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ACKNOWLEDGEMENTS
CIHR Co-Principal Applicants
Nicole Letourneau Director, CHILD Research Program, UNB
Linda Duffett-Leger Research Associate, CHILD Research Program
CIHR Co-Applicants
Cyndi Brannen IWK Health Centre, Dalhousie University
Kim Critchley University of Prince Edward Island
Cindy-Lee Dennis University of Toronto
Loretta Secco University of New Brunswick
Invited Presenters
Cyndi Brannen IWK Health Centre, Dalhousie University
Cindy-Lee Dennis University of Toronto
Peggy Strass Royal Jubilee Hospital, Vancouver, BC
CHILD Research Team, University of New Brunswick
Joni Leger Research Assistant
Lisa Pollock Program Assistant
Penny Tryphonopoulos Project Director
Natalie Weigum Research Assistant
Cheryl Hiscock Research Assistant
Meeting Participants
NB Claudette Landry Government of New Brunswick
Anne Lebans Public Health Agency of Canada
Alan Bechervaise Telecare, NB
Nicole Poirier Public Health, NB
Nancy Hambrook Public Health, NB
Jacqueline Poitras Public Health, NB
Jeffrey Den Otter Social Development, NB
Roberta McIntyre Social Development, NB
Freda Burdett University of New Brunswick
Sarah Clarke Kings Clear First Nations, NB
Lindsey Reinhart Birth Matters, NB
NS Kim McClellan Public Health, NS
Sandi Partridge Prevention and Community Education, NS
Helene Rudder Mental Health, NS
Sharon Griffin Public Health, NS
PE Sarah Henry Education and Early Childhood Development, PE
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REPORT PREPARED BY NICOLE LETOURNEAU AND JONI LEGER
TABLE OF CONTENTS
EXECUTIVE SUMMARY ........................................................................................................................................ 4
BACKGROUND ................................................................................................................................................... 5
PRESENTATION SUMMARIES
NICOLE LETOURNEAU PHD, RN ....................................................................................................................... 6
CYNDI BRANNEN PHD, R.PSYCH. ..................................................................................................................... 6
CINDY-LEE DENNIS PHD, RN .......................................................................................................................... 7
PEGGY STRAUSS, PHN, RN ............................................................................................................................. 7
PANEL SUMMARY .............................................................................................................................................. 8
RECOMMENDATIONS FOR ACTION ........................................................................................................................ 9
FUTURE OF PPD SCREENING AND INTERVENTION IN THE MARITIMES
BROAD IMPLICATIONS ................................................................................................................................... 10
TARGETS FOR CHANGE .................................................................................................................................. 10
REFERENCES .................................................................................................................................................... 11
4
EXECUTIVE SUMMARY
Background
Postpartum depression (PPD) is the most common mood disorder following pregnancy. It affects as
many as 15% of new mothers and can have long term negative consequences for women and their
families. The CHILD research program at the University of New Brunswick has been conducting PPD
research for the past five years and has found evidence of limited resources available to mothers and
families affected by PPD, stigma preventing mothers from seeking help, and a wide-spread lack of
knowledge about PPD by both the public and professionals. Across the country other PPD researchers
have found similar results. These findings were the motivation for this meeting. The purpose of this
meeting was to bring together Maritime stakeholders and experts in PPD screening and intervention to
discuss current issues and priorities in PPD screening and intervention, to explore the potential for
partnerships, and to determine next steps in achieving change in the Maritimes.
Key Findings
The research evidence and the experiences of meeting participants working with women and their
families affected by PPD confirm the need to make changes to current practices. The major themes that
emerged from the meeting were needs for:
• universal PPD screening
• increased awareness of PPD
• support services that are effective, timely and accessible
• addressing barriers that prevent women from getting help
The Way Forward
How do we achieve these changes? Our first step is to seek feedback from policy and decision makers.
Then researchers and policy and decision makers will identify and pursue opportunities for
interdisciplinary and intersectoral partnerships. Through these partnerships, we can establish a
framework for universal screening, actively raise awareness of PPD, and establish care pathways and
appropriate PPD support services for women and their families in the Maritimes.
5
BACKGROUND
What is Postpartum Depression?
Postpartum depression (PPD) is characterized by low mood, anxiety, confusion, emotional
instability, tearfulness, feelings of inadequacy, inability to cope, and suicidal ideation [1]. Thirteen to
15% of new mothers suffer from postpartum depression and many do not receive the help they need.
PPD affects women of all socioeconomic backgrounds and can occur months after a child is born [2].
Why is Postpartum Depression a Societal Concern?
Without diagnosis or treatment, PPD can have lasting negative effects on women’s and families’
health and on children’s intellectual, social and emotional development [3-11]. Often women do not get
better on their own – over 60% of affected women remain symptomatic for up to 12 years after the
birth their child (Letourneau, in review). Women’s marriages and employment prospects are often
collateral damage. Moreover, children exposed to PPD are vulnerable to health, learning and
behavioural problems [12, 13]. A growing body of evidence suggests that children of mothers with PPD
are prone to asthma, allergies, hyperactivity, and attention disorders [14, 15]. A lack of public and
professional awareness has made it difficult for many women to seek and receive treatment for this
highly stigmatized mental illness. In addition to stigmatization there can be multiple other barriers to
mothers seeking treatment [16].
What Can We Do to Help?
Screening is the first step in providing help to mothers at risk for PPD. Early intervention is
important to enhance protective factors and reduce risk factors influencing maternal mental health [2].
Though not well understood, the birth experience itself may play a role in the development of PPD and
more research is needed to ensure evidence based best practices for birth.
Early identification and intervention improves long term outcomes for most women. Using a
standardized screening tool, such as the Edinburgh Postnatal Depression Scale (EPDS), is an easy-to-
implement first-level intervention to identify mothers with symptoms of PPD and refer them for
appropriate diagnosis and treatment [17-19]. Appropriate follow-up is the other significant area for
change.
Current practices rely on referrals to mental health, public health, private services or family
doctors. Public services are overburdened and under resourced creating long wait lists. Private services
can be costly to the individual. Often, family doctors and other health care professionals are not aware
of tools and methods to sensitively assess and treat women with PPD. As women enter the health care
system at various points and present with different care needs, it is essential to establish a framework to
ensure accessible, timely and effective service to all women and their families affected by PPD.
The Next Steps
In the Maritimes, partnerships between researchers and policy and decision makers have begun
to be formed and need to be nurtured and expanded to help these women and their families. With buy-
in from stakeholders, including senior government officials, a framework for feasibly implementing
universal PPD screening and intervention can be realized. Working together we can determine the best
methods for raising awareness of PPD and ensuring the development of appropriate support services.
These next steps are vital for Maritime women and their families to access essential PPD screening and
intervention.
6
PRESENTATION SUMMARIES
PRESENTATION SUMMARY KEY FINDINGS KEY RECOMMENDATIONS
Mothers Offering
Mentorship and
Support (MOMS)
Study
Dr. Nicole Letourneau
The MOMS study was an
RCT to examine the
relationship between
peer support and
maternal-infant
interactions, infant
health and maternal
depression. One-on-one
peer support was
provided in home to
mothers with depressive
symptomatology
assessed by the EPDS.
No differences in
maternal-infant
interaction quality at
any point in time.
Significant difference
between groups on
measure of
depression, favouring
the control group.
Peer support may not be
best for moms with high
depression scores.
Some level of support
from a professional
familiar with PPD may be
needed.
Helping mothers with
PPD interact with their
infants may be better
provided by a
professional than a peer.
Mothers with PPD may
need flexible support,
available when they need
it, not rigidly applied in
weekly visits.
Care mapping may be
useful for determining
optimal support.
Reducing Barriers to
Women’s Mental
Health Services: Using
Technology in
Interventions for
Depressed Mothers
Dr. Cyndi Brannen
Rural living increases the
risks associated with
social and economic
exclusion. Women
already face barriers to
seeking treatment for
PPD and rural living is an
additional barrier. The
Managing Our Mood
(MOM) RCT provides
telephone support to
rural mothers at risk for
PPD. Mothers can access
support provided by a
female coach at their
own pace from their
own home.
The MOM model has
the ingredients for a
strong community-
based PPD
intervention.
Barriers to seeking
treatment for PPD
remain powerful.
There is a lack of
awareness about PPD,
its impact, and
treatment.
Distance delivery of
treatment, including
ehealth and
telecare/telehealth offers
promise.
Cross-disciplinary
collaboration is needed
to develop accessible,
appropriate, evidence
based, cost-effective
treatment for PPD.
7
PRESENTATION SUMMARIES
PRESENTATION SUMMARY KEY FINDINGS KEY RECOMMENDATIONS
Innovative
Interventions for
Postpartum
Depression
Dr. Cindy-Lee Dennis
The presentation
focussed on a PPD peer
support trial [20].
Telephone support was
provided by trained peer
volunteers to mothers
at-risk for PPD. Also
discussed was an
ongoing interpersonal
therapy (IPT) trial, how
to identify women at
risk for PPD, and
screening and care
pathways.
Mothers who received
support were at half
the risk of developing
PPD.
Majority of mothers
were receptive to
screening with the
EPDS.
With training, lay
women who have had
similar experiences
with PPD can have a
positive effect.
Screening alone does
not lead to appropriate
treatment.
Care pathways may be
essential to improving
outcomes.
Telephone based peer
support may be an
effective means to
prevent PPD in women at
risk.
Two phase PPD screening
with EPDS integrated into
current practice.
Care mapping with a
stepped care framework
asking at each step: Who
is responsible for care?
What is the focus? What
do they do?
PPD Screening
Experience in Rural
Alberta “If You Ask
the Questions They
Will Tell”
Peggy Strauss, RN
A pilot project was
developed to address
the support needs of
women with PPD in rural
Alberta. Also presented
was an antenatal project
aimed at increasing
access to health services
during pregnancy.
Reduction in acute
psychiatric admissions.
Increased self referrals
to program.
Increased health care
provider referrals.
Decrease in symptoms
of depression.
Immediate risk
reduction.
Opportunities for
teachable moments.
Screen, assess and refer
early.
Acknowledge and
validate mothers’
experiences and provide
choices for care.
Practice phrasing for
assessment questions.
Increase perinatal mood
disorder education for
professionals and public.
Include fathers in care.
8
PANEL SUMMARY
The following is a summary of the panel discussion on PPD in the Maritimes: Practitioners’ Perspectives.
Each of the panel members has worked with programs aimed at helping women with PPD.
Key Statements Key Recommendations
• We need to link up service providers and
make sure there is a safe space for
mothers.
• Mothers fear they’ll lose their children.
• If we’re going to ask questions about PPD
we need to follow-up, and we often do not
have the capacity/support available.
• Family doctors are not aware of how to
treat women that have postpartum
depression.
• They want to get better. They want to do
what’s best for the baby.
• Mother’s health is linked directly to the
child’s health.
• Why are we spending so much time
teaching expectant mothers how to
breathe during labour and delivery? Why
are we not helping them deal more with
parenting?
• We need to get this information to the
people who are making the decisions.
• Make sure that health care professionals
are aware of PPD and how to treat women
with PPD.
• More resources are needed to provide
support and treatment for PPD.
• Universal screening for all mothers is
essential.
• Include PPD in school curriculum to help
recognize risks and create acceptance.
• Employ care mapping by asking: Who
should be looking at this? Are we doing
the right thing?
• Policies should be developed or amended
to reflect current PPD research evidence.
9
RECOMMENDATIONS FOR ACTION
Meeting participants took part in discussion groups to answer questions about taking the next steps in
PPD screening and intervention in the Maritimes. The following is a summary of their recommendations
which have been grouped in to four broad categories: Screening, Intervention, Increase Awareness and
Address Barriers.
Screening Interventions
• Implement universal screening
o Possibly through Telecare/Telehealth
o Possibly through pairing with routine
immunization
• Provide a central intake point
• Screen more than once to reduce false
positives
• Explore potential for an online screening tool
which could be linked to health care services
• Look to examples of successful screening in
other provinces
• Telephone support
o Telecare/Telehealth
o Volunteer peer support
• Support group
o Professional or peer led
o No fixed start date
o Web based
• Professionals trained in PPD
• Care mapping
o Appropriate level/type of
intervention
o Integration of services
o Single point of entry into care
Increase Awareness Address Barriers
• Public awareness campaign
• Prenatal PPD education
• Educate fathers about PPD
• Provide professionals with the training and
tools to help women with PPD
• Include information on PPD in school
curriculum
• Garner buy-in and support from various
stakeholders
o Government
o Community
• Need political and professional will to
move forward
• Need to reduce stigma
o Increase awareness
• Funding and human resources
o Perform a cost-benefit analysis
for decision makers
• Accessibility
o Private services can be costly
o Public services often have long
wait lists
o Develop innovative publicly-
funded service
• Perform needs assessment to address:
o Regional/cultural differences
o Language differences
o Rural issues
o Transportation issues
10
FUTURE OF PPD SCREENING AND INTERVENTION IN THE MARITIMES
The presentations, discussions, and comments from meeting participants clearly point to the need for
action in addressing PPD screening and intervention in the Maritimes. Current and emerging research
evidence will help guide us and support the changes that are needed to ensure improved maternal
mental health, family functioning, and childhood developmental outcomes. In partnership, researchers,
government officials, and community stakeholders may be guided by the following broad implications
for screening and intervention in the Maritimes and suggestions for specific change targets.
BROAD IMPLICATIONS
Changing Current Practices
Research and anecdotal evidence suggest that current practices are ineffective and in some
cases even harmful for women and families affected by PPD. Without adoption of evidence-
based best practices, the status quo will result in undesirable, preventable outcomes for women
with PPD and their families. One of the key recommended changes is universal screening.
Universal Screening
Research is clear on the need to screen mothers for PPD. Universal screening is necessary to
reduce societal stigma associated with postpartum mental illness, improve service delivery to
improve maternal mental health, and target interventions to reduce risks to child health and
developmental outcomes. Successful models are implemented in others provinces and current
opportunities exist with telecare/telehealth and immunization clinic in the Maritimes to
implement universal screening.
Support Services
Current structures create wait lists and gaps in service for women affected by PPD. Innovative
strategies (e.g., ehealth, telecare/telehealth) and the resolve to develop and implement changes
will work to reduce wait lists and address gaps. Care mapping will help ensure the right service is
delivered to the right patient by the right person. Researchers and policy and decision makers
need to collaborate to conduct needs assessments, cost-benefit analyses, and establish
evaluative measures to assess the effectiveness of new services and programs.
TARGETS FOR CHANGE
• Increase awareness (e.g. media campaigns)
o Professionals
o Public
o Media
• Develop a framework for implementing universal screening and intervention
• Establish available, readily accessible PPD support
o Telephone based (telecare/telehealth), web based (ehealth), face-to-face
o Professional and/or peer delivery
• Employ care mapping to ensure appropriate service delivery/intervention
• Increase collaboration between researchers and policy and decision makers
• Conduct cost-benefit analysis for providing screening and intervention
• Build in evaluative components to assess the effectiveness of screening and intervention in an
evidence based framework of screening and intervention for PPD
11
REFERENCES
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2. Dennis, C. L., The effect of peer support on postpartum depression: a pilot randomized controlled
trial. The Canadian Journal of Psychiatry, 2003. 48(2): p. 115-124.
3. Murray, L. and P. Cooper, Effects of postnatal depression on infant development. Archives of Disease
of Childhood, 1997. 77(2): p. 97-101.
4. Murray, L. and P. Cooper, eds. Postpartum depression and child development. 1999, Guilford Press:
New York, NY.
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infant interactions, and infant outcome, in Postpartum depression and child development, L. Murray
and P.J. Cooper, Editors. 1997, Guilford Press: New York, NY. p. 111-135.
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mothers. Journal of Child Psychology & Psychiatry & Allied Disciplines, 1999. 40(8): p. 1259-1271.
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Developmental Psychopathology, 2000. 12(2): p. 157-175.
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15. Kozyrskyj A. L., et al., Continued exposure to maternal distress in early life is associated with an
increased risk of childhood asthma. American Journal of Respiratory & Critical Care Medicine. 2008,
177(2): p. 142-147.
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Journal of Obstetric, Gynecologic and Neonatal Nursing, 2007. 36(5): p. 441-449.
17. Chaudron, L. and J. Jefferson, Mood stablizers during breastfeeding: A review. Journal of Clinical
Psychiatry, 2000. 61(2): p. 79-90.
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randomized controlled trial. British Medical Journal, 338:a3064, doi:
10.1136/bmj.a3064
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