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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

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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.

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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.

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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.

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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.

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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.

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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

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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

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