This study compared practitioners’ and mothers’ opinions on the use of a screening tool in health care
Linda Mason, PhD, MSc, BSc, is senior research fellow, Faculty of Health and Applied Social Sciences; Helen Poole, PhD, BSc, CPsychol, is senior lecturer, Faculty of Science; both at Liverpool John Moores University.
Mason, L., Poole, H. (2008) Views of healthcare staff and mothers on postnatal depression screening. Nursing Times; 104: 50/51, 44–47.
Background: More research is needed on views of using the Edinburgh Postnatal Depression Scale to screen recent mothers for this condition.
Aim: To examine healthcare professionals’ and mothers’ views of using this tool.
Method: Findings of two qualitative studies on screening for postnatal depression were compared to provide an overview.
Results: There were differences in views within and between groups, although all practitioners found the tool helpful for introducing the topic. Symptom disclosure was an issue for all, although practitioners were unaware that some mothers feared their child would be taken into care.
Conclusion: Pragmatic reasons (such as lack of time and resources) meant practice was not always optimal but, if recommendations are followed, mothers may be encouraged to disclose symptoms.
Implications for practice
Postnatal depression (PND) is the most common medical problem new mothers face, affecting around 10–15% (Lee et al, 2004). Left untreated, it can persist for many months with adverse consequences for mothers, children and families (Josefsson et al, 2001).
This article brings together data from two previously published studies (Mason and Poole, 2008; Poole et al, 2006) which explored views of health professionals and recent mothers on screening for PND using the Edinburgh Postnatal Depression Scale (EPDS).
We wanted to highlight issues of concern to both groups and to assess how comfortable they were with the screening process. Comparisons and contrasts of views were sought and highlighted.
Primary care providers have the most contact with postpartum mothers and are well placed to assess and identify PND.
However, primary healthcare professionals detect fewer than half of cases (Hearn et al, 1998).
The reasons for this are complex but can be viewed under the following categories – mothers, healthcare professionals or systems of care. Mothers may not seek help or may mask symptoms because they are reluctant to be identified as having PND (Poole et al, 2006). Healthcare staff may lack training or experience in assessing the condition (Mason and Poole, 2008; Appleby et al, 2003). Additionally, resource constraints can limit their ability to provide coordinated postnatal care, and fragmented responsibility may lead to cases being missed.
Nevertheless, there has been much research on the use of screening tools to identify mothers with PND (Elliott and Leverton, 2000). The most commonly used is the EPDS (Boyd et al, 2005; Cox et al, 1987), a 10-item self-report scale designed to assess the presence and severity of depressive symptoms in recent mothers. Despite its frequent use, there are issues around sensitivity and specificity (Leverton and Elliott, 2000). For this reason, current guidelines suggest the EPDS should not be used as a ‘pass/fail’ tool but as a framework for assessing mothers’ moods that also incorporates a clinical interview. Many trusts in England have developed care pathways for the identification and treatment of PND based on these guidelines. Similarly, Scottish guidance supports the use of the EPDS in this context (SIGN, 2002).
Although the acceptability of screening tools has been widely researched for some conditions, this is not the case with the EPDS. Results of a small number of studies on mothers’ views of screening using this measure have been mixed (Buist et al, 2006; Gemmill et al, 2006; Poole et al, 2006). While the majority found it acceptable, a significant minority did not.
Practitioners’ views appear similar, though data on this is even more limited. We found only one study, which showed 25% were ‘somewhat’ or ‘very’ uncomfortable using it (Buist et al, 2006). Box 1 outlines the study’s aims.
Box 1. Study aims
The project was conducted in one PCT. Ethical approval was obtained from the local NHS and the university ethics committees.
A qualitative approach was adopted, using interpretative phenomenological analysis (IPA), which aims to gain an understanding of the individual’s perspective regarding their experiences.
Two rounds of semi-structured interviews were conducted, the first with a sample of recent mothers who had been screened for PND using the EPDS, and the second with practitioners who routinely use the EPDS.
Fifteen mothers were interviewed. To reduce the possibility of unnecessary distress, any who had experienced an infant death in their most recent birth or had been diagnosed with puerperal psychosis were excluded. The mean age was 30.4 (SD 6.2) years. Their EPDS scores ranged from 1–23, which represents scores from ‘not’ to ‘significantly’ at risk of depression.
Nineteen healthcare professionals (mainly health visitors, plus some nurses training to be health visitors) were interviewed, with no exclusion criteria. Length of time in their profession ranged from 15 months to 28 years; most had worked as nurses or midwives before their present position in the community.
As the researchers had no direct contact with them before the study, mothers were recruited by the practitioner who had screened them for PND. Arrangements were made to interview mothers in their own homes. All healthcare professionals involved in caring for postnatal women were invited to participate by the trust’s lead for PND. Their interviews took place in the clinic.
Before interviews, both groups were given the opportunity to ask questions then asked to give written consent. All participants gave permission for interviews to be recorded and these were transcribed verbatim. Interviews lasted 20–75 minutes. The original data was analysed using guidelines for interpretative phenomenological analysis. For a list of topics discussed, see Box 2.
Box 2. Interview topics
Initially, the data was analysed separately for the two groups, so the findings could be viewed independently. Findings were initially written up separately for the two groups (Mason and Poole, 2008; Poole et al, 2006). Further analysis was undertaken to compare and contrast the views of mothers and practitioners, and provide an overview of the overarching issues emerging.
Administration of the EPDS
Notification: Both practitioners and mothers had similar views on administration. Practitioners acknowledged the need to notify mothers that they would be screened in the future, and that this was routine practice. They felt this helped reduce fears about screening and stigma. Mothers found prior notice was useful for the same reasons. Two instances where mothers were not prepared gave concerns, with one saying: ‘I just worried, she is screening me because I’ve shown these signs.’
Timing: Staff varied as to when they administered the first screening (usually for pragmatic reasons) but most viewed later screenings as preferable because it gave mothers an adjustment period. Similarly, many mothers felt they needed time to adapt to having a baby as they had difficulty distinguishing between the overwhelming but ‘normal’ feelings of coping with a new baby and being overcome by depression.
The few mothers who thought earlier screening would be better had experienced an early onset of depression and wanted help sooner than they received it. Both mothers and staff suggested an extra screening would be useful as the gap between first and second screen was too long.
Setting: There was consensus between groups that home screening was preferable to the clinic, with similar reasons given by both groups; the clinic was busy and not conducive to concentration or disclosure. Practitioners were also aware that screening could raise personal issues for mothers that would need extra support, and felt mothers could not be left to go home: ‘We wouldn’t want to go opening a can of worms and then you know you have three other people sat outside waiting for you’ (practitioner). However, despite their views on best practice, sometimes staff were obliged to screen in the clinic for pragmatic reasons.
Repeat screening: Staff views on repeat screening varied; some routinely repeated it following a high score. Others were strongly against this, feeling it pressured mothers to show improvement. Mothers who had repeat screenings felt it was too often and added pressure to show improvement.
Views on the EPDS
Both practitioners and mothers varied in their views on the EPDS’ overall use. Opinion was equally divided within each group on how useful it was: ‘I think it’s great’ (practitioner); ‘No I don’t like them’ [the questions] (practitioner); ‘The questions you’re answering, they just lock on to the way you are feeling’ (mother).
All practitioners were positive about using the tool to open discussion on PND. It gave them the context to talk about sensitive issues without introducing them blindly, or avoiding subjects for fear of causing offence.
However, while staff spoke about using this as a starting point for discussion, some mothers felt it had not been used as such and would have welcomed the chance to explain their answers further. Indeed, being able to talk to practitioners was deemed to be an important part of the screening process.
Inexperience and lack of training: Despite all practitioners saying the EPDS was helpful for introducing sensitive topics, some were wary of probing mothers’ responses too deeply. This was related to training and experience. One reported feeling ‘out of my depth’ in dealing with mothers with depression, and this was echoed by others. In contrast, some had received additional training that gave them the skills and confidence to deal with sensitive issues.
Both groups acknowledged some difficulties with specific questions and each highlighted one on self-harm as problematic. Mothers in particular felt either it did not relate to their feelings or would be something to which they would not admit in this context.
The context of screening
Disclosure: This topic recurred in many accounts. Practitioners recognised mothers may have a variety of reasons for trying to disguise problems. For mothers it mainly related to fear of the consequences. While they worried about the stigma of being labelled depressed, their main concern was about what would happen to themselves, their child and family after a diagnosis: ‘My main thing I was so frightened of was that they would take the baby off me’ (mother).
One mother had experienced PND following the birth of each of her three children; no child had been removed from her care, yet this remained a fear. While practitioners acknowledged that stigma could be a problem, none mentioned mothers’ concerns about having children taken into care.
Both groups acknowledged that some mothers were not entirely truthful when completing the EPDS and, while practitioners talked about how frustrating this was, they felt there was little they could do to remedy the situation, other than to keep an eye on the mother. Mothers equally acknowledged reluctance to disclose their feelings.
Dialogue and cues: Practitioners identified some troubled mothers by use of non-verbal cues. These were seen as an important facet of their clinical skills. Some mothers were aware of these skills and recognised this dual approach provided the best screening method.
However, rather than by observations, practitioners felt dialogue was the best way of obtaining the true picture. A lack of dialogue was a hindrance to completing the EPDS, and sometimes could only be achieved over a long period and building up a relationship with the practitioner.
Feedback: Finally, most practitioners referred to the importance of giving feedback to mothers, and mothers also reported this as necessary. Indeed, those who were not given feedback said this was unsatisfactory, even if they were not symptomatic. Both groups felt it was a good opportunity to provide reassurance. In practice, staff varied as to what type of feedback they gave.
There was some variation in screening practice between practitioners, and also between what they reported as usual practice and the mothers’ perceptions of it. While all practitioners said they notified mothers that they would be screened, not all mothers thought this had occurred and felt this was unacceptable, a finding also reported by Shakespeare et al (2003).
Similar results were found in relation to reporting feedback – all practitioners reported routinely giving feedback, yet some mothers said they had not received any. Furthermore, while all practitioners reported the EPDS was a good starting point for discussion, mothers’ comments suggest this did not always occur. These differences in reported practice may be due to differences in recall, the reporting of ‘usual’ rather than all practice, or simply that some mothers were screened by staff who did not take part in our study.
There was no consensus either between or within the groups on the usefulness of the EPDS as a screening tool. While all practitioners agreed it was helpful as an introduction to PND, whether it should be used beyond this was debatable.
Shakespeare et al (2003) recommended it be used as an ‘unscored tool’ for practitioners to open up discussions about PND. Indeed, some mothers wanted to be able to talk around and justify their answers, and there was an implicit concern that because they did not have this opportunity, the score might not reflect their true situation and be misinterpreted.
Staff sought to explain they were not only relying on this tool but also using other skills, a finding also reported by Chew-Graham et al (2008). Clearly, there needs to be adjustment in practice to reassure mothers, by giving them the opportunity to talk through and explain their responses.
However, from practitioners’ perspective, this may be problematic. Although staff thought the EPDS allowed them to raise issues they may be uncomfortable about bringing up in another context, this might be at quite a superficial level. Some were concerned about what might be revealed if they questioned mothers closely. Partly this was related to the environment in which screening took place.
Mothers and practitioners could see problems with screening in the clinic, and this has also been reported in other studies (Brown and Bacigalupo, 2006; Shakespeare et al, 2003). It is possible this situation might affect practice – that is, practitioners may be less likely to probe responses if they perceive there may be difficult consequences in having a mother disclose serious or additional issues in the clinic.
Other reasons the discussion of EPDS topics may be perceived as superficial relate to resources for practitioners, training and their ability to deal with issues that may come up through more in-depth questioning. Some staff admitted they felt ill-equipped to deal with such issues.
Studies of community healthcare professionals have found that they report a lack of mental health training but identified a need for it (Brown and Bacigalupo, 2006; Haddad et al, 2004). Brown and Bacigalupo (2006) concluded that health visitors seem ‘unprepared’ in managing PND.
This may be compounded by a lack of resources. Indeed, Young (2006) reported that the number of health visitors is at its lowest for 12 years. Health visitors in Chew-Graham et al’s (2008) study expressed the view that staffing issues and the introduction of corporate working meant that ‘the detection and management of women with PND was no longer a priority for them’.
We acknowledge that the EPDS may be a good way to broach the subject of PND but pose the following question: if a practitioner is reluctant to probe mothers’ feelings because of the potential consequences, or lack of resources, should they introduce the subject at all?
Two themes occurring throughout interviews were disclosure and stigma. Both commonly feature in PND studies (for example Brown and Bacigalupo, 2006).
While both mothers and practitioners were aware not all mothers would disclose symptoms, the theme of stigma was viewed slightly differently by the two groups. Some mothers spoke about fearing the consequences of having PND, specifically the fear of having their child taken away, but practitioners seemed unaware this was a major concern. Instead, they talked about stigma in more general terms. This has implications for practice and highlights how – even when talking about the same issues – there are subtle differences in each group’s perceptions. As with other conditions where screening is usual, we feel it would benefit new mothers if practitioners asked about concerns and talked about the likely consequences of being diagnosed with PND before screening.
There were conflicting views between practitioners regarding repeat screening within a short space of time, and mothers who had been screened more than once were against this. Some staff felt it useful to monitor progress, whereas some mothers felt it pressured them to show improvement. However, this issue has not been recognised widely in published literature, and this might be specific to practice in this PCT. Although Cox and Holden (2003) reported that repeated high scores at successive visits should alert practitioners to an increased chance of an enduring depressive disorder, it is possible practitioners might be aware of this through close monitoring visits anyway. Our findings suggest this might be preferable for mothers. Small changes in scores over the short term may be related to measurement error rather than evidence of any real change in symptoms. We outline recommendations for practice, and also put these in the context of new NICE (2007) guidance published since this study was undertaken (Box 3).
Box 3. NICE guidance (2007)
This study was conducted in a PCT that provided both training and an integrated care pathway for screening. However, despite this, it appears that pragmatic reasons (such as lack of time and resources) often translate into a service that needs attention.
If these basic recommendations could be followed, mothers might be more encouraged to disclose their problems, and find their journey through the screening process less uncomfortable.
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