Cullinan (1991) explains that most women complete the questionnaire in less than five minutes. Joanne took less than three minutes, scoring 21 out of a possible 30 (See Appendix 5). On reflection I was satisfied that my skills and ability had recognised the PND, but more importantly that a plan of care needed to be negotiated. Leeds mental health guidelines (2002) state that if a woman scores above 12, the EPDS should be repeated after 7 - 14 days, if still above 12, offer 4 listening visits and inform the G.P. I decided that a number of areas needed to be covered, these included –
- Informing the G.P.
- Informing my CPT
- Discuss with Joanne, the issues highlighted in the questionnaire.
Following the use of the EPDS questionnaire, it was apparent that Joanne was suffering from post-natal depression. Having explained my role to Joanne and how I would support her, I explained that I needed to inform her G.P, my CPT and discuss the situation with the counsellor, based at the clinic, Joanne then asked about anti-depressants. I explained that her G.P would decide if these were appropriate. I asked if she would agree to see her G.P, she stated that she had an appointment the following day for her post-natal check. We agreed that Joanne would keep the appointment and I would contact the G.P that day to explain my findings and discuss her care from a Health Visiting perspective. We arranged for a repeat EPDS to be completed during the following weeks visit.
I discussed the visit with her G.P, we discussed the possibility of a course of anti-depressants, the G.P stated that these were a possibility and she would assess Joanne the following day.
2.5 Developing the Care Plan
Through further reflection with my CPT and Joanne’s G.P, I was able to critically analyse the situation. It was agreed that Joanne would benefit from extra support and listening visits could provide her with a method of moving forward. Joanne agreed and fortnightly listening visits were arranged.
The ‘Stages of Change Model’, (Prochaska and Diclemente, 1982) was chosen to structure the visits. This provided a framework, which allowed the need to change behaviour, to be worked through. The third post-natal visit appeared to promote Joanne’s attitude to change, from the pre-contemplation stage to the contemplation stage; “the individual thinks seriously about changing their behaviour” (Prochaska and Diclemente, 1982). Having previously used, this model it seemed a suitable way to structure the visits and plan her care. Egan (1990) describes a model of counselling. However, not having undertaken any counselling I felt that this model was inappropriate for my use. Orem (1991), describes a Self Care model, but I decided not to use this model, as Joanne did not perceive that she had a problem, therefore I decided that we could not have worked through her problem with ease, using this model.
I felt that using the Stages of Change Model (Prochaska and Diclemente, 1982), would allow Joanne to work through her problem of low self-esteem in order to make specific changes to her pattern of behaviour. Joanne ultimately became empowered understanding her role as a mother and accepting her individual limits. The Stages of Change model was chosen as at the initial ante-natal visit Joanne was placed at the pre-contemplation stage; this stage is seen as when the individual is not considering changing their behaviour; Joanne had expressed that she was coping and declined extra support. Rollnick, Mason and Butler (2000), state that the Stages of Change Model attempts to describe readiness and the way in which individuals move towards making decisions and behavioural changes in their everyday lives.
Mental health problems are a common occurrence in primary health care. Hannigan (1998) states that non-mental health specialist practitioners are increasingly becoming involved in identification, assessment, and care of people with mental health problems. It is noted by Eastwood (1998), that Health Visitors have an important role to play in individual counselling, but states that it has its limitations. With these thoughts in mind, several interventions were put into place to support Joanne; the rationale for these interventions will be discussed.
To meet Joanne’s individual needs and to develop a helping relationship, recognition of the links between my specialist practice setting and the wider mental health picture was identified. The National Service Framework for mental health (2000) identifies the promotion of mental health for all, explaining that –
“Mental health promotion is essentially concerned with how individuals,
families, organisations and communities feel, the factors which influence
how they feel and the impact that this has on
overall health and well-being”. (D.O.H, 2000, p 14)
In discussion with my CPT I expressed concern for Joanne and her score on the EPDS questionnaire. We agreed that an important role of the Health Visitor was early detection of post-natal depression where use of listening visits usually had a successful outcome (Mead, Bower and Gask, 1997). Trebble and Greenhill (1992) discuss the management of post-natal depression, concluding that the Health Visitor is in an ideal situation to offer non-directive counselling through listening visits.
The plan of care was discussed with Joanne who agreed to partake. Both the plan of care and Joanne’s agreement was documented in the Health Visiting notes.
2.6 The First Listening Visit
The first organised listening visit aimed to reduce Joanne’s feelings of low self-esteem and inability to cope with her present situation. The visit was structured and time managed allowing Joanne to talk at length. Joanne explained that she had seen a female G.P. and the appointment had been useful. Joanne had been prescribed a month’s course of anti-depressants, and felt that these were beginning to take effect. Within the visit, feelings were discussed. She expressed feelings of joy at the birth of Kelsie and was able to discuss her home life and relationships in more detail. The visit concluded by discussing Joanne’s progress, she felt that significant progress would be achieved with the help of the listening visits and the anti-depressants. This visit proved to be successful, with the unexpected outcome of Joanne wishing to take Oliver to a playgroup. I gave Joanne a list of playgroups in the area and agreed that this would be beneficial for herself and Oliver.
During this visit, Joanne was able to express her feelings in more detail, I felt that Joanne was prepared to take further action; this indicated that she had moved to the preparation stage of the model (Prochaska and Diclemente, 1982). The visit concluded by Joanne repeating the EPDS. Her score was 14 out of a possible 30 (See Appendix 6). I was pleased that, Joanne had moved forward in a positive direction and, thought that I had played a small part in her progress.
Unfortunately, until this visit it had not become clear to Joanne that there was an identified health need and a reason to change. Joanne described her mood as very low, recognised that she was obsessed by housework, and expressed concerns of not being a ‘good mother’.
On reflection, this visit provided a structured framework for future visits helping Joanne build up her confidence and resolve issues linked with low self-esteem and disempowerment.
2.7 Continuing Care
The listening visits are on-going, both Joanne and I feel that she is moving forward in a positive direction. The stage of ‘readiness of action’ is appearing. However, it should be noted that it is possible for individuals to relapse as well as progress, it is felt that Joanne’s acknowledgement of progress is a turning point. Issues were also raised about the listening visits that were both negative and positive. On the positive side I feel that Joanne might benefit from a post-natal group setting with other mothers experiencing the same feelings, however, negatively there are no groups of this nature in my area. Eastwood (1995) describes how promoting peer group support with post-natally depressed women can have a successful outcome, stating that the group’s self-esteem increased as the group members respected each others feelings and the confiding relationship counteracted their feelings of isolation.
- Conclusion.
I found the listening visits a very exhausting, draining, and strenuous experience having never trained in this field of practice. I received excellent clinical support from my CPT, which helped my reflexivity and development of better active listening skills (Rollnick, Mason and Butler, 1999). I feel also that a support group would be a positive move for future practice, especially if other Health Professionals were incorporated into the group i.e. Midwife, Counsellor, and Mental Health Practitioners. I personally would benefit from a formal basic counselling course.
Mead, Bower and Gask (1997), raised the question of concern between the boundaries of primary and specialist mental health practitioners. Evidence presented within this analysis suggests that care was taken to offer Joanne the best support and intervention at primary level, although closer communication between the community mental health team and me may have offered an enhanced approach to Joanne’s care.
10% - 15% of women experience PND, about 50% of these remain undetected by health professionals (Murray, 1997). May (1995) suggests that this is a transition period for all members of the family, often producing social, mental, and physical health distress.
This assignment has discussed the helping relationship and rationale for the plan of care to support my client with PND. It is apparent that symptoms of PND are compounded by a poor relationship with partners. This experience has been a useful learning experience and it is satisfying to know that Joanne has gained support from the listening visits and was able to discuss her feelings with me. For my part, I was encouraged by the feedback I received from the G.P and CPT who were supportive of the care I had provided for Joanne.
I found sharing my concerns with other health care professionals to be of great help - I felt that I had been able to adopt a multidisciplinary approach to mental health care, thus promoting Joanne’s mental health. Cox (1986), states that although primary health care workers regularly visit mothers in the puerperium, rarely is post-natal depression recognised. It is argued that primary health care professionals with appropriate training do recognise post-natal depression and share information regarding client’s mental health problems.
The EPDS was a helpful tool in assessing Joanne’s PND providing a baseline for treatment and a framework for the listening visits. However, it should be noted that it is only a tool and clinical judgement should be used at all times. May (1995), states that a good relationship between Health Visitors and mothers may help them confide their true feelings. Although it can be argued that without building a rapport, and having some basic counselling skills, the therapeutic value to a professional relationship may be significantly reduced.
-
Appendices
Appendix 1.
The Edinburgh Post-natal Depression Scale (EPDS)
explained. (Cox, Holden, Sagovsky, 1987)
The EPDS (See appendix 2) (Cox, Holden, Sagovsky, 1987) is a ten-item self-rating questionnaire which, when used 6 – 8 weeks after delivery, is a highly specific and sensitive in the detection of post-natal depression.
The scale consists of ten statements relating to symptoms of depression and women are asked to indicate on a four-point scale how closely each statement reflects their mood during the last seven days. It is important to discuss the possibility of depression at the ante-natal visit and explain the role of the Health Visitor and the EPDS.
If the woman scores over 12, the EPDS should be repeated in one week, this allows for the woman having a ‘bad’ week. At all times clinical judgement should be used. If the Health Visitor is concerned then referral to an appropriate person should be undertaken, with the woman’s consent. If the woman scores over 12 the following week, then listening visits should be undertaken and a plan of care discussed with the woman. Any woman scoring on question ten (see Appendix 2) should be referred to the G.P. immediately.
Appendix 2.
Edinburgh Post-Natal Depression Scale.
(Cox, Holden, Sagovsky, 1987)
How are you feeling?
As you have recently had a baby, we would like to know how you are feeling. Please tick the answer which comes closest to how you have felt in the past 7 days, not just how you feel today.
In the past seven days -
- I have been able to laugh and see
the funny side of things:
As much as I always could □
Not quite so much now □
Definitely no so much now □
Not at all □
- I have looked forward with
enjoyment to things:
As much as I ever did □
Rather less than I used to □
Definitely less than I used to □
Hardly at all □
- I have blamed myself unnecessarily when things went wrong:
Yes, most of the time □
Yes, some of the time □
Not very often □
No, never □
- I have felt worried and anxious for no very good reason:
No, not at all □
Hardly ever □
Yes, sometimes □
Yes, very often □
- I have felt scared or panicky for no very good reason:
Yes, quite a lot □
Yes, sometimes □
No, not much □
No, not at all □
- Things have been getting on top of
me:
Yes, most of the time I haven’t been able
to cope at all □
Yes, sometimes I haven’t been coping as
well as usual □
No, most of the time I have coped
quite well □
No, I have been coping as well as ever □
- I have been so unhappy that I have
difficulty sleeping:
Yes, most of the time □
Yes, sometime □
Not very often □
No, not at all □
- I have felt sad or miserable:
Yes, most of the time □
Yes, quite often □
Not very often □
No, not at all □
- I have been so unhappy that I have
been crying:
Yes, most of the time □
Yes, quite often □
Only occasionally □
No, never □
- The thought of harming myself has
occurred to me:
Yes, quite often □
Sometimes □
Hardly ever □
Never □
Appendix 3
Edinburgh Post-Natal Depression Scale – Scoring.
(Cox, Holden, Sagovsky, 1987)
- I have been able to laugh and see the funny side of things:
As much as I always could 0
Not quite so much now 1
Definitely no so much now 2
Not at all 3
- I have looked forward with enjoyment to things:
As much as I ever did 0
Rather less than I used to 1
Definitely less than I used to 2
Hardly at all 3
- I have blamed myself unnecessarily when things went wrong:
Yes, most of the time 3
Yes, some of the time 2
Not very often 1
No, never 0
- I have felt worried and anxious for no very good reason:
No, not at all 0
Hardly ever 1
Yes, sometimes 2
Yes, very often 3
- I have felt scared or panicky for no very good reason:
Yes, quite a lot 3
Yes, sometimes 2
No, not much 1
No, not at all 0
(Continued over)
- Things have been getting on top of me:
Yes, most of the time I haven’t been able to cope at all 3
Yes, sometimes I haven’t been coping as well as usual 2
No, most of the time I have coped quite well 1
No, I have been coping as well as ever 0
- I have been so unhappy that I have difficulty sleeping:
Yes, most of the time 3
Yes, sometime 2
Not very often 1
No, not at all 0
- I have felt sad or miserable:
Yes, most of the time 3
Yes, quite often 2
Not very often 1
No, not at all 0
- I have been so unhappy that I have been crying:
Yes, most of the time 3
Yes, quite often 2
Only occasionally 1
No, never 0
- The thought of harming myself has occurred to me:
Yes, quite often 3
Sometimes 2
Hardly ever 1
Never 0
Appendix 4
The Transtheoretical Model/Stages of Change Model.
(Prochaska and DiClemente, 1982)
PRECONTEMPLATION
CONTEMPLATION
PREPARATION
ACTION
MAINTENANCE
Appendix 5.
Edinburgh Post-Natal Depression Scale.
(Cox, Holden, Sagovsky, 1987)
How are you feeling?
As you have recently had a baby, we would like to know how you are feeling. Please tick the answer which comes closest to how you have felt in the past 7 days, not just how you feel today.
In the past seven days -
- I have been able to laugh and see the funny side of things:
As much as I always could □
Not quite so much now □
Definitely no so much now □
Not at all □
- I have looked forward with
enjoyment to things:
As much as I ever did □
Rather less than I used to □
Definitely less than I used to □
Hardly at all □
- I have blamed myself unnecessarily when things went wrong:
Yes, most of the time □
Yes, some of the time □
Not very often □
No, never □
- I have felt worried and anxious for no very good reason:
No, not at all □
Hardly ever □
Yes, sometimes □
Yes, very often □
- I have felt scared or panicky for no very good reason:
Yes, quite a lot □
Yes, sometimes □
No, not much □
No, not at all □
- Things have been getting on top of me:
Yes, most of the time I haven’t been able
to cope at all □
Yes, sometimes I haven’t been coping as
well as usual □
No, most of the time I have coped
quite well □
No, I have been coping as well as ever □
- I have been so unhappy that I have difficulty sleeping:
Yes, most of the time □
Yes, sometime □
Not very often □
No, not at all □
- I have felt sad or miserable:
Yes, most of the time □
Yes, quite often □
Not very often □
No, not at all □
- I have been so unhappy that I have been crying:
Yes, most of the time □
Yes, quite often □
Only occasionally □
No, never □
- The thought of harming myself has occurred to me:
Yes, quite often □
Sometimes □
Hardly ever □
Never □
Appendix 6.
Edinburgh Post-Natal Depression Scale.
(Cox, Holden, Sagovsky, 1987)
How are you feeling?
As you have recently had a baby, we would like to know how you are feeling. Please tick the answer which comes closest to how you have felt in the past 7 days, not just how you feel today.
In the past seven days -
- I have been able to laugh and see the funny side of things:
As much as I always could □
Not quite so much now □
Definitely no so much now □
Not at all □
- I have looked forward with
enjoyment to things:
As much as I ever did □
Rather less than I used to □
Definitely less than I used to □
Hardly at all □
- I have blamed myself unnecessarily when things went wrong:
Yes, most of the time □
Yes, some of the time □
Not very often □
No, never □
- I have felt worried and anxious for no very good reason:
No, not at all □
Hardly ever □
Yes, sometimes □
Yes, very often □
- I have felt scared or panicky for no very good reason:
Yes, quite a lot □
Yes, sometimes □
No, not much □
No, not at all □
- Things have been getting on top of me:
Yes, most of the time I haven’t been able
to cope at all □
Yes, sometimes I haven’t been coping as well as usual □
No, most of the time I have coped quite well □
No, I have been coping as well as ever □
- I have been so unhappy that I have difficulty sleeping:
Yes, most of the time □
Yes, sometime □
Not very often □
No, not at all □
- I have felt sad or miserable:
Yes, most of the time □
Yes, quite often □
Not very often □
No, not at all □
- I have been so unhappy that I have been crying:
Yes, most of the time □
Yes, quite often □
Only occasionally □
No, never □
- The thought of harming myself has occurred to me:
Yes, quite often □
Sometimes □
Hardly ever □
Never □
Appendix 7.
Post-Natal Series of Events
Joanne described the following in detail explaining that these were negative thoughts –
- Labour experience – No pain relief and experience too quick – Gavin was not at the birth as he was working and did not get to the hospital in time.
- Oliver had to be left with a friend as the labour began quickly.
- Gavin did not appear interested in the new baby.
- Gavin did not appear to want to share in the day-to-day housework.
- Joanne had not breastfeed Oliver and breastfeeding Kelsie was much more difficult, than Joanne had expected.
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