Tag Archives: Perinatal Mental Health

Precovery: a proactive version of recovery

Recovery

recoveryIn mental health services the term “recovery” has been all the rage for the last few years. Australia’s mental health services are encouraged to be “recovery orientated” and use the “recovery approach” or “recovery model” [same same]. In fact, Australia’s 2010 National Standards for Mental Health Services embed the recovery model in clinical practice [see here]. This is a move away from seeking to “cure” the individual. It is a move towards supporting the individual on their journey towards healing.

The recovery model emphasises hope for the person who is experiencing mental illness. Ingrained in the recovery approach is encouragement for the individual to increase their understanding of both their abilities and their disabilities, and to take-on as much autonomy as possible. The person can then use hope, insight and autonomy as a platform to engage in an active life – one with purpose and meaning – and thereby acquire and sustain a more positive sense of self.

All good stuff. What’s not to like?

Well, the recovery model assumes existing psychiatric disability and/or psychopathology, but in perinatal mental health we’re trying to head problems off at the pass. Recovery is a journey towards healing, but perinatal mental health seeks to decrease either the need for that journey or, at worst, that the journey is not too long or too complex. “There’s nothing to be gained from waiting for a pregnant woman or new mother to be in crisis before intervening, but there is much to be gained in preventing symptoms becoming severe or debilitating.“# So, if we’re doing perinatal mental health prevention and early-intervention the recovery model isn’t a great fit – we’re trying to avoid the level of acuity or chronicity that the recovery model caters for.

However, we don’t want to throw the baby out with the bathwater [dud idiom for a perinatal mental health nurse to use – sorry about that]. Recovery enshrines the uniqueness of the individual, that the individual will be treated with dignity and respect, that the individual will be empowered to make real choices, and that clinicians work in partnership with the individual and ensure that communication is a two-way street. We want to keep all those values from recovery and prevent symptoms/disability from becoming severe or long-lasting.

That’s why i suggest we start making-up words (a practice often classed as psychopathology in my business: look-up the word “neologism“). Anyway, undeterred, here’s a neologism I prepared earlier: “precovery” – please, let me explain:

Prehab

In October 2012 I attended a Health Roundtable workshop in Sydney. There were some really bright people from all over Australia and New Zealand there, representing just about every speciality in health care. During a break a I got chatting to a Physiotherapist, Judy Chen, who introduced me to the word/concept of “prehabilitation” or “prehab”. Prehab is where the patient is taught and practices the skills and exercises that s/he will required for post-operative recovery before the operation.

For example, let’s pretend that you require an operation on your right knee which will leave you on crutches for a week afterwards; you must avoiding twisting movements, but to maintain a full range of movement after the healing is completed, you’ll need to bend the knee and partially weight-bear as soon as possible post-op. Wouldn’t it be better to get accustomed to using crutches and practice the movements/exercises required when you’re not experiencing post-surgical pain, and you don’t have IV drips, drains and wound dressings hampering your mobility? That’s the premise of prehab; practice the exercises and/or using a mobility aid while in comparatively good shape, so when you’re in not-such-great shape you won’t have to be learning a new skill set from scratch.

Who would've guessed that physiotherapy could inform psychotherapy?

Who would’ve guessed that physiotherapy could inform psychotherapy?

Prehab is a good idea, eh?

It’s OK for perinatal mental health nurses to shamelessly steal ideas from physios, isn’t it?

I hope so.

Precovery

PrecoveryPerinatal Mental Health Precovery would borrow the prehab idea, and encourage pregnant women and new mums to acquire supports and practice skills before symptoms of depression and anxiety arise. Precovery will be built-in to antenatal care: just part of the everyday health service routine.

So, what would precovery include? Well that’s where I’m looking for input – I’m really hoping to draw on the wisdom of others to come-up with a more complete, more rounded-out notion as to what to include in precovery.

Reflecting some good clinical practices I’ve been exposed to/heard about, here are some of the components I’d suggest for Perinatal Mental Health Precovery:

[Precovery 1] Create or Reinforce Support Networks

Antenatal and Parenting classes – for most women I’ve spoken to, the content/information in the classes is less valued that the relationships/contacts made with other parents. The notion of “teaching” and “learning” is a bit of a smokescreen for the really valuable stuff: “connection” and “attachment”.

Playgroup – as long as it’s a supportive, friendly playgroup. Some of the mums I’ve met tell me that some playgroups can feel a bit competitive, and give their sense of confidence a bit of a bruising. To quote a delightful lady I met with a few times, “You know those f#@*%^g Lorna Jane mums? The perfect ones who look great, have babies that sleep well and breastfeed like champions? The playgroup I went to was full of them. And then there was milk-soured, frumpy, messy me with mastitis and a bottle-fed baby. It was awful. I felt worse. I had to stop going.”

Targeted supports – eg: teenage mums will almost certainly feel much more comfortable, better supported, if they get to meet with other young women who are pregnant/have new babies.

[Precovery 2] Informed & Supportive Significant Others

A supportive partner can have an incredibly positive influence; traditionally that is baby’s father, but families come in all shapes and sizes now – the supportive partner isn’t always a bloke, and there’s not always one on the scene. When baby’s father is on the scene, let’s get him worded-up on how important he is to both mother and baby. The beyondblueHey Dad” booklet can get the conversation started. In same-sex relationships, maybe grab the same free booklet, and a bottle of liquid paper and a pen… or (more seriously) connect with others who share your experience – there are some good online forums available, try the Raising Children Network for instance.

If baby’s Dad isn’t around, we need to go looking for a family member(s) or close friend(s) who can step-up and share some of the good, and not so good, stuff. Single parent families are the fastest growing type of family in Australia; some resources and agencies are responding to that better than others – more info here.

[Precovery 3] Symptom Awareness/Monitoring

This will happen to some degree with the universal screening as recommended by the National Perinatal Depression Initiative, and/or via regular contact with GP/Midwife/Obstetrician/Child Health Nurse/Perinatal Mental Health Worker/other clinician.

It is also worth encouraging people who experience depression, anxiety or other mental health difficulties in the past to have a good awareness of what their early-warning signs of relapse are. Significant others can play a part in this too. The online, self-scoring version of the Edinburgh Postnatal Depression Scale could also help some people keep an eye on things. For instance, I encourage many of the women I meet with to visit this site regularly (but not too frequently): justspeakup.com.au/epds Ask the woman’s significant other(s) to use it too – perhaps make a diary date for the first of each of month. This self-awareness/self-monitoring fits nicely with the empowering aspects of recovery, so certainly belongs in precovery.

[Precovery 4] Easy Access to Appropriate Information & Support

Often the supports that help the most aren’t specialist mental health supports. In my clinical experience many Mums have found an approachable Midwife or a friendly, relaxed Child Health Nurse has done more practical stuff to decrease anxiety than weeks of “talk therapy” could ever achieve. Practical parenting supports need to be easy to find – having an online presence, such as Parentline and Tresillian, is part of being easly accessible.

Sometimes the support required will be catered for by phoning the Post & Ante Natal Depression Association (PANDA) on 1300 726 306, and/or a visit to the PANDA website

Other websites such as beyondbabyblues, Just Speak Up, Black Dog Institute and mindhealthconnect are worth visiting, as are some of the grassroots supports that have sprung-up on Facebook – pages such as Daisy Chains Postnatal Support Network and Peach Tree Perinatal Wellness, amongst others.

Hopefully there will be specialist mental health support available in most health districts. Where there isn’t a perinatal mental health service GPs and local mainstream mental health services/clinicians will need to plug that gap as best they can.

[Precovery 5] Recognition of the Uniqueness of the Individual

This will assist us to resist the temptation to imagine “one size fits all’ solutions to complex, individualised circumstances. The values and the goals of the individual will determine what, if any, support is required.

Part of this will require health services to promote realistic expectations. Health services will make sure that families have heard of Donald Winnicott’s concept of “the good-enough mother”, and that those books which prescribe baby or parent behaviour are left in the bookshops just as they should be: unsold and dusty. Let parents know what to expect: if 25% of births end-up as emergency caesarean at this hospital, make sure that’s known: “There are 16 pregnant women in this antenatal class – a bookmaker would take a bet that 4 of you will have an unplanned caesarean section. If you happen to be one of those 4, how will that match-up with your hopes and expectations? Will it mean that you’re a ‘bad mother’ or ‘a failure’?” We need to be proactive about managing idealised, unrealistic versions of the pregnancy/parenting story.

[Precovery 6] Making Real, Informed Choices

This does carry the risk that the clinician’s recommendations are not always followed [see Exhibit A: the cigarette smokers]. However, it carries the benefits of avoiding coercion and inadvertently causing harm by disempowering the individual. Advocating for real, informed choices puts the clinician on a more realistic footing too. Let’s not even entertain the fantasy that every pregnancy/birthing/parenting experience will be ideal – we’re not aiming for perfection, we’re aiming to minimise harm. Bottle feeding works better for your family than breastfeeding? No judgement, no coercion, no worries – shall we run through bottle preparation together? Dignity and respect are also straight out of the recovery model – let’s include them in precovery too.

[Precovery 7] Partnership & Communication

As with advocating for real choices, these are the qualities that will build resilience and trust. Part of precovery will be to provide the individual with opportunities to ask questions and ventilate concerns, and to be supported by the clinician to explore the solutions together.

The other bit of partnership and communication is with the new baby. Let parents know that babies are born with a brain primed for experience, and ready to socialise and learn from day one. Show something like the Getting to Know You DVD in antenatal classes so parents can ready themselves for the communication part of early infancy. New parents may not be aware of baby’s capacity to socialise, learn and explore from the get-go – it would be cruel not to let them in on the secret. That information may, in turn, strengthen the partnership and the quality of attachment between baby and her/his primary caregivers.

Ideas? Comments?

That’s my little brainstorm on what precovery should include. What have I missed? Is this idea of “precovery” as a way to frame perinatal mental health early-intervention and prevention strategies a nutty neologism or a nifty notion?

Please add your thoughts/suggestions in the comments section below.

Paul McNamara, 5th March 2013

Reference

McNamara, P. (2011) Perinatal mental health, O&G Magazine, Vol 12, No 2, Winter 2011, pp 56-7. http://www.ranzcog.edu.au/publication/oandg-magazine/editions/cat_view/38-publications/409-o-g-magazine/410-o-g-magazine-editions/538-vol-13-no-2-winter-2011.html [tragically, shamelessly, self-refrencing again: please note that the “Dr” afforded me in this paper is a typo in the magazine – I don’t have a PhD]

Post Script (added 6th July 2013)

ANJKay McCauley, Senior Lecturer at the Monash University School of Nursing and Midwifery, suggested that I tidy-up this blog post so it would be suitable to publish in a journal. To be honest, I never would have thought of doing so without Kay’s prompt, and am very grateful to Kay for her encouragement and support. The waffly ramblings above were tidied-up and abbreviated to meet the ANJ word limit (I recruited Kay to help with the slash and burn as co-author).

Anyway, I just found out this morning that it has been published. Yay!

Here’s the citation, link and PDF:

McNamara, Paul and McCauley, Kay. (2013). ‘Precovery’: A proactive version of recovery in perinatal mental health. Australian Nursing Journal: , Vol. 21, No. 1, Jul 2013: 38.

http://search.informit.com.au/documentSummary;dn=396717147073212;res=IELHEA

PDF: ANJ

#bePNDaware: Looking Back at Postnatal Depression Awareness Week through a Social Media Lens

Postnatal Depression Awareness Week 2012 in Australia ran from Sunday 18th November to Saturday 24th November. I’m not entirely sure of the history of Postnatal Depression (PND) Awareness Week; my understanding is that it was initiated by beyondblue in the early 2000s, but am quite possibly completely wrong about that. If you know the history please let us all know via the comments section at the bottom of the page.

Reprising an idea I’ve used previously, this post will review PND Awareness Week through a social media lens. Why? Well, until June 2013 I’m in a role funded by the National Perinatal Depression Initiative (NPDI). One of the goals of the NPDI is to raise community awareness about depression and anxiety in the perinatal period. Promoting community awareness is something that I endeavour to do every week, but in PND Awareness Week we trot out a few extra posters and brochures in antenatal clinics and community health waiting rooms, and try out other ways to engage members of the media/community in the conversation. Social media lends itself very well to raising community awareness too, so that’s where I threw a fair bit of effort this year.

Looking back at PND Awareness Week 2011 (13th-19th November) on my now-mothballed @PiMHnurse Twitter account, I see that I used a #PND hashtag, and interacted with only two other Twitter users on the subject. In 2011 I sent twenty-five PND-specific tweets in PND Awareness Week, 18 of them starting with “For Postnatal Depression Awareness Week let’s focus on the positives…” In short, PND Awareness Week 2011 was pretty lonely on Twitter.

By contrast, Twitter was a much more lively, engaging place to be during Postnatal Depression Awareness Week 2012… just have a look at all the participants:

All #bePNDaware Participants 8th November 2012-25th November 2012, courtesy of www.symplur.com

All #bePNDaware Participants 8th November 2012-25th November 2012, courtesy of http://www.symplur.com

PANDA’s Social Media Strategy

For Postnatal Depression Awareness Week 2012 PANDA (Post and Antenatal Depression Awareness Association) released suggestions on how to get involved using social media via a page titled Join the Conversation #bePNDaware. PANDA encouraged use of Facebook, Blogs, Instagram and Twitter as avenues for people to get involved: the primary target group for this is pregnant women and new mums, especially those who have experienced or are experiencing anxiety and/or depression.

Facebook content is difficult to collate, so let’s skip past it here. BTW: if somebody knows an easy way, please let me know.

Fifty (50) blogs were submitted here – there are some very articulate, generous and gutsy stories of the lived experience of perinatal mental health problems on that page. Recommended reading for expecting couples, new parents and health professionals.

Instagram had over 500 photos tagged using the #bePNDaware hashtag. With Instagram installed you’ll be able to view the photos on your smartphone, or alternatively you can browse them online here.

For those interested, there’s an abbreviated compilation of #bePNDaware content from Twitter, Instagram and Facebook (very limited) available here via Storify,

twitter.com/meta4RNTwitter is Not a Toy

Twitter is a great tool for sharing information, which makes it a very good fit for awareness raising campaigns such as Postnatal Depression Awareness Week. PANDA had the wisdom to publicise the #bePNDaware Twitter hashtag a few weeks before Postnatal Depression Awareness Week, which gave me an opportunity to register it as a healthcare social media hashtag with Symplur. As discussed on a previous post Symplur offer an excellent way to track healthcare hashtags; have a look at their analytics here.

So, let’s summarise some of that data. From midnight beginning Thursday 8th November 2012 to midnight ending Sunday 25th November 2012 (Cairns time) there were:

  • 250 Twitter participants using the #bePNDaware hashtag
  • 928 tweets using the #bePNDaware hashtag
  • amongst these tweets, @PANDA_NATIONAL was mentioned more than any other individual or organisation
  • amongst these tweets @beyondblueorg was equal 4th number of mentions with Mamamia
  • @Mamamia, with its very large Twitter following, had the greatest amount of “Tweet Reach” of all those who used the #bePNDaware hashtag . In fact, Mamamia accounted for nearly half of the #bePNDaware impressions as calculated by Symplur (explanatory note here).
  • Overall, the potential Tweet Reach/Impressions topped one and a half million (no – not a typo: one and a half million!). It is an impressive number, but as touched-on in a previous post we should be a little cautious in our interpretation of this.

As a Mental Health Nurse, I’m very pleased that three of the ten most prolific Twitter accounts using #bePNDaware over the period were from my profession: @ACMHN, @nursewhitebeard and @meta4RN (my account). Also in the top ten of most prolific Tweeters were the Australian Multiple Birth Association (@AMBAconvention), PANDA and the social media agency account @BrandMeetsBlog and two of the agency’s members. Two women who shared their lived experience of postnatal depression made up the remaining spots in the top ten. The complete lists are here.

Extracting the #bePNDaware data from www.symplur.com day by day (and adjusting for time zone differences), we can see that Wednesday of Postnatal Depression Awareness Week was by far the busiest in terms of both traffic (312 Tweets) and participation on Twitter (120 participants). I assume that this is because Wednesday coincided with two events: [1] the planned “it’s not always black and white” Instagram event; and [2], this was the time when @Mamamia became involved in using the #bePNDaware hashtag. This needs to be understood in context: at time of writing the two most prolific accounts using the #bePNDaware hashtag were @PANDA_NATIONAL with 260 Twitter followers and @meta4RN with 234 followers. @Mamamia has over 65,000 followers – that’s significant social media clout in the right demographic.

Curious as to what was said on Twitter during the week? Browse through the transcript here: www.symplur.com

So what?

Let’s start with an assumption:

Raising community awareness regarding perinatal mental health = reduced fear/stigma = reduced barriers to support = improved uptake of information and services = reduced impact of anxiety/depression for pregnant women, new mums and their significant others.

I guess that’s the whole idea behind the NPDI citing improved community awareness as one of their key performance indicators. Social media has become another tool (not the only tool) for health promotion. Although I would caution against taking the one and half million impressions too literally, there is no doubt perinatal mental health became part of the thoughts and conversations for many hundreds, probably many, many thousands of people using social media during the week.

What does it cost?

Time. Using HootSuite, I scheduled most of my #bePNDaware Tweets for the week last Saturday morning while watching Rage and drinking coffee (who said blokes can’t multitask?). That allowed me to maintain a presence in the Twitter stream while I went about my paid work. Before and after work and during breaks I could check-in on the hashtag and see what else was going on, then interact and respond as time allowed.

What lessons have we learnt?

PANDA’s multi-channel strategy was certainly instrumental in the success of Postnatal Depression Awareness Week on social media. Pre-announcing the hashtags primed a core group of social media enthusiasts to get the conversation started, to get #bePNDaware off the ground. It was a very sophisticated idea to not just organise a place for relevent blogs to be compiled, but also to provide resources and tips to assist bloggers frame their information in a helpful manner. PANDA and the people supporting their social media strategy deserve to be congratulated. Apart from keeping an eye out for changes in social media fashions (eg: farewell MySpace, hello Pinterest), I don’t think PANDA will need to change their strategy much.

PANDA took the leadership role in this year’s social media campaign; I hope they do so again in 2013.

Next year, it would be great to see the other big-hitters in online info/support/funding re perinatal mental health get more involved in using the same hashtag: @HealthAgeingAU, the state and territory health departments, @beyondblueorg, @beyondbabyblues@blackdoginst, @headspace_aus could each contribute to a #bePNDaware hashtag blitzkrieg. Health professionals and the organisations that unite them could also plan to join in and amplify the social media buzz – I’m proud that the Australian College of Mental Health Nurses @ACMHN is so active in this space. I’m also pleased that NGOs, clinicians, private enterprise, interest groups and those who have “been there, done that” with perinatal depression/anxiety were all able to share their insights into the same subject. Exposure to a range of perspectives is the antidote to tunnel vision.

In 2013, let’s go out of our way to include the non-health sector people in the conversation too. The extra “Tweet Reach” that one social media enterprise – @Mamamia – bought along this year was fantastic. It would be great to have them, and other organisations that interact with the target demographic, onboard in time for the launch of PND Awareness Week 2013.

Now that the #bePNDaware hashtag has been established and has some recognition, let’s try to use it for all tweets that relate to the subject of perinatal mental health: we can use the hashtag all the time, not just for one week a year. The data/analytics/transcripts on www.symplur.com are available to us all.

Never Tweeted before?

If not, a lot of this might be a bit baffling. Like most things, Twitter is odd until you’ve spent a little bit of time with it. When it clicks-in with you you’ll love it.

I’ve covered getting started on Twitter in a previous post (scroll down to about 3/4 mark).

One last thing.

A 12 month old Tweet; the question still remains.

The language around postnatal depression week gets clumsy, because we’re trying to include anxiety and the antenatal period as well, and we don’t want to leave men out of the equation. Should we bite the bullet in 2013 and call it Perinatal Depression Awareness Week? Why not? It would be in keeping with the terminology used in the National Perinatal Depression Initiative. #bePNDaware

As always, your thoughts/comments are welcomed.

Paul McNamara, 25th November 2012

Short URL meta4RN.com/bePNDaware

Using the Edinburgh Postnatal Depression Scale

A core component of Australia’s National Perinatal Depression Initiative (NPDI) is universal screening of all pregnant women and new mums using the Edinburgh Postnatal Depression Scale. The Commonwealth Department of Health and Ageing (DoHA) suggests using it twice – once antenatally, and again a month or so postpartum [reference here]. In Queensland’s public health service, the aim is to use it four times: twice in the antenatal period (usually around 20 weeks, and again midway through the third trimester), and twice postpartum (at 6-8 weeks, and again at 12-16 weeks).

There’s a heap of academic papers about the Edinburgh Postnatal Depression Scale (EPDS), as this simple internet search reveals. This post won’t attempt to replicate such highfalutin work, but just give a few practical tips for clinicians using it.

Tip One: Don’t Believe The Hype

Meaning no disrespect to the authors of the EPDS or those who decided to build Australia’s universal perinatal mental health screening around it, but let’s clearly call the EPDS exactly what it is: a quick and dirty screening tool. Yes it’s been validated in about eleventy-seven different studies, but like all screening tools the EPDS doesn’t pretend to replicate or replace clinical judgement and it certainly doesn’t masquerade as a diagnostic tool. All it does it measure some signs and symptoms of depression and, to a lesser extent, anxiety (more about that in a moment).

The EPDS intentionally limits the screening questions to one week in time. So we need to keep in mind that it’s only takes a snapshot of what’s happening – it doesn’t show us the whole movie. It’s up to the Midwife/General Practitioner/Indigenous Health Worker/Child Health Nurse/whoever to chat with the woman* about whether the snapshot that the EPDS reveals is an accurate glimpse of the big picture. If the woman has had a particularly good or bad week prior to screening the EPDS result will reflect this.

So, when we’re using the EPDS let’s always remind ourselves, and the woman/family we’re working with, that the EPDS isn’t a measure of someone’s psychological strengths or vulnerabilities, nor is it a psychiatric diagnosis. It’s just a reminder, an aidemémoire, that anxiety and depression are pretty common in the perinatal period**, and that we should keep an eye out for some of the common early warning signs.

Tip Two: There’s More Than One Score

Casually (and irreverently) stated, the usual way EPDS results are interpreted goes a bit like this:

  • zero = this person does not trust this service at this time
  • single digits = about what’s expected
  • between ten and twelve = dodgy mood: we had better check-up on the supports in place and arrange to do the EPDS again in a fortnight or so
  • over thirteen = nudge the woman to chat with someone she loves and trusts and/or accept referral for follow-up

That’s pretty good, but we can, and probably should, get a bit smarter about using the results.

Let’s think of the EPDS as four scales.

Yep: four.

The first (most crude) scale is the overall EPDS result [range = 0 to 30]. Interpret as above.

The second (most important) scale is the self-harm/suicide ideation scale: question 10 on the EPDS [range = 0 to 3]. Question 10 asks for a response to the statement, “The thought of harming myself has occurred to me [in the last week]”. If the result is zero that means one of two things: this person hasn’t had thoughts of self-harm recently or this person doen’t trust this service at this time. The response to a score of zero could be something like, “Cool. Just so you know for when you’re chatting to other Mums: it’s not unusual for somebody to feel so overwhelmed that they have uninvited thoughts about hurting themselves. It doesn’t always mean they’re going to do anything silly, of course, but we do like to make sure that they know there are supports available.” Any result on question ten other than zero will require your sensitive, authentic care and some follow-up questions to check on the woman’s safety. Check on whether these thoughts have ever become actions, whether the thoughts are about suicide or non-suicidal self harm, whether there are protective factors in place, and whether this person is safe to go home today (Have you thought about what you would do? When would you would act on those plans?). In my experience people are usually pleased to have an opportunity to speak openly about thoughts of self harm to someone who is caring, not-freaked-out, and non-judgemental. All you’re doing is sensibly, calmly, professionally following-up on a question about depression/risk with the goal of greater understanding.

The third (most ignored) scale is the seven-question depression sub-scale. Questions one and two are fishing around for anhedonia***. Question six seeks to find out whether the woman is feeling overwhelmed, question eight intends to measure mood. Questions seven and nine look to measure for uncharacteristic tearfulness and sleep disturbance. Question ten may be an indicator of feelings of worthlessness. Together, these seven questions measure some of the common neurovegetative symptoms of depression. So, the EPDS depression sub-scale can be expressed as a result out of twenty-one.

The fourth (most handy) scale is the three-question anxiety sub-scale: a measure obtained from scoring questions 3, 4 and 5 in isolation. I find this score out of nine surprisingly useful in clinical practice. Most weeks I’ll get at least one referral where the EPDS total result isn’t very high: say 6 or 7 out of 30. However, a cursory glance at the EPDS reveals that the entire score was generated over just those three questions exploring anxiety symptoms. This transforms a low score into a high score:  6 or 7 out of 30 on the EPDS usually isn’t a big deal, but 6 or 7 out of 9 on the anxiety sub-scale deserves attention.

Confused? Don’t be. Further down the page we will put the four scales into practice using an example EPDS.

Tip Three: EPDS DIY

A spin-off from the beyondblue and beyondbabyblues web sites is the site justspeakup.com.au. There’s some good info there: a first-time Mum I was meeting with earlier this year found Jessica Rowe’s description of her experience of postnatal depression more recognisable, more poignant, and more helpful than anything I said or did. Empowering for her, humbling for me. Sometimes there’s nothing more powerful than sharing stories of the lived experience.

Another good thing about the Just Speak Up site is the self-scoring online version of the Edinburgh Postnatal Depression Scale here: justspeakup.com.au/epds.

If in a room with a PC and it’s appropriate to check the EPDS, you could bring that site up and ask that it be completed (ten mouse-clicks; takes no time) while you busy yourself with another task. Instant scoring! No mathematical challenges or errors! “Shall I print a copy for you to take home or to give your GP?” 

Why not email the justspeakup.com.au/epds link to the woman as a way to promote self-monitoring of changes in mood? If the partner doesn’t quite get with the whole depression/talking about depression thing, suggest that s/he has a go too (it’s fine to use with blokes). You could suggest to the woman that she puts a reminder in her phone to re-visit the EPDS on the first of every month, “You and your partner can compare and contrast scores, if you like. Also, if you’re not sure how to start a chat with your Midwife/GP/Child Health Nurse about your mood you could just print-off the results page and take it in with you to your next appointment… Hey Doc: what do you make of this?

Tip Four: EPDS? There’s an app for that.

There are three iPhone apps that I know of that include the Edinburgh Postnatal Depression Scale (EPDS). NovoPsych is frightfully expensive for the full version so I havent bought it/tried it. SadScale has the EPDS, but it’s kind of… umm… sad. It’s the least attractive iPhone app I’ve ever seen and has a really dodgy email set-up which I’m reluctant to use (no other app has asked me for my email password). The graphing of the results is laughably bad. It’s cheap to try for yourself if you’d like, but I have another suggestion…

Want the EPDS on your phone?

The best app I’ve found so far for the Edinburgh Postnatal Depression Scale is on Mediquations – it’s available for iPhone/iPod Touch/iPad and Android devices for about AU$5. It’s very easy and intuitive to use, calculates the result instantly, and allows you to quickly and easily email the results, including the answer to each of the variables (see below). At least a couple of times a week I’ll hand over my phone the woman I’m meeting with at the time, so we can both compare/contrast today’s EPDS result with previous results. Then I can email the (unidentified) results to my work email address. Why bother? Well, it’s pretty handy to be able to cut and paste the EPDS results directly into the electronic health record, and/or into the letter to the GP, and/or into the follow-up email to the pregnant woman/new mum.

Here’s a cut and paste example of the emailed EPDS result as served-up by Mediquations (for fun: spot the typo on Q9):

Edinburgh Postnatal Depression Scale

Variables:

Able to laugh and see funny side of things: Not so much now (+1)
Have looked forward with enjoyment to things: Rather less than I used to (+1)
Blamed self unnecessarily when things went wrong: Yes, some of the time (+2)
Been anxious or worried for no good reason: Yes, very often (+3)
Felt scared/panicky for no good reason: Yes, quite a lot (+3)
Things have been getting on top of me: No.  Coping as well as ever (+0)
So unhappy resulting in difficulty sleeping: Not very often (+1)
Felt sad or miserable: No, never (+0)
So unhappy that I’ve been crying: Only occassionaly (+1)
Thoughts of harming self: Never (+0)

Results: Score: 12 Depression: Possible

Sent with Mediquations Medical Calculator for iPhone and iPad.

While we’ve got this example here in front of us let’s revisit the four scales thing and see if we can come up with some info that could guide us in clinical practice:

EPDS = 12/30 [let’s repeat it in a fortnight or so]

Q10 = 0/3 [estimate low risk at present]

Depression Sub-Scale = 4/21 [not very indicative of depression, is it?]

Anxiety Sub-Scale = 8/9 [this person is REALLY anxious]

So, despite being a quick and dirty screening tool, the EPDS can be pretty useful. In the example above we would steer the conversation away from depression and get some information and support with the anxiety instead.

Tip Five: Hate Bagpipes but love Didgeridoo?

From the lofty mountains of science/academia the stone tablets have been handed-down: if you change the questions on a scale it will need to be studied to see if it still has validity and fidelity. In the swampy lowlands of clinical practice we sometimes need to be more pragmatic: if the woman/family we are with don’t understand the wording of a tool written for use in Scotland in the mid-1980s, and/or aren’t all that literate with written English, we need to be adaptive. After all, we’re not doing pure research; we’re doing screening, and we’re doing the best we can with what we’ve got.

One example of how the language of the EPDS can be adapted to be more user-friendly for Aboriginal and Torres Strait Islander women is online courtesy of the Kimberley Aboriginal Medical Services Council; see page 3 of their resource here. I’m not suggesting for a moment that you automatically use this version for every Aboriginal or Torres Strait Islander woman who walks through your door, but it might be a handy reference point for other ways to frame the questions if/when required. There’s probably a lot of non-Indigenous Australians who rather use the style of language of this resource too.

Tip Six: English isn’t for Everyone

Half the fun of travelling overseas is practicing (well, mangling) other languages in pursuit of transport, coffee, toilets, hotel rooms and beer. Using bad translations is fine for that sort of stuff, but it’s pretty dopey to go down that path when looking at something important like emotions or, as per question 10 on the EPDS, about thoughts of self harm.

So, what’s a dude to do? Pull out a translated version: there is a very handy resource with 36 translations into languages other than English. Please note that half of the translations aren’t validated, and have a look at the other tips about working across languages/cultures included on the resource.

Reference: Department of Health, Government of Western Australia. (2006). Edinburgh Postnatal Depression Scale (EPDS): Translated versions – validated. Perth, Western Australia: State Perinatal Mental Health Reference Group.

Tip Seven: You Are A Tool

I mean that it the nicest possible way.

The EPDS is a static screening tool that was written over 25 years ago in place 15000km away from Australia. It relies on the woman’s literacy and your numeracy to make it work, and even then it’s not replacing your clinical judgement. The EPDS certainly has validity and usefulness, but at the end of the day it’s still just a screening tool and an aide-mémoire.

You, however, are an educated, empathetic, responsive and proactive human being. You have emotional intelligence, a desire to be of use/service, and an incredible capacity to use your communication and life skills in a warm, caring manner. The EPDS can’t compete with you. You are a potent screening tool for emotional distress. You are more subtle and more powerful than ten questions on a form could ever hope to be. You’re a really sophisticated screening tool: please don’t let that dumb EPDS make you leave the best tool available sitting around unused.

What About Your Tips?

Thanks for reading this far (oops: I didn’t intend to be so verbose). Please feel free to add your tips/suggestions in comments section below.

Author’s Notes

* Every now and then you’ll see that the term “the woman” is used in this post; there’s an explanation for that. Nomenclature is taken pretty seriously in mental health: years ago the term “patient” was replaced with “client”, which has subsequently been replaced with “consumer” or “service user”. There are other terms that are getting bandied-about and trialled too. Midwives call the pregnant people and new mums they see “women” as a collective noun, or “the woman” if using the de-identified singular. I’m currently working with the same customer group and in the same venues as the Midwives, that’s why I’m speaking their language,

** The definition of “perinatal period” varies quite a bit. For data purposes, the Australian Institute of Health and Welfare defines the perinatal period being from 20 weeks gestation until 4 weeks postpartum. In clinical practice the perinatal period includes all of the antenatal period and (here comes the confusing bit) either up to one, two or three years postpartum. Many clinical services, including the one I’m currently working for, include pre-pregnancy, ie: women preparing for pregnancy.  In everyday use, it’s accurate enough to think of perinatal women as those who are planning pregnancy, pregnant or new mums.

*** Anhedonia is psychobabble jargon for loss of pleasure/joy. Anhedonia is the opposite of being hedonistic. Somebody who is being hedonistic might dance on the tables at nightclubs, shag backpackers, and say “Whoohoo!” a lot. Somebody experiencing anhedonia might still do things that would usually be fun, but just not get much enjoyment from them.

Paul McNamara, 14th November 2012

Short URL meta4RN.com/EPD

What is social media saying about perinatal and infant mental health this week?

For the last 12 months or so, under the soon-to-be-mothballed @PiMHnurse Twitter handle, I have been using a tool/website called paper.li to collate information into a weekly “online newspaper” called The Perinatal Mental Health Nurse. I’ve now given it a refresh using my new Twitter account/online social media “brand” @meta4RN.

“The Perinatal Mental Health Nurse” is an online newspaper that attempts to answer the question, “What is social media saying about perinatal and infant mental health this week?”

The purpose of The Perinatal Mental Health Nurse is to attempt to answer the question, “What is social media saying about perinatal and infant mental health this week?”. To flush-out that answer, Twitter, Facebook & Google+ are being used as the data sources, and these search terms have been set: “perinatal mental health” and “infant mental health”. To add a little local and mental health nursing flavour, the terms “ACMHN” (abbreviation/hashtag for “Australian College of Mental Health Nurses”) and “HCSMANZ” (abbreviation/hashtag for “Health Care Social Media Australia & New Zealand”) are also searched on Twitter.

[Addit. 28th November 2012] An additional search term has been added: “#bePNDaware”; this hashtag had strong uptake on social media during Australia’s Postnatal Depression Awareness Week (more info about that here).

The beauty of using paper.li is that it is one of those set-and-forget tools which, at first blush, seems kind of magical and empowering: “Who needs Rupert Murdoch? I just made my own newspaper!” Just set the sources and search terms and paper.li does all the rest for you. How much does it cost? Nothing. How much time does it take to set up? Not much; less than half an hour. However, over time too-frequent updates can become a bit tired, just part of the background noise, the flotsam and jetsam of Web 2.0. Hopefully with The Perinatal Mental Health Nurse the “noise” won’t be too intrusive – the updates have been set to just once a week (Wednesdays at 6.00am, Cairns time), which will be accompanied by an automagical Twitter and Facebook anouncement.

I hope that you’ll find some items of interest in The Perinatal Mental Health Nurse. If not, why not see if there are other paper.li online newspapers that are more to your tastes or, better again, start your own?

One last thing. If you’re looking for a more thoughtfully and academically curated compilation of information regarding perinatal and infant mental health, the best website that I know of is the Perintal and Infant Mental Health LibGuide

Paul McNamara, 20th October 2012

short URL meta4RN.com/PMH-paper

Deploying complex information via a QR Code

The Health Roundtable

The Health Roundtable hosted the Innovation Workshop and Awards in Sydney on 11th and 12th October 2012. David Dean, General Manager of The Health Roundtable, endorsed the views of Futurist Tim Longhurst who said, in his lively and entertaining opening Keynote, “It’s not enough to say it anymore. It’s not enough to publish it anymore. Post it. Get it online. Sharing is the rent you pay for using the internet.” It is with those words echoing in my ears that I have posted a YouTube version of my poster presentation (it’s my first time at this – I’m not all that happy with the visual quality of the video, but want to get it online sooner rather than later).

There were 16 concurrent sessions grouped into 4 streams at the conference. In each session participants were asked to vote for the poster presentation which provided the most useful ideas for implementation at their service. At the end of the conference a summary of all session winners was presentated, and participants were again asked to vote on the idea their health service would be most likely to utilise – this yielded four awards: one for each of the four conference streams.

2012 Innovation Award

That’s me on the left, grinning like a Cheshire Cat. Presenting the Health Roundtable 2012 innovation Awards is Dr Nigel Lyons, Chief Executive of The Agency for Clinical Innovation.

My presentation, “Deploying complex information via a QR Code” won the 2012 Innovation Award in the “Improving Quality of Patient Care” stream of the Health Roundtable’s Innovation Workshops and Awards. Naturally, I am thrilled with the award – it carries prestige and is worth $6000 to the health service that employs me. It is also quite humbling because this certainly wasn’t the “best” idea in terms of sophistication, complexity or outcome – many of the other ideas presented have made more significant acheivements in regards to the quality of patient care, in my view. However, the feedback was that the no-cost/low-cost nature of using QR Codes, the simplicity of implementation, and the ability to apply them to a number of different uses in a number of different settings, made this an idea that could easily be adopted and adapted by many health services. This reflects the stated objective of the Innovation Workshop and Awards: “Shamelessly steal at least one good idea to take back to your health service and use”.

Alternative ideas for using QR Codes in health care seetings include:

  • put a QR Code on a piece of equipment; scanning the code takes the user directly to procedure for using that equipment (procedures will be online)
  • put a QR Code on appoinment letters; scanning the code gives directions to where the appointment will be (using geolocation/the smartphone’s map function)
  • put a QR Code on the closed clinic/office door; scanning the code puts the alternative phone number and/or address straight on to the user’s phone
  • put a QR Code on brochures/posters; this keeps visual clutter on the print version to a minimum, but allows the user to get further information/contact details PRN

Let’s not overstate the utility of QR Codes – they won’t be an effective tool for every demographic group, and certainly won’t replace the written word/existing methods of communication. However, with a little bit of imagination, you might be able to find an application for QR Codes that will enhance your workflow/workplace. Have a look at the YouTube video above if you’re still unsure what this is all about.

Acknowledgements

Joe Petrucci and Kevin Freele of the Cairns & Hinterland Mental Health Service for introducing me to The Health Roundtable earlier this year.

Marion Dixon and Pieter Walker, who are both with The Health Roundtable team, gave very strong encouragement to bring the idea to Sydney. I certainly would not have had the confidence to present the idea to my peers without their encouragement, so hope that Pieter and Marion feel very much a part of the success of the presentation and the 2012 Innovation Award.

Try It For Yourself Now

[1] Grab your smartphone.
[2] Go to the appstore and search “QR Reader”.
[3] Select a free version and download it.
[4] Open the app.
[5] Using the app, line-up this QR code in the middle of scanning screen.
[6] Be amazed.
[7] Ponder and discuss: “How could my workplace use this technology?”

There is a PDF version of the presentation available here: QRprintVersion

Below are JPEG images of the individual slides (click to enlarge).

QR1

 

QR2

 

QR3

QR4

 

QR5

 

QR6

 

QR7

QR8

QR9

 

 

Thanks for visiting – please feel free to leave comments/feedback below – especially if you know how to make future videos less blurry!. 🙂

Paul McNamara, 13th October 2012

Short URL meta4RN.com/QRcode

Breast is best. Bottles are good enough.

Food Standards Australia New Zealand (FSANZ) call for submissions; should infant formula have a risk warning?

Food Standards Australia New Zealand (FSANZ) have released a consultation paper on the regulation of infant formula products in the Food Standards Code. You can access the complete documentation and instructions on submission via this link. Below is one section of consultation paper:

6.7 ‘Breast is best’ warning statement

Subclause 14(3) of Standard 2.9.1 requires the label on a package of infant formula product to contain the warning statement: ‘Breast milk is best for babies. Before you decide to use this product, consult your doctor or health worker for advice’. This statement is often referred to as the ‘breast is best’ statement. This requirement aligns with the recommendations in Article 4a of the WHO Code and Article 4.2 in both the New Zealand CoPMIF and the Australian MAIF agreement (see section 2.1.3). The WHO Code also recommends a statement advising consumers to seek advice from their healthcare professional prior to deciding to use an infant formula product.

Some stakeholders have suggested that the ‘breast is best’ warning statement be amended to a risk-based statement about the risks to infant health of not breastfeeding. These stakeholders state that such a statement would reflect a body of evidence showing that compared to formula feeding, breastfeeding is associated with lower incidence of infection and some chronic diseases, and evidence for improved cognitive development in the breastfed infant.

There should not be a risk-based statement about the risks to infant health of not breastfeeding.

First, please let me attempt to establish my credentials to comment. I have hospital-acquired certificates in both general nursing and mental health nursing, I hold a Bachelor of Nursing, a Master of Mental Health Nursing, and a Certificate in Infant Mental Health. I am a Fellow of the Australian College of Mental Health Nurses. I have been working with pregnant women and new mothers since July 2000, initially on a mental health consultation liaison team, since August 2010 I’ve been in a position that is exclusively to do with perinatal mental health. In these roles I have triaged, spoken-with and supported many hundreds of pregnant women and new mothers (we get about 300 referrals every year).

I don’t have expert knowledge in nutrition, I have never breastfed a baby, and I have no relationship with the Infant Nutrition Council (an industry group representing the manufacturers and marketers of infant formula in Australia and New Zealand).

What I have been privileged with is a front-row seat to pregnant women and new mothers discussing, experiencing, managing and recovering-from the two most prevalent mental health conditions: anxiety and depression. This privileged position has provided more insights into being a Mum than I, as a childless bloke, ever expected to have. On a future post I’ll discuss my position and present the biopsychosocial model of perinatal mood disorders in a bit more detail, but for now I’ll highlight just some of the information relevant to the suggestion that there should be a risk-based statement about not breastfeeding on infant formula packaging.

Austin M-P, Highet N and the Guidelines Expert Advisory Committee (2011) Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Melbourne: beyondblue: the national depression initiative.

The 2011 Australian perinatal mental health clinical practice guidelines state that, “While estimates vary, research suggests that depression, anxiety or both are experienced by at least one in ten women during pregnancy and one in six women in the year following birth.”

1 in 10 antenatally. 1 in 6 postpartum. It’s a big deal.

Not one of the women that I have seen in my clinical role has ever told me that bottle-feeding is the healthiest or easiest thing they can do for their baby. None. Zero. Nada. Zip.

In clinical practice, often women report that one of their biggest disappointments in motherhood has been attempting to breastfeed their baby but being unable to sustain it. Unmet expectations about an ideal pregnancy/birth/parenting experience are very common amongst women who experience anxiety or depression.

We (we the health system, that is) don’t help. As one new Mum said, “I get it: I’ve been to the classes, seen the posters, read the brochures. The message is loud and clear: GOOD MOTHERS BREASTFEED. That makes me a bad mother.”

There are other insights that have come from clinical practice;

  • Depression robs you of resilience and dampens your capacity for pain tolerance, so much so that a cracked nipple, mastitis, or baby that chomps can become intolerable.
  • Depression robs you of the skill of being assertive, so that you don’t feel empowered to have a balanced discussion and feel like you’re being heard if the clinician/health system is relentless in reinforcing the single message that breast is best.
  • Depression robs you of sleep and the luxury of feeling refreshed – if I can offload some of the demands on my time I will feel better; hopefully.
  • Depression makes you feel inadequate, ineffective and stupid – that’s why I can’t breastfeed, no matter how hard I try.
  • Depression and anxiety make me so negative, so prone to thinking the worst, that I just don’t feel safe breastfeeding. It doesn’t matter how good breastfeeding is, I feel as if spending time alone holding this baby is a risk that is not worth taking right now.
  • Depression robs you of joy; I don’t hate my baby, but I can’t stand being around him/her as much as I have been.
  • Depression robs you of power. I don’t have a voice. It is ridiculous that every time I bottle-feed the language and attitude of others makes me feel invalidated. I am making informed decisions about what works best for me/my family right now.

So, with this information in mind, how should we respond to suggestions to concentrate on the risks of not breastfeeding? Perhaps we need a tool to support our decision-making; here’s one I prepared earlier:

We (the health system, the community) need to be respectful of what happens within families – they’re a bit like icebergs sometimes, and we don’t always see what’s going-on below the surface. Obviously infant nutrition is important; infants also benefit from having parents who feel supported in making informed decisions, parents who don’t feel that they have to hide from the health system/their peers, and parents that have their emotional and mental health taken into consideration.

Breast is best, but when breast-feeding doesn’t work-out bottles (like parents) are good enough.

Paul McNamara, 29 September 2012

Short URL meta4RN.com/breat-is-best-1