and subsequent management of post natal depression within primary care services.

Method

We decided to obtain baseline information by surveying GPs, health visitors, midwives and ante natal mothers to ascertain current knowledge of PND and awareness of service provision. At the end of the project these groups will be surveyed again to evaluate intervention outcomes.

Intervention

Approximately 50 per cent of the work in the Foyle post natal depression therapy group project is dedicated to clinical intervention. The group was originally formed in 1984 as a result of a need, identified by health visitors in the community among mothers suffering depression after childbirth. The group, facilitated by health visitors, CPNs and social workers stopped in 1993 for one year due to various difficulties at this time. In 1994, due to demand from GPs, health professionals and former members, the group was re-established. At this time, community mental health team workers (CPNs and social workers) facilitated weekly group sessions. In 2000, again the group came into difficulties as facilitators tried to balance full-time caseloads and run the group. The present project has enabled the two professionals now involved to dedicate 50 per cent of their workload to clinical intervention.

Beck's (1995) results of a metaanalysis of 19 studies, indicated that PND has a moderate to large adverse effect on infant interactions. This is re-iterated by Murray and Cooper's (1997) research which illustrates the well-recognised detrimental effects of PND on infant development. Based on the findings of such research, our aim is to help mothers overcome

difficulties associated with PND. The objectives of the group are:

1. To provide a safe environment to share knowledge and experiences.

2. To provide education on PND and associated symptoms.

3. To enable women to identify problems and empower them to seek their own solutions.

4. To develop coping skills which can be incorporated into all areas of a client's life.

5. To place emphasis on communication and interaction with children.

6. To help improve relationships with partners and relevant others.

7. To build self-esteem and confidence.

8. To provide a network of peer support.

9. To refer to other appropriate agencies as appropriate.

Following a referral from primary or secondary care health professionals, an assessment is then arranged for the woman, to assess suitability for group work. Suitability is determined if the problems identified are specifically related to post natal depression occurring within the first two years of the baby's life.

During the initial assessment the Edinburgh Post Natal Depression Scale (EPDS) is used as identified by Cox et al (1987). This is a 10-item selfreporting scale that is a validated screening tool for PND that is completed by the mother. It consists of 10 statements with a choice of four answers. The mother scores the answer that is most appropriate to how she has been feeling in the past seven days. A cut-off score of 12 is used to identify women suffering from PND. All mothers are encouraged to complete the scale on their own unless any literacy problems are identified. This tool does not replace clinical judgement but is used in conjunction with a mental state assessment.

If a mother is suitable, her name is placed on a waiting list. Information may be given on initial assessment to educate her about her specific difficulties, e.g. anxiety, depression. If mothers identify problems that are not related to a post natal illness, they may require other specialised intervention by a more appropriate agency, e.g. Relate, CMHT