Perinatal Depression FINAL Web 0 (001-078) PDF

Best Practice Guideline
OCTOBER 2018
Assessment and Interventions

for Perinatal Depression
Second Edition
Disclaimer
These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should
be flexible and based on individual needs and local circumstances. They neither constitute a liability nor discharge
from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication,
neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy
of the information contained in them or accepts any liability, with respect to loss, damage, injury, or expense arising
from any such errors or omissions in the contents of this work.
Copyright
With the exception of those portions of this document for which a specific prohibition or limitation against
copying appears, the balance of this document may be produced, reproduced, and published in its entirety, without
modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any
adaptation of the material be required for any reason, written permission must be obtained from RNAO. Appropriate
credit or citation must appear on all copied materials as follows:
Registered Nurses’ Association of Ontario. Assessment and Interventions for Perinatal Depression. 2nd ed. Toronto
(ON): Registered Nurses’ Association of Ontario; 2018.
Funding
This work is funded by the Ontario Ministry of Health and Long-Term Care. All work produced by RNAO is
editorially independent of its funding source.
Contact Information
Registered Nurses’ Association of Ontario
158 Pearl Street, Toronto, Ontario, M5H 1L3
Website: www.RNAO.ca/bpg
Assessment and Interventions
for Perinatal Depression
Second Edition
Assessment and Interventions for Perinatal Depression, Second Edition
Greetings from Doris Grinspun,

Chief Executive Officer, Registered Nurses’ Association of Ontario
The Registered Nurses’ Association of Ontario (RNAO) is delighted to present the

second edition of the clinical best practice guideline Assessment and Interventions
for Perinatal Depression. Evidence-based practice supports the excellence in service
that health professionals are committed to delivering every day. RNAO is delighted
to provide this key resource.
We offer our heartfelt thanks to the many stakeholders who are making our vision
for best practice guidelines a reality, starting with the Government of Ontario
for recognizing RNAO’s ability to lead the program and for providing multi-
year funding. For their invaluable expertise and leadership, I want to thank the
co-chairs of the expert panel—Dr. Angela Bowen (Professor, College of Nursing and Department of Psychiatry,
University of Saskatchewan) and Dr. Phyllis Montgomery (Professor, School of Nursing, Laurentian University).
Thanks to RNAO staff Katherine Wallace (Guideline Development Lead), Glynis Gittens (Project Coordinator),
Laura Ferreira-Legere (Lead Nursing Research Associate), Greeshma Jacob (Nursing Research Associate), Dr.
Lucia Costantini, (Former Associate Director of Guideline Development, Research and Evaluation), Dr. Valerie
Grdisa (Former Director, International Affairs and Best Practice Guidelines) and the rest of the RNAO Best Practice
Guidelines Research and Development Team for their intense work in the production of this Guideline. Special
thanks to the members of the RNAO expert panel for generously providing their time and expertise to deliver a
rigorous and robust clinical resource. We couldn’t have done it without you!
Successful uptake of best practice guidelines requires a concerted effort from educators, clinicians, employers,
policy-makers and researchers. With their unwavering commitment and passion for excellence in-patient care, the
nursing and health-care communities have provided the expertise and countless hours of volunteer work essential
to the development and revision of each best practice guideline. Employers have responded enthusiastically by
nominating best practice champions, implementing guidelines, and evaluating their impact on patients and
organizations. Governments at home and abroad have joined in this journey. Together, we are building a culture of
evidence-based practice.
We invite you to share this guideline with your colleagues from other professions because we have so much to learn
from one another. Together, we must ensure that the public receives the best possible care every time they come in
contact with us—making them the real winners in this important effort!
Doris Grinspun, RN, MSN, PhD, LLD(Hon), Dr (hc), FAAN, O. ONT

Chief Executive Officer
Table of Contents
How to Use This Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Purpose and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Interpretation of Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Quality of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
BACKGROUND
Summary of Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
RNAO Best Practice Guidelines Research and Development Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
RNAO Best Practice Guidelines Expert Panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Stakeholder Acknowledgement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Background Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Guiding Frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Algorithm for Perinatal Depression Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Practice Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Education Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
R E C O M M E N D AT I O N S
Organization and System Policy Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Research Gaps and Future Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Implementation Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Guideline Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Process for Update and Review of Best Practice Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Reference List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

REFERENCES
BEST PRACTICE GUIDELINES • w w w. R N A O . c a 3

Table of Contents
Appendix A: Glossary of Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Appendix B: Best Practice Guideline Development Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Appendix C: Process for Systematic Review and Search Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Appendix D: Diversity among Pregnant and Postpartum Persons with Perinatal Depression. . . . . . . . . . . . . . . . . . . . 134
Appendix E: Examples of Perinatal Depression Screening Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Appendix F: Examples of Perinatal Depression Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

APPENDICES
Appendix G: Considerations for Selecting a Perinatal Depression Screening Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Appendix H: Responding to an Identified Risk of Maternal Suicide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Appendix I: Edinburgh Postnatal Depression Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Appendix J: Edinburgh Postnatal Depression Scale – French / Échelle de dépression postpartum d’Edinburgh. . . . . . 155
Appendix K: Administration and Interpretation of the Edinburgh Postnatal Depression Scale . . . . . . . . . . . . . . . . . . 156
Appendix L: Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Appendix M: Description of the Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

ENDORSEMENTS
Endorsements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
N OT E S
4 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O
How to Use This Document
BACKGROUND
This nursing Best Practice Guideline (BPG)G* is a comprehensive document that provides resources for evidence-
based nursing practice. It is not intended to be a manual or “how-to” guide, but rather a tool to guide best practices
and enhance decision-making for nursesG, the interprofessional teamG, educators, policy-makers, personsG, and
familiesG in the assessment and interventionsG for perinatal depressionG. This BPG should be reviewed and applied
in accordance with the needs of individual organizations or practice settings and the needs and preferences of
persons and their families accessing the health system. In addition, it offers an overview of appropriate structures and
supports for providing the best possible care, based on evidence.
Nurses, the interprofessional team, and administrators who lead and facilitate practice changes will find this
document invaluable for developing policies, procedures, protocols, educational programs, assessments,
interventions, and documentation tools. Those who provide direct care will benefit from reviewing the
recommendations and supporting evidence. We encourage practice settings to adapt the BPG in formats that are
feasible for daily use.
If your organization is adopting this BPG, we recommend that you follow these steps:
1. Assess your existing policies, procedures, protocols, and educational programs in relation to the
recommendations in this Guideline.
2. Identify existing needs or gaps in your policies, procedures, protocols, and educational programs.
3. Note the recommendations that are applicable to your setting and that can be used to address your organization’s
existing needs or gaps.
4. Develop a plan for implementing the recommendations, sustaining best practices, and evaluating outcomes.
Implementation science resources, including the Registered Nurses’ Association of Ontario (RNAO) Toolkit:
Implementation of Best Practice Guidelines (1), are available at www.RNAO.ca. In addition, all of the RNAO BPGs
are available for download on the RNAO website at RNAO.ca/bpg. To locate a particular BPG, search by keyword or
browse by topic.
We are interested in hearing how you have implemented this Guideline. Please contact us to share your story.
* Throughout this document, terms in bold marked with a superscript G (G) can be found in the Glossary of Terms
(Appendix A).

Purpose and Scope

BACKGROUND
RNAO’s BPGs are systematically developed, evidence-based documents that include recommendations for nurses,
the interprofessional team (including, but not limited to physicians, midwives, social workers, lactation consultants,
and psychologists), educators, policy-makers, and persons and their families to improve outcomes on specific clinical
and healthy work environment topics (2). This BPG replaces the RNAO BPG Interventions for Postpartum Depression
(3). The purpose of this BPG is to present evidence-based recommendations for nurses and the interprofessional
team across all care settings to enhance the quality of their practices to support the reduced incidence of perinatal
depression through the implementation of five components of care: routine screeningG, assessment, prevention,
coordinated interventionsG, and evaluation. In this BPG, perinatal depression refers to a mood disorder occurring
during pregnancy and postpartum, up to one year following childbirth. Where applicable, depression occurring only
during pregnancy (i.e., prenatal depressionG) or postpartum (i.e., postpartum depressionG) is identified.
RNAO convened an expert panel in 2015 consisting of a group of individuals across a variety of health-care settings
with expertise in perinatal depression. The RNAO expert panel was interprofessional: it was comprised of nurses and
members of the interprofessional team who hold clinical, administrative, and academic positions. The expert panel
has experience working with persons with perinatal depression and their families in different health-care settings
such as acute, community, public, and primary health care, and organizations, including associations and teaching
institutions.
The scope of this BPG recognizes perinatal depression as the most commonly occurring mood disorder during
pregnancy and postpartum, as determined through findings in evidence in this area and RNAO expert panel
consensus. As such, all other perinatal mood disorders (e.g., postpartum psychosis) or anxiety, as either a co-
morbidity or sole morbidity, were excluded. Furthermore, while recognition is given to the impact that perinatal
depression can have on partners, infants, other children, and families (as defined by the person), the scope of this
BPG is limited to the person at risk for or experiencing perinatal depression.
As an overarching principle, the expert panel asserted that all persons who are at risk for or are experiencing perinatal
depression must have access to available routine screening, assessment, prevention, intervention, and evaluation,
using evidence-informed approaches. Such an approach creates opportunities to address a person’s perinatal
depression needs and goals, improve outcomes, and mitigate risks associated with a lack of treatment.
Types of Recommendations
The recommendations in this BPG apply to clinical care in a range of community and health-care settings. All of the
recommendations are based on findings from systematic reviewsG on the most effective clinical assessments and
interventions, educational approaches, and organization and system policy strategies.
Most of the recommendations in this BPG pertain to depression throughout pregnancy and postpartum.
The exception is where the evidence is focused on either pregnant or postpartum persons, in which case the
recommendation specifies it as either for prenatal or postpartum depression. The recommendations are provided at
three levels.
 Practice recommendationsG are directed primarily to nurses and the interprofessional team who provide care to
pregnant and postpartum persons at risk for or experiencing perinatal depression across health system settings
BACKGROUND
(e.g., acute care, home health care) and in the community (e.g., primary care and public health). All of the
recommendations are applicable to the scope of practice of registered nurses, registered practical nurses, and nurse
practitioners.
 Education recommendationsG are directed to those responsible for educating nurses and the interprofessional
team, such as educators, quality improvement teams, managers, administrators, and academic and professional
institutions. These recommendations outline core training strategies required for postsecondary curriculum,
ongoing education, and professional development.
 Organization and System Policy recommendationsG apply to managers, administrators, and policy-makers
responsible for developing policy or securing the supports required within health-care organizations for
implementing best practices.
Recommendations in the three areas (practice, education, and organization and system policy) focus on evidence-
based strategies that nurses and the interprofessional team require for perinatal depression screening, assessment,
prevention, interventions, and evaluation. Additionally, the recommendations describe the necessary resources for
coordinated mental health services and supports in perinatal depression across regions and communities. As such,
the three types of recommendations should be implemented together for optimal effectiveness.
Recommendations pertaining to screening and assessment tools integrate the reviewed literature but do not include
a preference for any one tool. Organizations are encouraged to choose a screening and assessment tool supported
by evidence. Examples of tools for perinatal depression screening or assessment are included in Appendix E and
Appendix F.
Various factors will affect the implementation of the recommendations in this BPG. These include individual
organizations’ policies and procedures, government legislation, and the demographic and socio-economic
characteristics of the person accessing mental health services and supports in perinatal depression.
Discussion of Evidence
The Discussion of Evidence that follows each recommendation statement has five main sections:
1. The “Evidence Summary” outlines the supporting research from the systematic review(s) that directly relates to
the recommendation.
2. “Benefits and Harms” inform any aspect of care that promotes or deters from the health and well-being of a
person with perinatal depression. Content in this section includes research from the systematic review(s).
3. “Values and Preferences” denote the prioritization of approaches that facilitate health equality and the importance
of consideration for desired care. Content for the “Values and Preferences” section may or may not include
research from the systematic review(s). When applicable, the RNAO expert panel and stakeholdersG contributed
to these areas.
4. “Practice Notes” highlight pragmatic information for nurses and the interprofessional team. This section may
include supportive evidence from other sources (e.g., other BPGs or the RNAO expert panel).
5. “Supporting Resources” includes a list of relevant research studies, resources, and websites that support clinical
practice, education, and organization and system policy recommendations. Content listed in this section was not
part of the systematic review and was not quality appraised. As such, the list is not exhaustive and the inclusion of
a resource in one of these lists does not imply an endorsement from RNAO.

Use of the Term “Person” in this BPG

It is recognized that perinatal depression is not solely experienced by pregnant and postpartum women, but that it
BACKGROUND
also may be experienced by others who may not find identifiers such as ‘woman’, ‘she’ or ‘mother’ representative or
inclusive (4). With respect to this consideration, the term “person”, or “parent” is used whenever possible. Further
discussion of diverse populations and perinatal depression is found in Appendix D.
RNAO Guidelines and Resources That Align with This Guideline:

The following RNAO BPGs and resources may further inform nurses and the interprofessional team when
implementing this Guideline:
 Toolkit: Implementation of Best Practice Guidelines (2012)

 Developing and Sustaining Interprofessional Health Care (2013)
 Social determinants of healthG (2013)
 Working with Families to Promote Safe Sleep for Infants 0 – 12 Months of Age (2014)
 Engaging Clients Who Use Substances (2015)
 Person- and Family-Centred Care (2015)
 Intra-Professional Collaborative Practices among Nurses (2016)
 Crisis Intervention for Adults Using a Trauma-Informed Approach (2017)
 Integrating Tobacco Interventions into Daily Practice (2017)
 Implementing Supervised Injection Services (2018)
 Breastfeeding – Promoting and Supporting the Initiation, Exclusivity, and Continuation of Breastfeeding for
Newborns, Infants, and Young Children (2018)
A reference list and collection of appendices follow the guideline’s recommendations and discussions of evidence.
Appendix B details the BPG development process and Appendix C describes the process utilized for the systematic
reviews and search strategies. The remaining appendices include resources related to the screening, assessment,
prevention, interventions, and evaluation of perinatal depression.
Interpretation of Evidence
BACKGROUND
Levels of evidence are assigned to each study to denote the research design. Higher levels of evidence indicate
that fewer potential sources of bias influenced the research findings, thus reducing alternative explanations of the
phenomenon of interest. Levels of evidence do not reflect the quality of individual studies or reviews.
In some cases, guideline recommendations are assigned more than one level of evidence. This reflects the inclusion of
multiple studies to support the recommendation. For transparency, the level of evidence for each component of the
recommendation statement is identified in the discussion of evidence.
Table 1: Levels of Evidence
LEVEL SOURCE OF EVIDENCE
Ia Evidence obtained from meta-analysisG or systematic reviews of randomized controlled

trialsG, and/or synthesis of multiple studies primarily of quantitative research.
Ib Evidence obtained from at least one randomized controlled trial.
IIa Evidence obtained from at least one well-designed controlled studyG without
randomization.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental
studyG, without randomization.
III Synthesis of multiple studies primarily of qualitative researchG.
IV Evidence obtained from well-designed non-experimental observational studies, such as

analytical studiesG or descriptive studiesG, and/or qualitative studies.
V Evidence obtained from expert opinion or committee reports, and/or clinical experiences
of respected authorities.
Sources: Adapted by the RNAO Best Practice Guideline Research and Development team from Scottish Intercollegiate Guidelines Network. SIGN 50: a
guideline developer’s handbook. Edinburgh (UK): Scottish Intercollegiate Guidelines Network; 2011; and Pati D. A framework for evaluating evidence in
evidence-based design. HERD. 2011;21(3):105-12.

Quality of Evidence
BACKGROUND
The quality of each research study was determined using critical appraisal tools. Quality was ranked as high,
moderate or low and cited in the discussion of evidence. The validatedG and published quality appraisal tools used to
judge the methodological strength of the studies included The Critical Appraisal Skills Program (CASP) for primary
studies and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) for systematic reviews. The
quality rating was calculated by converting the score on the appraisal tool into a percentage.
When other guidelines informed the recommendation and discussion of evidence, the Appraisal of Guidelines for
Research and Evaluation Instrument II (AGREE II) tool was used to determine the quality rating. Tables 2 and 3
highlights the scores required to achieve a high, moderate, or low-quality rating.
Table 2: Quality Rating for Reviews using Critical Appraisal Tools
QUALITY SCORE ON APPRAISAL TOOLS OVERALL QUALITY RATING
Greater than, or equal to, a converted score of 82.4 per cent High
A converted score of 62.5–82.3 per cent Moderate
Less than, or equal to, a converted score of 62.4 per cent Low
Table 3: Quality Rating for Guidelines using the AGREE II tool
QUALITY SCORE ON THE AGREE II OVERALL QUALITY RATING
A score of 6 or 7 on the overall guideline quality High
A score of 4 or 5 on the overall guideline quality Moderate
A score of less than 4 on the overall guideline quality Low

(Not used to support recommendations)
Summary of Recommendations
BACKGROUND
This guideline replaces the RNAO BPG Interventions for Postpartum Depression (3).
LEVEL OF
PRACTICE RECOMMENDATIONS EVIDENCE
Research Question #1:

In the area of perinatal mental health, what are effective screening and assessment strategies for identifying symptoms of
depression during pregnancy and postpartum for up to one year after childbirth?
1.0 Recommendation 1.1:

Assessment Ia, IV, V
Routinely screen for risk of perinatal depression, using a valid tool, as part of prenatal
and postpartum care.
Recommendation 1.2:
Conduct or facilitate access to a comprehensive perinatal depression assessment with IIb, IV, V
persons who screen positive for perinatal depression.

In the area of perinatal mental health, what are effective interventions for persons experiencing depression during pregnancy
and postpartum for up to one year after childbirth?

Interventions Collaborate with the person to develop a comprehensive person-centred plan of Ia, IV, V
care, including goals, for those with a positive screen or assessment for perinatal
depression.
Recommendation 2.2:
Implement prevention strategies for perinatal depression to reduce the risk Ia, Ib, IIb
of illness progression.
Recommendation 2.3:
Promote self-care strategies for persons at risk for or experiencing perinatal
depression including:
 Time for self (level of evidence= IV); Ia, Ib, IV
 Exercise (level of evidence = Ia);
 Relaxation (level of evidence = Ib); and
 Sleep (level of evidence = Ia, IV).
Recommendation 2.4:
Encourage persons with perinatal depression symptoms to seek support from their Ia, Ib, IV
partner, family members, social networks and peers, where appropriate.

LEVEL OF
PRACTICE RECOMMENDATIONS EVIDENCE
BACKGROUND

Interventions Provide or facilitate access to psychoeducational interventions to persons at risk for or Ib
experiencing perinatal depression.
Recommendation 2.6:
Provide or facilitate access to professionally-led psychosocial interventions, including Ia, Ib
non-directive counselling, for persons with perinatal depression.
Recommendation 2.7:
Provide or facilitate access to psychotherapies, such as cognitive behavioural therapy Ia, Ib
or interpersonal therapy, for perinatal depression.
Recommendation 2.8:
Support informed decision-making and advocate for access to pharmacological Ia, Ib
interventions for perinatal depression, as appropriate.
Recommendation 2.9:
Facilitate informed decision-making regarding the use of complementary and Ia
alternative medicine therapies for perinatal depression.
Recommendation 2.10:
Evaluate and revise a plan of care for perinatal depression, in collaboration with the V
person, until goals are met. Include the person’s partner, family, and support network,
where applicable.
LEVEL OF
EDUCATION RECOMMENDATIONS EVIDENCE
BACKGROUND
What education and training in perinatal depression are required to ensure the provision of effective assessment and
interventions among nurses and the interprofessional team?
3.0 Recommendation 3.1

Education Develop educational programs on perinatal depression care incorporating both theory IV
and clinical practice into undergraduate nursing and other allied health professional
pre-licensure curricula.
Recommendation 3.2:
Participate in ongoing professional development to enhance knowledge and skills in Ia, IIb, IV
mental health services and supports for perinatal depression.
Recommendation 3.3:
Ia, IV
Perform regular self-reflection on attitudes and beliefs regarding perinatal depression.
LEVEL OF
ORGANIZATION AND SYSTEM POLICY RECOMMENDATIONS EVIDENCE

How do health-care organizations and the broader health-care system ensure optimal prevention, assessment, and interventions
for perinatal depression?
4.0 Recommendation 4.1

Organization Implement comprehensive and coordinated mental health services and supports for
and System Ib, IV
perinatal depression across communities to support care strategies provided by nurses
Policy and the interprofessional team.

Registered Nurses’ Association of Ontario (RNAO)

Best Practice Guidelines Research and
BACKGROUND
Development Team
Katherine Wallace, RN, BScN, BHSc Dr. Lucia Costantini, RN, PhD
(Midwifery), MHS Former Associate Director
Guideline Development Lead Guideline Development, Research & Evaluation
Registered Nurses’ Association of Ontario Registered Nurses’ Association of Ontario
Toronto, ON Toronto, ON
Greeshma Jacob, RN, MScN Laura Legere, RN, MScN

Guideline Development Methodologist Former Senior Nursing Research Associate
Glynis Gittens, BA (Hons.) Ifrah Ali, BA (Hons)

Guideline Development Project Coordinator Guideline Development Project Coordinator
Megan Bamford, RN, BScN, MScN Dr. Valerie Grdisa, RN, MS, PhD
Senior Manager Former Director
Guideline Development and Research International Affairs and Best Practice Guidelines
Registered Nurses’ Association of Ontario Centre
Toronto, ON Registered Nurses’ Association of Ontario
Toronto, ON
Dr. Lynn Anne Mulrooney, RN, MPH, PhD
Senior Policy Analyst Rita Wilson, RN, MN, MEd
Registered Nurses’ Association of Ontario eHealth Program Manager
Toronto, ON Registered Nurses’ Association of Ontario
Toronto, ON
Dr. Shanoja Naik, PhD, MPhil, MSc, BEd, BSc
Data Scientist/Statistician-Health Outcomes Research,
NQuIRE
Toronto, ON
Registered Nurses’ Association of Ontario (RNAO)

Best Practice Guidelines Expert Panel
BACKGROUND
Angela Bowen, RN, PhD Barbara Bowles, RN, BScN, PNC(C)
Panel Co-Chair Staff Nurse
Professor Niagara Health
College of Nursing and Department of Psychiatry St. Catharine’s, ON
College of Medicine
University of Saskatchewan Shannon Dowdall-Smith, RN, PhD
Saskatoon, SK Foundational Standard Specialist
Sudbury District Health Unit
Phyllis Montgomery, RN, PhD Sudbury, ON
Panel Co-Chair
Professor, School of Nursing Marilyn Evans, RN, PhD
Laurentian University Associate Professor
Sudbury, ON Arthur Labatt Family School of Nursing
University of Western Ontario
Teresa Bandrowska, RM London, ON
Lead Midwife, Ottawa Birth and Wellness Centre
Partner, Midwifery Group of Ottawa Denise Hébert, RN, MSc
Ottawa, ON Program Manager
Healthy Babies, Healthy Children Program
Jessica Bawden, RN (EC), MScN Ottawa Public Health
Primary Health Care Nurse Practitioner Ottawa, ON
Women’s College Hospital Family Health Centre
Toronto, ON Bernadette Kint, RN, BACUR, CCHN
Manager, Healthy Families
Heidi Birks, RPN Toronto Public Health
Professional Practice Associate Toronto, ON
Registered Practical Nurses Association of Ontario
Mississauga, ON Karen McQueen, RN, PhD
Associate Professor
Sue Bookey-Bassett, RN, BScN, MEd, PhD School of Nursing
Research and Development Leader Lakehead University
Collaborative Academic Practice, Thunder Bay, ON
Academic Affairs Research & Innovation
University Health Network Lynn Moulton, RN, BN, MPH, IBCLC
Toronto, ON Public Health Nurse
Reproductive Child Health Program
Durham Region Health Department
Whitby, ON

Linda Rankin, EdD(c), MA, BSW, RSW, ECE Simone Vigod, MD, MSc, FRCPC
Director, Psychiatrist, Women’s College Hospital
BACKGROUND
Northern Ontario Postpartum Mood Disorder Strategy Assistant Professor, University of Toronto
Thunder Bay, ON Toronto, ON
Declarations of interest that might be construed as constituting an actual, potential, or apparent conflict were made
by all members of the RNAO expert panel, and members were asked to update their disclosures regularly throughout
the BPG development process. Information was requested about financial, intellectual, personal, and other interests
and documented for future reference. No limiting conflicts were identified. Declarations of competing interest are
posted as a separate document on the RNAO website.
Stakeholder Acknowledgement
BACKGROUND
RNAO is committed to obtaining feedback from (a) nurses from a wide range of practice settings and roles, (b)
knowledgeable administrators and funders of health-care services, and (c) stakeholder associations as part of the
guideline development process. For this Guideline, stakeholders representing diverse perspectives were solicited* for
their feedback, and RNAO wishes to acknowledge the following individuals for their contribution.
Sarah Anderson, RN, BScN, MN(c) Cindy-Lee Dennis, RN, PhD

Nursing Instructor Algonquin College Professor and Canada Research Chair in Perinatal
Ottawa, ON Community Health
University of Toronto and St. Michael’s Hospital
Philippa Bodolai, MSc, RECE Toronto, ON
Analyst, Research and Policy
Peel Public Health Jocelyne Doucet, RN
Mississauga, ON Public Health Nurse
Algoma Public Health
Ruth Burtnik, RN, BScN Sault Ste. Marie, ON
Public Health Nurse
Niagara Region Public Health Jasmine Gandhi, MD, FRCPC
Thorold, ON Program Leader
Ottawa Regional Perinatal Mental Health Program
Jaime Charlebois, RN, BScN, PNC(C), MScN The Ottawa Hospital
Perinatal Mood Disorder Community Development Ottawa, ON
Coordinator
Orillia Soldiers’ Memorial Hospital Valerie Giroux, MDCM, FRCPC
Orillia, ON Psychiatrist
Montfort Hospital
Barbara Chyzzy, PhD(c) Ottawa, ON
PhD Candidate, Research
University of Toronto Bettyann Goertz, RN, BScN
Toronto, ON Staff Nurse
London Health Sciences Centre
Stefanie Culp, RN, BScN London, ON
NICU/Pediatrics
William Osler Health System Meghan Gyorffy, RN, BScN
Brampton, ON Public Health Nurse, Child Health Program
Simcoe Muskoka District Health Unit
Ariel Dalfen, MD, FRCP(c) Gravenhurst, ON
Psychiatrist, Perinatal Mental Health
Mount Sinai Hospital Kimberley Harkness, RN (EC), MN, PNC(C)
Toronto, ON Nurse Practitioner
University Health Network
Lisa De Panfilis RN, BScN Toronto, ON
Research Assistant
McMaster University
Hamilton, ON

The Healthy Human Kimberley Marshall, RN, BScN

Development Table Public Health Nurse
BACKGROUND
Public Health Ontario Leeds, Grenville, and Lanark District Health Unit
Toronto, ON Gananoque, ON
Carol Johnson, RN, BScN, CMPHN(C) PHN Christine McIntee, RN

Postpartum Clinician Lived Experience
Timiskaming Health Unit Oshawa, ON
New Liskeard, ON
Efisia Orsini, RN, BScN, MHA
Michelle Jones, RN, BScN Public Health Nurse
Public Health Nurse Niagara Region Public Health
Algoma Public Health St. Catharines, ON
Sault Ste. Marie, ON
Sarah Parkinson, RN, MScN, PNC(C)
Lisa Keenan-Lindsay RN, MN, PNC(C) Clinical Nurse Specialist
Professor of Nursing London Health Sciences Centre
Seneca College London, ON
Toronto, ON
Tanya Patry, RN, BScN, IBCLC
Margaret Lebold, RN, BSc, BA, BScN Public Health Nurse
Public Health Nurse Huron County Health Unit
Region of Peel Walkerton, ON
Mississauga, ON
Laurie Peachey, RN, MN, PNC(C)
Nicole Letourneau, RN, BN, MN, PhD, FCAHS Assistant Professor
Professor & ACHF Chair Nipissing University
Parent-Infant Mental Health North Bay, ON
University of Calgary
Calgary, AB Cindy Pritchard, NP, RN(EC)
Nurse Practitioner
Madeline Logan-John Baptiste, RN, Outpatient Mental Health
BSCN, ENC(c), MBA Ontario Shores for Mental Health Sciences
Patient Care Manager Whitby, ON
Mackenzie Health
Richmond Hill, ON Fiona Proctor, RN
Lived Experience
Cailin MacMillan, RN, BNSc Singhampton, ON
Public Health Nurse
Leeds, Grenville, and Lanark District Health Unit Lorrie Reynolds, RN, BScN, MHA, CHE
Gananoque, ON Director Maternal Child
Professional Practice/Deputy Chief of Nursing
Grazyna Mancewicz, RSW, MEd Southlake Regional Health Centre
Social Worker/Therapist Newmarket, ON
Parkdale Community Health Centre
Toronto, ON
Lori Ross, PhD Donna Stewart, CM, MD, FRCPC

Associate Professor Professor
BACKGROUND
Dalla Lana School of Public Health University Health Network
University of Toronto Centre for Mental Health
Toronto, ON University of Toronto
Toronto, ON
Rosemary Scofich, RN, BScN, BA
Public Health Nurse Hilda Swirsky, RN, BScN, MEd
Thunder Bay District Health Unit Staff Nurse
Thunder Bay, ON Sinai Health System
Toronto, ON
Joanne Seitz, MSN, WHNP-BC, CPHQ
Women’s Health Nurse Practitioner Tanya Tulipan, MD
Kaiser Permanente Napa Solano Psychiatrist and Physician
Napa, CA, US Co-Lead Reproductive Mental Health Services
IWK Health Centre
Poonam Sharma, RN, MN Halifax, NS
Public Health Nurse
Region of Peel, Public Health Division Kari Van Camp, RN (EC), MScN, CPMHN(C),
Mississauga, ON CARN-AP, PMHS, CPNP-PC, FNP-BC
Nurse Practitioner
Janet Siverns, RN, MSc Centre for Addiction and Mental Health (CAMH)
Reproductive Health Team Toronto, ON
Public Health Unit
Oakville, ON Jeanie Wyre-Clarke, RN, BScN, MSN
Public Health Nurse
Mary Srebot, RN, PNC(C) Toronto Public Health
Charge Nurse Toronto, ON
Southlake Regional Health Centre
Newmarket, ON
*Stakeholder reviewers for RNAO BPGs are identified in two ways. First, stakeholders are recruited through a public
call issued on the RNAO website (RNAO.ca/bpg/get-involved/stakeholder). Second, individuals and organizations
with expertise in the Guideline topic area are identified by the RNAO Best Practice Guideline Research and
Development Team and the expert panel and are directly invited to participate in the review.
Stakeholder reviewers are individuals with subject matter expertise in the guideline topic or those who may be
affected by its implementation. Reviewers may be nurses, members of the interprofessional team, nurse executives,
administrators, research experts, educators, nursing students, or persons with lived experience and family. RNAO
aims to solicit stakeholder expertise and perspectives representing diverse health-care sectors, roles within nursing
and other professions (e.g., clinical practice, research, education, and policy), and geographic locations.

Reviewers are asked to read a full draft of the BPG and participate in the review prior to its publication. Stakeholder
feedback is submitted online by completing a survey questionnaire. The stakeholders are asked the following
BACKGROUND
questions about each recommendation:

 Is this recommendation clear?
 Do you agree with this recommendation?
 Is the discussion of evidence thorough and does the evidence support the recommendation?
Stakeholders also participated in validating the quality indicators developed to evaluate this BPG’s implementation by
completing a survey questionnaire. The stakeholders assessed certain validation criteria on a 7-point Likert scale for
each quality indicator.
The surveys also provide an opportunity to include comments and feedback for each section of the BPG. Survey
submissions are compiled and feedback is summarized by the RNAO Best Practice Guidelines Research and
Development Team. The team and the members of the RNAO expert panel review and consider all feedback and,
if necessary, modify the BPG content recommendations and indicators prior to publication.
Stakeholder reviewers have given consent to the publication of their names and relevant information in this BPG.
Stakeholder reviewers’ details are current as of the time of their review.
Background Context
BACKGROUND
Perinatal depression is a type of a mood disorder that occurs during pregnancy and postpartum up to one year
following childbirth (5 – 7). Perinatal depression is recognized as one of the most commonly occurring mental illnesses
and, in developed countries, the most frequently under-diagnosed pregnancy complication (5 - 7). It is a significant
cause of disease burden globally as measured by health-care costs, morbidity, mortality, and the number of years
lost to disease; in the province of Ontario, an estimated $20,000,000 is spent annually on complications of untreated
or discontinued prenatal depression treatment, such as preterm and/or low birth weight infants (8 - 9). Globally,
approximately 10 per cent of persons during pregnancy and 13 per cent during early postpartum in industrialized
countries will experience a mental illness, primarily depression (10). Depression can present at different time
points during pregnancy and/or postpartum; it may be a chronic mental illness that continues during pregnancy
and postpartum, a new condition during pregnancy or postpartum, or a relapse (11). Perinatal depression results
in both short- and long-term adverse consequences for the person; those consequences can extend to the person’s
partner, family members, and social network (6, 12). These consequences make it essential that nurses and the
interprofessional team have the knowledge and skills to competently screen, assess, prevent, intervene, and evaluate
perinatal depression (6 – 7).
Any psychiatric disorder can occur during pregnancy or postpartum. The Background Context section outlines
perinatal depression symptoms and risk factors. Adjustment disorder, perinatal anxiety, and postpartum psychosis
are briefly introduced however their specific implications for perinatal practices are beyond the scope of this BPG.
The section begins with a description of postpartum blues, a very common mild mood change. It is included in the
Guideline to differentiate it from perinatal mood disorders spectrum.
Mild Mood Changes

Postpartum Blues
It is important to differentiate postpartum depression from postpartum blues, a very common presentation with a
prevalence of 30 to 75 per cent across diverse culturesG that typically occurs in the first three to five days postpartum
and resolves spontaneously within two weeks (6). Symptoms of postpartum blues may include tearfulness, agitation,
mood swings, generalized anxiety, acute disturbances in appetite and sleep, a perception of being overwhelmed and
uncertain, and irritability (6). Despite this, postpartum blues is not a mild form of depression, and it is not part of the
perinatal mood disorders spectrum. It is unrelated to stress or psychiatric history and it does not impair the person’s
ability to take care of themselves or their infant or cause suicidal ideations (6). Postpartum blues can be attributed to
the rapid decrease in estrogen and progesterone levels following childbirth as the symptoms typically worsen in the
first week and then dissipate once hormonal levels stabilize (6, 13). Care for postpartum blues includes recognition,
reassurance, education, and awareness that it can be a risk factor for postpartum depression (6, 13).
Mood Disorders
Perinatal Depression - Prenatal Period
The prevalence of prenatal depression in Canada can vary depending on the population studied and the screening
toolG used (14). For example, in 2014 the Public Health Agency of Canada reported a prevalence of ten per cent;
whereas a longitudinal community sample indicated a rate of 14.1 per cent in early pregnancy and 10.4 per cent in
late pregnancy (15). Despite the high prevalence, persons at risk are often not detected or treated (14).

Treatments for prenatal depression include psychotherapies and pharmacological approaches, depending on the
severity of symptoms and responsiveness to treatment. Care options may be complex and limited due to concerns of
BACKGROUND
potential harm to the developing fetus or available supports and services (16). As such, nurses and the interprofessional
team must actively support pregnant persons in informed decision-makingG regarding their care (16 - 17). Careful
consideration of the risks and benefits to the person and the fetus are essential (18).
Undetected and/or untreated depression during pregnancy can contribute to complications such as reduced
attendance at prenatal appointments, increased tobacco or alcohol use, higher risk of preterm labour, or low birth
weight (6, 14, 16 – 17, 19). In identifying these complications, however, linkages to social determinants of mental
health are indicated (20). Persons who face social inequalities (such as poverty, discriminationG, and trauma) are at
increased risk of mental illnesses, particularly those experiencing multiple inequalities, and that for interventions to
be effective and to avoid further inadvertent discrimination, they must acknowledge the complex underlying causes
and contributors to depression. For example, missed prenatal appointments may be due to precarious work and
fear of job loss or living in poverty and being unable to afford transportation; continued or increased use of tobacco
during pregnancy may be a coping strategy to reduce hunger pangs or manage stressful emotions (20 - 21).
Perinatal Depression - Postpartum Period

Postpartum depression is the most common complication of childbirth with approximately half of the cases starting
in the prenatal period (5 - 6). Prevalence rates vary; in Canada, data from the Canadian Maternity Experience Survey
indicated a rate of 8.46 per cent of possible depression as measured on the Edinburgh Postnatal Depression Scale
(EPDS) (with a total score of 10 - 12) and 8.69 per cent of probable depression (with a total score of 13 or greater)
(22). In the United States, a 21 per cent prevalence rate of postpartum depression was found during the first year
following childbirth (23). The findings indicated that the majority developed depression following childbirth (40.1
per cent), as opposed to prenatally (33.4 per cent), or pre-conceptually (i.e., prior to pregnancy; 26.5 per cent).
Qualitative research on postpartum depression provides insight into person's lived experiences and reflects the illness
and recovery continuum (24). Four different and unique phases have been identified that describe the journey from
illness to recovery for postpartum depression:
1. Spiralling downward: the experience of emotions, such as anxiety, feeling overwhelmed, isolation and guilt.
2. The incongruity between expectations and reality of motherhood: the experience of conflicting expectations
and fear of being labelled.
3. Pervasive loss: a sense of loss (including loss of self, control, relationships with others, and voice).
4. Making gains: the experience of struggling to survive, reaching out for help and reintegration, and change.
Symptom recognition, support, and treatment are essential as a lack of care leads to adverse outcomes, including
further isolation, helplessness, and hopelessness (25). Untreated postpartum depression can result in a person feeling
a lack of bonding, gratification, or fulfillment in their role as a parent or miss cues for their infant, such as hunger
or other needs (26 - 27). For children of parents with untreated depression, there is an increased risk of behavioural
problems and delayed language, motor, social, and cognitive development (26, 28). In the long-term, children can be
at higher risk of continued emotional issues or exhibiting aggressive behaviours as adults (26).
Perinatal Depression Symptoms

Although symptoms of postpartum depression vary for each person, they typically begin within the first four to
BACKGROUND
six weeks following birth, but they can occur at any time within the first year following childbirth (23, 29). Criteria
of symptoms of perinatal depression are varied, depending on the source. For example, the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders - 5 (DSM-5) identifies perinatal depression as a type of major
depressive disorder with a peripartum onset, and symptoms occurring on a daily or near-daily basis over a two-
week time frame or longer (29). Criteria for a diagnosis of perinatal depression, according to the DSM-5, include
experiencing either a depressed mood or a loss of interest or pleasure in activities previously enjoyed, in addition to
other symptoms including:
 difficulties with sleep (insomnia or hypersomnia), almost every day;
 a weight loss or gain of at least five percent or more over one month not due to dieting or overconsumption;
 observed agitation;
 loss of energy or fatigue on a daily basis;
 difficulties with concentration or decisiveness;
 feelings of worthlessness or inappropriate guilt; or
 recurring thoughts of death or suicidal ideation with or without a specific plan (29).
Table 4 lists additional signs and symptoms of perinatal depression categorized here according to mood, thoughts,
and physical health/behaviours.
Table 4: Moods, Thoughts, and Physical Health/Behaviours Associated with Perinatal Depression
PHYSICAL HEALTH/
MOODS THOUGHTS
BEHAVIOURS
 Sadness  Difficulties with  Loss of appetite

 Loss of interest or pleasure concentration  Changes in physical
(anhedonia)  Low self-esteem appearance
 Feelings of guilt  Loss of focus  Sleep disturbances
 Mood swings  Difficulties with decision-  Tearfulness
 Anxiety
making and thought  Low energy
processes
 Hopelessness
 Suicidal ideation
 Fear of being alone with
 Excessive worrying
the baby due to difficulties
with coping  Irritability
 Self-doubt in activities, such

as care-taking of the infant
Sources: Banti S, Borri C, Camilleri V, et al. Perinatal mood and anxiety disorders. Clinical assessment and management. A review of current literature. Ital
J Psychopath. 2009;15(4):351–366; O’Hara MW, McCabe JE. Postpartum depression: Current status and future directions. Annu Rev Clin Psychol. 2013;
9:379–407; and Zauderer C, Davis W. Treating postpartum depression and anxiety naturally. Holist Nurs Pract. 2012;26(4):203–209.

Some symptoms of perinatal depression, such as sleep disturbances and irritability, are also common in pregnancy
therefore the severity and impact on functional status need further assessment to determine whether they are
BACKGROUND
depression symptoms or normal transition. Similarly, as feelings experienced during infant care-taking, such as self-
doubt or worrying, can resemble perinatal depression, it is important that nurses and the interprofessional team are
educated on the differences to be able to determine if a depression is developing or not (6 – 7, 30).
Although symptoms of perinatal depression may vary, there can be commonalities in how persons express or describe
their symptoms as listed in Table 5.
Table 5: Examples of Statements Suggesting Depression Symptoms
DEPRESSION
EXAMPLE OF STATEMENTS TO DESCRIBE THESE SYMPTOMS
SYMPTOM
Low energy, “Everything is an effort.”

lethargy
Low self-esteem “I am a failure as a parent, person, and spouse.”
Sadness “I want to cry all the time.”
Suicidal ideation “I think everyone would be better off without me.”
Anxiety, regret, “I have made a terrible mistake.”

remorse
Loss of focus, “I feel like I am living in a fog.”

disorientation,
confusion
Source: Accortt E, Wong M. It is time for routine screening for perinatal mood and anxiety disorders in obstetrics and gynecology settings. Obstet Gynecol
Surv. 2017;72(9):553-568.
Risk Factors for Perinatal Depression

The etiology of perinatal depression is unique for each person and often multi-factorial (6, 31). As such, life
circumstances and situations that affect mental health and depression risk must be recognized. Through the processes
of history taking, screening, and assessment for perinatal depression, awareness of risk factors can support the
identification of those factors and the potential need for and benefits of interventions (20).
Several recommendations in this BPG refer to persons at risk for perinatal depression and recognize the impact
that multiple or intersecting risk factors, including the social determinants of mental health, have on increasing
the risk of perinatal depression. Those living with social inequities may be at highest risk (6, 20, 32). For example,
persons such as new immigrants who experience barriers to accessing mental health services and supports due
to factors such as services not available in their first language or low decision-making power in a family can be at
higher risk for perinatal depression (33).
Table 6 lists the risk factors for perinatal depression as categorized in three levels: strong, moderate, and weak. In
listing the risk factors, those identified as the strongest are characterized as variables with the highest likelihood of
BACKGROUND
perinatal depression; moderate risks are those with a medium level of risk; and weak risk factors are those with the
lowest risk for perinatal depression. Examples of risk factors are provided, but they are not meant to be exhaustive of
all possibilities.
Table 6: Risk Factors for Perinatal Depression
STRONG MODERATE WEAK

RISK FACTORS RISK FACTORS RISK FACTORS
 A history of psychiatric  Stressful life events (e.g.,  Low socio-economic status

illness, including depression relationship breakdown  Lack of significant other or
or anxiety at any time, or divorce, losing a job, partner; single parent
including, but not limited to, incarceration, housing
during the perinatal period insecurity)  Pregnancy, as defined by
the person, as unplanned
 Prenatal symptoms of  Refugee or immigrant status or unwanted
anxiety  Low social support or  Breastfeeding challenges,
 The onset of depression perception of low support including a lack of social
during pregnancy or  Unfavourable obstetric support or support by a
postpartum outcome(s) health-care providerG
 Low self-esteem
 A history of physical
or sexual abuse during
childhood or adulthood
 Intimate partner violence
 A history of reproductive
trauma (e.g., infertility)
 Grief related to miscarriage,
stillbirth, or infant loss
 Substance use, including the
use of tobacco
Sources: Bhat A, Byatt N. Infertility and perinatal loss: When the bough breaks. Curr Psychiatry Rep. 2016;18(3):1-11; Ferszt G, Hickey J, Seleyman K.
Advocating for pregnant women in prison: the role of the correctional nurse. J Forensic Nurs. 2013;9(2):105-10; Hamdan A, Tamim H. The relationship
between postpartum depression and breastfeeding. Int J Psychiatry Med. 2012;43(3):243–259; Kozinszky Z, Dudas RB, Devosa I, et al. Can a brief antepartum
preventive group intervention help reduce postpartum depression symptomatology? Psychother Psychosom. 2012;81(2): 98–107; Lancaster CA, Gold KJ,
Flynn HA, et al. Risk factors for depression symptoms during pregnancy: A systematic review. Am J Obstet Gynecol. 2010;202(1):5–14; and O’Hara MW,
McCabe JE. Postpartum depression: Current status and future directions. Annu Rev Clin Psychol. 2013; 9:379–407.
Adjustment Disorders
Adjustment disorders are common and can present with depressed mood (including perinatal depression), anxiety,
or both (29). The diagnostic features of adjustment disorder, as identified by the American Psychiatric Association in
the DSM - 5, includes emotional or behavioural symptoms in response to a specific stressor, such as a developmental
event (e.g., becoming a parent) or other event (e.g., a “difficult” birth or a pregnancy loss) in which the person’s
distress response exceeds what would normally be expected in intensity, quality, or duration or when it negatively
impacts function (29). The disorder occurs within three months from the time of the stressor and resolves within six
months after the stressor.

Perinatal Anxiety
In comparison to perinatal depression, perinatal anxiety is less understood (34). As it is a precipitating factor for
BACKGROUND
postpartum depression, nurses and the interprofessional team must assess anxiety symptoms as either a co-morbidity
with postpartum depression, or a separate condition in the perinatal period (34).
The prevalence and type of anxiety during pregnancy and postpartum varies across study populations (34). It is
estimated that up to 10 per cent of pregnant women will experience a generalized anxiety disorder (i.e., a type of
anxiety with non-specific worries regarding several aspects of life) and up to five per cent will experience a panic
disorder (i.e., a type of anxiety characterized by sudden excessive fear) (34).
Anxiety disorders can present clinically with symptoms such as agitation, cognitive distortions, constant worry,
racing thoughts, shortness of breath, heart palpitations, and restlessness (34). For pregnant persons experiencing
anxiety, they can present with unique concerns and behaviours, such as:
Recurring thoughts about the fetus that may interfere with the person's role and social functioning and that

contribute to generating a heightened emotional state (34).
Experiences of panic and concerns of panic attacks complicating the pregnancy (34).

More frequently reported nausea and vomiting (34).

Requesting more prenatal appointments than others (34).

Increased absences from work due to difficulties coping with the normal physiological changes associated with

pregnancy (34).
Increased reports concerning fetal movements (increased or decreased) (35 – 36).

During labour, anxiety-related complications may include premature labour, including premature rupture of
membranes, low birth weight infants, or a higher risk of birth via caesarean section (35 - 37). In postpartum,
symptoms of anxiety may be aggravated by sleep deprivation, caring for a newborn, or the associated physical,
psychological, and social transitions of parenthood (34).
Perinatal anxiety can be correlated with depression during pregnancy and postpartum (38). There is a positive
correlation between developing anxiety disorders in late pregnancy for persons who experience depression
concurrently (39). Late prenatal anxiety symptoms are also predictive of worsening depression symptoms in the first
three months postpartum (30, 39).
To measure perinatal anxiety, a screening tool, such as the EPDS, can be used as it measures both depression and
anxiety symptoms (37). A valid tool specific to perinatal anxiety has not been established in the evidence as the
feasibility and utility of screening for anxiety is still being determined (37).
Postpartum Psychosis
Postpartum psychosis is the rarest and most severe form of postpartum psychiatric illness occurring in 0.1 to 0.5
BACKGROUND
per cent of persons (6, 30). It is a psychiatric emergency of an acute psychotic event with a rapid clinical onset;
symptoms typically present within the first two to four weeks following birth (6, 40). It is a state in which a person
has bizarre delusions or hallucinations (e.g., the baby is a devil) and/or disorganized speech, thoughts, or behaviours
(6, 30). The person experiences overwhelming confusion and intense changes in their emotional state, such as mood
swings (6). Postpartum psychosis requires an urgent psychiatric assessment most often in an acute care setting. An
untreated psychosis is a potential risk factor for self-harm, suicide, or harm to the infant or other children, therefore,
supervision is required to protect the person (6, 30, 41).
Due to the psychotic state, a partner or family member may need to advocate or seek mental health services or
supports for perinatal depression as the affected person may be unaware of their condition or unable to access
services (6, 30). Prognosis is typically favourable, with a full recovery once the postpartum psychosis has been
identified and treated (6, 30). The underlying cause of postpartum psychosis is unknown, but persons with a history
of bipolar disorder or a previous postpartum psychosis have an increased risk (6, 30).

Guiding Frameworks
BACKGROUND
The following frameworks were used to guide the systematic reviews and the development of recommendations:
social determinants of mental health, person-centred careG, and informed decision-making. Each framework
provides fundamental prerequisite knowledge as a background to the clinical topic. It is recommended that nurses
and the interprofessional team receive adequate education and training through professional development with
respect to these guiding frameworks and apply them in their daily practice.
Social Determinants of Mental Health

When working collaboratively with persons who are at risk for or experiencing perinatal depression, it is essential
to recognize the social determinants that affect their health and well-being, including their mental health (20).
These determinants include a person’s place of birth, where they grew up and currently live, their work, age and
other economic, social, cultural, political and environmental forces and conditions (42). Social determinants of
mental health include health inequities that are modifiable as they are derived from social inequalities (20, 42). They
are systemic in their distribution across the population and are inherently unfair and unjust (43). Public policies,
including those on mental health services and supports for perinatal depression, can address the inequitable division
of power and resources and improve conditions of daily life across the lifespan, including during pregnancy and
postpartum, and in multiple sectors and levels in areas such as work, education, and social programs (20, 42).
Nurses and the interprofessional team must recognize the significance of the social determinants of mental health
to effectively advocate for and work towards eliminating health inequities (44). Knowledge of the impact of social
determinants of mental health needs to be incorporated into all of the components of perinatal depression care
(screening, assessment, prevention, interventions, and evaluation).
Person-Centred Care
Person-centred care is an approach to care that is beneficial to persons at risk for or experiencing perinatal
depression. It focuses on coming to know the whole personG, their experiences of health, and the role of the partner
and family in the person’s life (including the role they may play in supporting the person to achieve health) (45 -
46). Person-centred care is organized around and with the person that reflects their needs, culture, value, beliefs,
and changing health states (47). It respects a person’s preferences, demonstrates cultural sensitivityG and cultural
awarenessG, and involves the sharing of power within a therapeutic relationshipG to improve clinical outcomes and
satisfaction with care (48). It is a shift away from the biomedical model, where the person is viewed within a disease
context as someone who must be diagnosed and treated (45 - 46). For further details regarding the role of nurses and
the interprofessional team and the provision of person- and family-centred careG, refer to the 2015 RNAO clinical
BPG Person- and Family-Centred Care at http://rnao.ca/bpg/guidelines/person-and-family-centred-care
Informed Decision-Making
Throughout the perinatal period, pregnant and postpartum persons make decisions regarding their care. These
decisions may be influenced by their beliefs, values, and social circumstances. It is the responsibility of nurses and
the interprofessional team to facilitate informed decision-making by collaborating with persons and families (where
applicable), and by providing evidence-based information (49). Nurses have an ethical responsibility to recognize,
respect, and promote a person’s right to make informed decisions (49).
The Association of Women’s Health, Obstetrical and Neonatal Nurses (AWHONN) identifies informed decision-
making as a key value of perinatal nursing practice (50). It states that perinatal nurses should:
BACKGROUND
Respect and promote the autonomy of women, helping them to meet their health needs by obtaining appropriate

information and services.
Provide women and families with evidence-based information to facilitate informed decision-making.

Work in partnership with women and their families by respecting their view and supporting their choices,

whenever possible.
Advocate for women, newborns, and families within the context of law and institutional processes.

Work in collaboration with other health-care providers to support the care choices of women and families,

whenever possible (49, p.22).

Algorithm for Perinatal Depression Care

BACKGROUND
The expert panel developed an algorithm that depicts all of the practice and education recommendations for this
guideline. The algorithm embodies the guiding principles of a person-centred approach, informed decision-making
and the social determinants of mental health as factors that influence health outcomes. It should be utilized across
all practice settings in which care is provided to persons during pregnancy and postpartum up to one year following
childbirth (Figure 1, on the following page). In communities where there is limited access to and/or available mental
health services and supports for perinatal depression, the algorithm can guide the mobilization and plan for these
essential services.
The algorithm includes strategies for the five components of perinatal depression care described in this BPG:
screening, assessment, prevention, interventions, and evaluation. Perinatal depression care begins with routine
screening with a follow-up assessment indicated for those with a positive screen. The selection of the screening
tool and its associated cut-off score is recommended to be chosen based on research findings and supported by
organizational policies. Appendix G discusses considerations for the selection of a perinatal depression screening
tool by organizations.
Following the routine screening, persons who have a negative screen (i.e., a total score below a threshold) are
provided knowledge of self-care strategies and the benefits of social support. For persons with a positive screen
(i.e., a total score above a threshold) and a positive assessment to identify perinatal depression, mental health
services and supports will be selected collaboratively including psychosocial, psychological, pharmacological, or
psychoeducational therapies, in addition to examples and benefits of self-care strategies and psychosocial support,
or select complementary therapies. Ongoing evaluation and revisions to the plan of care are required, including
determining the effectiveness of the services and supports, until recovery is achieved.
Figure 1: Algorithm for Perinatal Depression Care
BACKGROUND
Negative Screen Implement routine screening using Positive Screen
(i.e., total screening a valid tool for perinatal (i.e., total screening
score is below the depression, including screening for score is above the
threshold) risk of self harm and suicidal threshold)
ideation
GUIDING FRAMEWORKS: Social Determinants of Health; Person-Centered Care; Informed Decision-Making

Negative Comprehensive assessment,
Assessment (i.e., including risk of self-harm and
PROFFESIONAL DEVELOPMENT & REFLECTIVE PRACTICE REQUIRED (3.1 -3.3)
absence of suicidal ideation

depression signs (Rec. 1.2 and Appendix H)
and symptoms)
Positive Assessment (i.e., confirmed

depression symptoms)
Develop a plan of care and set

Support the person to utilize, as
goals in consultation with the
needed (Rec. 2.3 - 2.4):
person (Rec. 2.1)
 Self-care strategies (Rec. 2.3)
 Social support (Rec. 2.4)
Selective or indicated prevention
strategies to reduce illness
progression (Rec. 2.2)
Continue to monitor for any risks Conduct or facilitate access to available

or signs of perinatal depression. perinatal depression services or supports
Re-screen, if indicated. aligned with the person’s
goals and preferences
(Rec.2.3 - 2.9):
 Self-care strategies (Rec. 2.3)
 Social support (Rec. 2.4)
 Psychoeducation (Rec. 2.5)
 Professionally-led psychosocial
interventions (Rec. 2.6)
 Psychological therapies (Rec. 2.7)
 Pharmacological interventions (Rec. 2.8)
 Select complementary therapies (Rec. 2.9)
Ongoing evaluation and revisions to plan of

care until recovery (as needed)
(Rec. 2.10)
*If at any step in the implementation of this algorithm you have reasonable grounds to suspect that an infant
or child is or may be in need of protection, promptly report your suspicions, concerns, and the information on
which they are based to your local child protection services.

Practice Recommendations
RESEARCH QUESTION #1:
In the area of perinatal mental health, what are effective screening and assessment
strategies for identifying symptoms of depression during pregnancy and postpartum for up
to one year after childbirth?
RECOMMENDATION 1.1:
RECOMMENDATIONS
Routinely screen for risk of perinatal depression, using a valid tool, as part of prenatal and
postpartum care.
Level of Evidence for Summary: Ia, IV, V

Quality of Evidence for Summary: High = 1; Moderate = 3; Low = 1; Guideline: High = 1
Discussion of Evidence:
Evidence Summary
The expert panel strongly recommends routine screening for perinatal depression for all pregnant and postpartum
persons up to one year following childbirth as it remains under-recognized and untreated as a mental illness, despite
available treatments. Routine screening of perinatal depression provides a mechanism for early identification of
those in need of further assessment, care planning, and initiation of mental health services and supports, (where
appropriate) to reduce the adverse health outcomes for the person, their infant, and family in the short- and long-
term (51 - 52). Furthermore, early interventions through routine screening can reduce stigmaG, break down
barriers associated with the identification of a mental illness, and detect nearly 50 per cent of persons with perinatal
depression (53). Routine screening is also positively associated with increased detection (in comparison to standard
care that is often reliant upon the health-care providers’ clinical judgment or history taking) and a significant decrease
in depression symptoms (51).
A specific screening or assessment tool for perinatal depression is not promoted in this Guideline, because the
research questions that shaped the systematic reviews focused on the identification of effective interventions to
support the screening and assessment for perinatal depression. Instead, examples of valid screening tools discussed in
the literature are included in Appendix E, including the EPDS.
Screening by Nurses and the Interprofessional Team in a Variety of Settings

Screening for perinatal depression can be conducted effectively by trained nurses and members of the interprofessional
team in a variety of settings offered in-person and via telephone (51, 54). Examples include primary care and pediatric
settings (e.g. well-baby care clinics, emergency departments), as well as the person’s residence (51, 54).
To be effective, screening should be part of a comprehensive strategy that includes coordinated follow-up, regardless
of the results of the screen (55). Screening cannot be done in isolation without access to follow-up assessment and
referrals, where indicated. In regions lacking mental health services and supports in perinatal depression, the expert
panel recommends continued screening and advocacy for local integrated services. Alternative formats of perinatal
depression screening such as via telephone or internet can be considered. Nonetheless, as part of an informed consent
process prior to screening, transparency regarding available supports and services should be included.
Perinatal Depression Screening Frequency and Timing

Evidence on the optimal timing and frequency of perinatal depression screening is inconsistent. For example, in an
obstetric setting, screening was scheduled twice prenatally (i.e., at the first visit and at 26 – 28 weeks gestation) and
RECOMMENDATIONS
once in the postpartum period at three to eight weeks following childbirth (51). A primary care setting screened once
routinely at two to three weeks postpartum (26) and at one, three, and six months postpartum in a well-baby child
setting (55). The US Preventative Services Task Force, American Academy of Pediatrics, and the American College of
Obstetricians and Gynecologists support universal screening at least once or more during the perinatal period, but
do not recommend a specific time point (51, 55). Further details regarding these associations' recommendations for
perinatal depression screening frequency and timing can be can be found in the 'Supporting Resources' section. As
the findings are not consistent, no recommendations regarding specific frequency and timing can be made.
Responding to Screening Risk for Maternal Self-harm or Suicide

Many screening tools for perinatal depression include one or more question(s) pertaining to a potential risk of self-
harm or suicide (56). A positive screen for suicide or self-harm, regardless of whether the total screening score is
above or below the threshold, warrants a comprehensive assessmentG of risk by the nurse and the interprofessional
team; this includes evidence of suicidal thoughts, plan, lethality, and means (56). Additionally, inquiries must be
made about any safety risks to the infant and other children (where applicable), as their safety is paramount (56).
These steps must be followed by the nurse and the interprofessional team whenever they are required, regardless
of the stage of the screening, assessment, prevention, intervention, and evaluation. More information pertaining to
responding to maternal suicidal ideation can be found in Appendix H.
Benefits and Harms

A qualitative study indicated that persons who were screened for perinatal depression experienced distress and
discomfort when asked about previous traumatic histories or concerns of suicidal thoughts due to the personal nature
of these events (57). Further, some participants reported regret in disclosing a history of depression or anxiety as they
felt health-care providers focused too much on this aspect of their health history.
Values and Preferences

Acceptance of perinatal depression screening is enhanced when nurses establish a therapeutic relationship with the
person and a full explanation of the use of the screening tool is provided. For example, qualitative findings indicate
that persons were more accepting of perinatal depression follow-up screening and assessment when they were
conducted by a health-care provider whom they knew and trusted (58).

Practice Notes
Screening Scores
In regards to screening scores, evidence of moderate and strong quality indicates that the following nursing
considerations should be taken:
 The total score and the interpretation of the results—and, where indicated, the follow-up—are ideally discussed
immediately after the screening tool has been completed (59).
 For persons with scores above the cut-off value indicating a positive screen, support, information about
depression, and an individualized plan of care are essential (59). The nurse or member of the interprofessional
team must be cognizant that a positive screen may trigger fears, such as being labelled as an incompetent parent,
RECOMMENDATIONS
having their infant apprehended or experiencing difficulties securing work or crossing borders (59).
 The total screening score needs to be interpreted cautiously. Scores below the screen’s cut-off value warrant further
assessment if clinical judgment suspects the presence of depression symptoms (53). Scores above the cut-off value
indicate further assessment as this will include persons who are not depressed; that this is a function of the
sensitivity of a screening tool, which allows it to better ensure that those at higher risk are detected (53). In these
cases, the nurse or member of the interprofessional team can offer reassurance to a person that a positive screen is
not a determination of depression, and that further assessment should identify and confirm their lack of risk of
depression.
Considerations for Administering a Perinatal Depression Screening Tool

When administering a perinatal depression screening tool, nurses and the interprofessional team must i) recognize
the person’s information and support needs, ii) recognize the person’s readiness for perinatal depression screening,
and iii) integrate the person’s cultural background and practices.
I. RECOGNITION OF THE PERSON’S INFORMATION AND SUPPORT NEEDS
Begin the screening process with a general discussion about the person’s mental health and well-
being. This discussion can be part of an initial visit, according to the judgment of the nurse or member
of the interprofessional team (56).
Fully explain the purpose of the screening tool so that the person has been informed of the nature
and intention of the tool to support consent and acceptance (57, 59). Ensure that the person
understands that an elevated score above the threshold is not diagnostic nor an indication for
RECOMMENDATIONS
treatment; instead, it is an indication for further assessment (11).
Take measures to support the person’s comfort and privacy during the administration of the screening
tool. This includes having an open dialogue about any concerns the person may have about the
screening process or remaining flexible regarding the timing and use of the screen (59).
Recognize that screening for perinatal depression can be perceived as intrusive (57). The style,
approach, and displayed trustworthiness by the health-care provider are critical to ensuring that the
person feels empowered and supported to seek help where indicated (57).
A demonstration of a caring and empathic attitude, an unrushed environment, and a displayed

interest in the person and their screening score can facilitate support and minimize any shame or
stigma that the person may feel when discussing concerns about their mental health (59).
As part of a relational practice that applies a person-centred, holistic approach, seek to contextualize
the person’s lived experience and health care needs. Incorporate an understanding of personal,
interpersonal, and social factors by recognizing any inequities and social structures that may influence
the process of screening and screening outcomes (59 - 60).

II. RECOGNITION OF THE PERSON’S READINESS TO BE SCREENED
Communicate to the person that the completion of the screening process is voluntary and requires
their consent (57). The person maintains the right to refuse or decline to answer any (or all) of the
components of the screening tool.
To provide consent, persons must be made fully aware of how the screening tool will be used during
the plan of care, including possible follow-up (57).
RECOMMENDATIONS
A person’s consent to complete a screening process does not imply consent for any further follow-up.
This is true regardless of the score and screening assessment, except in cases of an identified urgent
risk of self-harm, suicide, infanticide, or harm to others (57).
When consent has not been given, inquire about any changes in mood or the presence of any
depression symptoms can be made in lieu of a formal screening process. The offer for formal screening
should be made at a follow-up visit if the person gives consent (57, 59).
III. INTEGRATION OF THE PERSON’S CULTURAL BACKGROUND AND PRACTICES
Nurses and the interprofessional team must recognize and integrate cultural awareness and sensitivity
throughout the screening process. Pregnant and postpartum persons may experience and express
depression signs and symptoms differently, depending on their culture (61).
To engage in culturally sensitive care, the following components are integral:

 Recognize that persons who are less proficient in the language where they are residing or who are
recent immigrants are at increased risk of perinatal depression (48).
RECOMMENDATIONS
 Seek to establish a therapeutic relationship by overcoming language difficulties by establishing trust
and making a connection with the person as the quality of the relationship is central to effective
screening, assessment, and possible intervention. By demonstrating compassion and genuine
interest in getting to know the individual’s culture, life circumstances, and way of parenting, the
person can be empowered. Being available, receptive, and responsive is also important (48).
 Interpreters may be helpful, but the nurse or member of the interprofessional team need to pay
attention at each encounter to any verbal or non-verbal signs of perinatal depression. Observe
for signs such as the person appearing tired or having a stiff facial expression or blankness in the
eyes. The person may appear to have a lack of interest in their infant or be slow to respond to their
cues. Behaviours suggestive of perinatal depression include being quiet, not asking any questions
or offering only brief answers, seeming hurried at visits, or, conversely, having many questions and
worries and constantly seeking help or reassurance (48).
 If a screening tool is used with a cultural interpreter, the validity of the tool may be threatened.
Additional explanation and clarification may be needed (48). The selection of the screening tool
must consider available languages and the validity of the translated tool (61). See Appendices E and
G for further details on perinatal depression screening tools.
 A screen with a total score of zero would suggest absolutely no risk of perinatal depression.
However, the score may instead reflect, in some cultures, a shame and guilt associated with having
a mental illness. In such cases, observance of signs and symptoms of perinatal depression and the
establishment of a therapeutic relationship is essential to be able to talk to the person regarding
their mental health. Use of tacit knowledge based on a health-care providers’ practice and
experience may also be beneficial to the interpretation of mood (48).
 For some persons, being given practical advice and direction by a health-care provider regarding
their plan of care was perceived as helpful (48).
See Appendix D (Diversity among Persons with Perinatal Depression) and the ‘Supporting Resources’
section for further details on cultural considerations in mental health services and supports in perinatal
depression.

Supporting Resources
RESOURCE DESCRIPTION
SUPPORT BY THE INTERPROFESSIONAL TEAM FOR ROUTINE PERINATAL DEPRESSION

SCREENING
American College of Obstetricians and  Recommendations from the American

Gynecologists. Screening for perinatal College of Obstetricians and Gynecologists
depression. Committee Opinion No. 630. Obstet on perinatal depression screening including
RECOMMENDATIONS
that it should be strongly considered, at a

Gynecol. 2015;125:1268-1271. Available from:
minimum, once during the perinatal period
https://www.acog.org/Clinical-Guidance-and- using a standardized and validated tool.
Publications/Committee-Opinions/Committee-
on-Obstetric-Practice/Screening-for-Perinatal-
Depression
Earls F, The Committee on Psychosocial Aspects  Routine screening for postpartum depression
of Child and Family Health. Clinical report – in pediatric settings is recommended as
Incorporating recognition and management postpartum depression can have adverse
effects on infants and children, such as a
of perinatal and postpartum depression into
shorter duration of breastfeeding and an
pediatric practice. Pediatr. 2010;126:1032-1039. increased risk of child abuse and neglect.
Available from: http://pediatrics.aappublications.
org/content/126/5/1032
Association of Women’s Health Obstetric and  Recommendations from the Association of

Neonatal Nurses. Mood and anxiety disorders Women’s Health Obstetric and Neonatal
in pregnant and postpartum women. J Obstet Nurses include support for routine screening
in pregnancy and postpartum, implementing
Gynecol Neonatal Nurs. 2015;44:687-689.
staff training and education on mood
Available from: https://onlinelibrary.wiley.com/ disorders, and and support for staff to
doi/full/10.1111/1552-6909.12734 conduct or facilitate access to follow-up
care for persons with positive screens for
depression.
SUPPORT BY THE INTERPROFESSIONAL TEAM FOR ROUTINE PERINATAL DEPRESSION

SCREENING
Marsay C, Manderson L, Subramaney U. Changes  A study examining pregnant persons’

in mood after screening for antenatal anxiety experiences of being screened for prenatal
and depression. J Reprod Infant Psychol. 2018: depression and anxiety.
Mar 30:1-16. Available from: https://www.  Results indicate that screening appeared to
tandfonline.com/doi/abs/10.1080/02646838.2018 improve outcomes as participants described
positive experiences such as gaining self-
.1453601
awareness and knowledge, validation from a
RECOMMENDATIONS
health-care provider, and self-agency to seek
out support from others.
 The results may be due to measurement
reactivity.
CULTURAL CONSIDERATIONS AND PERINATAL DEPRESSION SCREENING
Pottie K, Greenaway C, Feightner J, et  Routine screening for depression is

al. Evidence-based clinical guidelines recommended, in settings where integrated
for immigrants and refugees. CMAJ. treatment programs are available.
2011;183(12):E824-E925. Available from: http://
www.cmaj.ca/content/183/12/E824
Carteret M. Cross-cultural use of the Edinburgh  Depression can be conceptualized, explained,

Postnatal Depression Scale [Internet]. [place and reported differently across cultures.
unknown]: Dimensions of Culture; 2018.  Examples of expressions of postpartum
Available from: http://www.dimensionsofculture. depression include feelings of sadness
com/2018/03/screening-for-pregnancy-related- regarding the infant's gender or delays or
problems in the naming of the baby.
depression-in-private-practice-settings-cross-
cultural-considerations/

IMPLEMENTING PERINATAL DEPRESSION SCREENING
DC Collaborative for Mental Health in  A resource geared to pediatric primary care

Pediatric Primary Care. Perinatal mental health providers in the promotion of mental health.
toolkit for pediatric primary care: overview  Recommends screening for postpartum
and primer [Internet]. Washington (DC): DC depression at the one, two, four, six, and
Collaborative for Mental Health in Pediatric twelve-month visit.
Primary Care; 2017. Available from: https://  The resource includes examples of
www.dchealthcheck.net/documents/PMH- standardized responses to EPDS scores
RECOMMENDATIONS
indicating a negative screen, at-risk screen,

Toolkit-V-2-2.pdf
and a probable screen.
 The resource also includes an action crisis
plan in cases of reported self-harm or harm to
others.
Irwin-Vitela L. People-centered screening and  An evidence-based PowerPoint presentation

assessment. Module 4: Edinburgh Postnatal on the EPDS.
Depression Scale, EPDS [Video]. Milwaukee  Includes a simulation of screening for
(WI): Wisconsin Department of Children and postpartum depression using the EPDS.
Families, the University of Wisconsin-Milwaukee  Emphasizes the role of reflective practice by
Child Welfare Training Partnership (MCWP), the provider.
and Common Worth, LLC; 2016. Available from:
https://www.youtube.com/watch?v=JBgVlaBg-aU
RECOMMENDATION 1.2:
Conduct or facilitate access to a comprehensive perinatal depression assessment with persons

who screen positive for perinatal depression.
Level of Evidence for Summary: IIb, IV, V

Quality of Evidence for Summary: High = 1; Moderate = 1; Guidelines High = 1; Moderate = 1
RECOMMENDATIONS
Evidence Summary
In cases of a positive screen for perinatal depression and consent by the person, a follow-up comprehensive
assessment is indicated (56 – 57, 62). Persons need to be aware of the types of questions that make up the assessment,
and that some areas may be of a more sensitive and personal nature (57). While persons may consent to be assessed,
their experiences may influence their decisions of whether to pursue mental health services and supports or adhere to
the plan of care, where treatment is indicated (57). Accordingly, skills such as respect and empathy from nurses and
the interprofessional team are essential (57).
A comprehensive assessment seeks to confirm signs, symptoms, and severity of perinatal depression within an overall
health assessment and may include the following components:
 The results of the screening tool, which can facilitate a more in-depth discussion of mood and any changes in
symptoms that the person has noticed (62).
 Risk factors for perinatal depression, especially for persons with strong risk factors that suggest a high likelihood of
perinatal depression (such as a history of a mood disorder, depression, or anxiety during a previous pregnancy)
(56). A listing of risk factors for perinatal depression is included in the Background Context section (p. 21).
 Emotional status, such as recurring periods of sadness, discouragement, irritation, disappointment, or difficulties
with decision-making (56).
 Somatic concerns, such as changes in sleeping and eating patterns or periods of crying (56).
 Physical status, including nutritional intake, activity level, or any physical health problems (56).
 Health inequities associated with a history of mental illness, marginalization, or stigma (63).
 Disparities, such as poverty, as well as inequities such as disability, incarceration, or food insecurity (63).
 Contributory psychosocial factors, such as a lack of social support, negative attitude towards pregnancy, history of
substance use, history of current or past abuse or trauma, low socio-economic status, or being a refugee or a recent
immigrant (56).
 A risk assessment of self-harm, self-neglect, suicidal ideation, or thoughts of harming the infant or other children
(56). Appendix H describes the nurse and the interprofessional team’s responses to an identified suicide risk.
Benefits and Harms

A qualitative study examined the perspectives of pregnant and postpartum persons who had a psychosocial
assessment conducted by child and family health nurses (57). Participants reported that they were accepting of
psychosocial assessments that included questions regarding a history of abuse, interpersonal violence, or depression.
However, some persons felt the questions were intrusive, particularly if the health-care provider appeared to be
insensitive or lacked empathy.

Assessment for perinatal depression requires nurses and the interprofessional team to demonstrate compassion
and trust. The approach taken by the nurse and the interprofessional team can impact the person’s experience
of being assessed and what is reported (57). In cases where trust was developed, the person was more likely to
disclose sensitive issues, such as depression, feel empowered, and be more likely to engage in follow-up care. See
Recommendation 3.2 for a discussion of the importance of ongoing professional development to provide perinatal
depression assessment and interventions.

An evaluation study conducted suggests that persons were accepting of an assessment of perinatal depression by their
primary care provider (64). Participants reported such assessments to be accessible and not stigmatizing.
RECOMMENDATIONS
Practice Notes
Examples of assessment tools for perinatal depression varied in the evidence. These tools were developed to assess
pregnant persons for the presence of psychosocial risk factors associated with perinatal mental health disorders,
including depression (65). However, there is insufficient evidence that supports or refutes the use of a psychosocial
assessment tool in the assessment of perinatal depression (40). Examples of assessment tools for perinatal depression
are included in Appendix F.
The assessment of perinatal depression was found to be feasible in primary care settings with the following
components:
 A user-friendly assessment tool that was brief and semi-structured.
 A streamlined process using an algorithm to guide decisions regarding referral to mental health services based on
symptom severity, where indicated.
 Guidelines on antidepressant medication for prescribing health-care providers.
 Rapid access to expert mental health consultants either via telephone or internet to support on-site treatment.
 A checklist to support documentation.
 A referral pathway to off-site consultants in cases of severe symptoms or complex co-morbidities (64).
Mother Reach London & Middlesex. Post-  A flowchart for the assessment of postpartum
partum mental health assessment flow chart depression.
[Internet]. London (ON): Mother Reach London  A decision tree for assessment and
& Middlesex; 2012. intervention of women with thoughts of
harming themselves and/or their child(ren).
RECOMMENDATIONS
Registered Nurses’ Association of Ontario.  A free online course to support enhanced
Nursing towards equity: applying the social knowledge and skill in applying the social
determinants of health in practice (Internet). determinants of health and health inequities
in clinical practice.
Toronto (ON): Registered Nurses Association of
Ontario; 2016. Available from: https://rnao.ca/  An examination of health and health
bpg/courses/nursing-towards-equity-applying- inequities may be a component of perinatal
depression assessment.
social-determinants-health-practice

RESEARCH QUESTION #2:

In the area of perinatal mental health, what are effective interventions for persons
experiencing depression during pregnancy and postpartum for up to one year after
childbirth?
RECOMMENDATION 2.1:
Collaborate with the person to develop a comprehensive person-centred plan of care, including
goals, for those with a positive screen or assessment for perinatal depression.
RECOMMENDATIONS
Level of Evidence for Summary: Ia, IV, V

Quality of Evidence for Summary: High = 2; Guidelines: High = 1; Moderate = 3
Evidence Summary
In collaboration with the person at risk for, or experiencing perinatal depression, nurses and the interprofessional
team must create a plan of care using a person-centred approach. Through purposeful discussions, the person is
supported to choose available options for mental health services and supports in local community programs, primary
care, home health, public health, or acute care settings (62).
Collaborative careG planning integrates holistic, humane, respectful, and ethical components from a person-
centred approach (47). It includes the establishment of individualized goals for perinatal depression and addressing
any barriers to accessing mental health services and supports for perinatal depression—such as direct costs
for transportation or child care necessary for attending clinic visits or the availability of services—to develop a
unique care plan that realistically reflects the individual’s concerns, preferences, needs, and options (57). Taking a
collaborative approach better ensures that the person is central to care planning and goal setting.
The success of a collaborative partnership between the person, the nurse, and the interprofessional team in care
planning necessitates:
 Recognition that the person’s partner, family, or social network is central to their care and may influence whether
or not to seek or continue care. As part of a family-centred approach, the partner, family, or social network may
aid in the care and support of the affected person, the infant or other children (where applicable). They, therefore,
need to understand the plan of care and how they can constructively and practically support the person (40).
 Clarification of roles and responsibilities of the involved interprofessional team and the available resources (66).
Careful attention must be paid to fears of stigma or labelling—or to feelings of shame—related to initiating
interventions for perinatal depression (66). The nurse and the interprofessional team should observe, ask, or listen for
any feelings of anxiety, fear, threat, guilt, hostility, or denial throughout care planning—if detected, these emotions or
coping strategies must be addressed. Since persons typically have many questions regarding available mental health
services and supports and the implications for pregnancy or postpartum, it is important to take the time to address
any worries, questions, concerns, and potential consequences. The care plan must reflect informed decision-making
and personal preference and be regularly updated, as needed. Taking these steps to assess psychological readiness to
initiate and engage in mental health services and supports and to assist with care transition can help to support the
individual, thus increasing the likelihood of improving health outcomes and reaching goals (66).
Care Planning Following an Assessment of Perinatal Depression

An individualized plan of care should be developed with the person based on the outcome of a screening and/
or comprehensive assessment for perinatal depression and clinical judgment. Examples of five potential outcomes
with suggested follow-up strategies are listed in Table 7. In each case, the expert panel recommends a collaborative
approach that supports person-centred care and informed decision-making. The care plan needs to be documented,
reviewed, and revised, as required, according to the person’s response to the intervention(s) or changing needs (67).
Benefits and Harms

When referring to a mental health specialist, attention should be paid to any sensitive personal information (e.g.,
RECOMMENDATIONS
history of trauma or abuse) that has been disclosed in confidence, to determine whether this history can also be
shared. Recognizing these issues will ensure maintenance of the therapeutic relationship and preserve ongoing trust
between the person and the interprofessional team (40).

The person must be supported to determine their preferences, concerns, and priorities in regards to their plan of care
(62). The person’s partner and other family members (where applicable) may also be included and/or participate in
this process (47).

Table 7: Clinical Considerations Following a Screening and/or an Assessment for Perinatal Depression
PERSON’S SCREENING CLINICAL CONSIDERATIONS

AND/OR ASSESSMENT
RESULT(S)
Consent not given for  Maintain contact and continue to support the person for the duration
screening or assessment. of care during pregnancy or postpartum, as appropriate (62, 68).
 Explore any changes in mood, any concerns about depression
symptoms, and how the person is coping with the transitions of
RECOMMENDATIONS
pregnancy or as a new parent (as needed) (62, 68).

 Remain vigilant for any possible developing symptoms of depression
and discuss them with the person (68).
 Incorporate holistic approaches to detecting signs of depression.
Observe the person’s appearance, mood, and interactions with their
infant or family members for any depression symptoms (69).
 If a person reports any concerns about possible depression symptoms,
encourage follow-up, including screening or conducting or facilitating
access to further assessment, as clinically indicated (62, 68).
A screen negative (i.e.,  Provide ongoing care as usual to support the person.
screening results below  Encourage the person to engage in self-care activities and seek out
cut-off score). social support as prevention strategies (56).
 Continue to observe for any presence of altered mood, thoughts,
perceptions, and at-risk behaviours (56).
A positive screen (i.e.,  Review the results of the assessment and the lack of perinatal
screening results above depression symptoms. Encourage and answer any questions or
cut-off score). concerns they might have (40).
 Reinforce that any screening tool has false positives.
The follow-up
 Provide care listed under “No confirmed perinatal depression
assessment does not
symptoms” (above) (56, 62).
identify perinatal
depression.
A positive screen (i.e.,  Review the results of the assessment and the confirmation of perinatal
screening results above depression symptoms. Encourage and answer any questions or
cut-off score). concerns raised (40).
 In collaboration with the person, develop a plan of care based on the
The assessment results to determine suitable mental health services and supports for
identifies perinatal perinatal depression and care goals. Revise, as needed.
depression.  Include a copy of the assessment results in the person’s chart and
provide a copy to the person (56).
PERSON’S SCREENING CLINICAL CONSIDERATIONS

AND/OR ASSESSMENT
RESULT(S)
A screening or  Develop a documented care plan in collaboration with the person.

assessment indicating Ensure care plan goals and outcomes are communicated to the
risk of self-harm primary care provider (67).
(regardless of results of  Conduct a risk assessment with the individual to survey areas of
screening or assessment potential risk, such as self-harm, self-neglect, suicidal thoughts and
RECOMMENDATIONS
intent, or any risks to others (including the infant or other children,
results)
where applicable) (56). See Appendix H (Responding to an Identified
Risk of Maternal Suicide) for an example.
 Report a positive screen or assessment for self-harm to the primary
care provider (56).
 In the event of an urgent or immediate risk of self-harm, arrange
access to care regardless of whether consent has been given. This will
necessitate an urgent psychiatric assessment likely in an acute care
setting (such as an emergency department) (56).
 In the event that there is an identified or suspected neglect or abuse
of the newborn, infant, or other children, report concerns immediately
to the local child protection agency (56).
 In the event of a suspected or identified risk of self-harm of low or
medium risk, perform the following steps:
 Encourage the person to utilize their support network to reduce
isolation.
 Discuss available mental health services and supports, and where
needed, facilitate access with the person’s consent (56).
 To build and encourage social support, ask the person if there is
anyone whom they wish to have included in their care. This recognizes
the positive impact of social support (56). Involve the person’s partner
and family members, where indicated (56).
 Include a copy of the plan in the personal record and to the referring
clinician. Offer a copy to the person, their partner, and family, where
applicable (56).

Practice Notes
To develop a comprehensive and person-centred plan of care for perinatal depression, the following practices were
identified as central:
 Discuss all treatment options that are appropriate and the availability of trained and local health-care providers.
This will ensure that the individual is aware of the full spectrum of mental health services and supports,
interventions, and potential outcomes. Support the individual’s right to choice, the timing of care, and the selection
of tailored approaches (where available) (40).
 Provide a full explanation of what an intervention or treatment option entails in order to support informed
decision-making (47, 57). Providing a person with details related to their treatment options follows a participatory
RECOMMENDATIONS
model of decision-making and respects their right to self-manage their care (including the right to decline or
accept care components or the timing of care, unless where court-mandated). By making persons more aware of
the expectations and demands of a particular treatment, they can determine if it is feasible for them and
compatible with their defined care goals and priorities (47, 57). For example, a person considering group cognitive
behavioural therapy (CBT) should be made aware that this typically involves participation in weekly two hour
sessions for between eight to 12 weeks. Furthermore, the person should know that participants are asked to share
their experiences with others in a group setting and that there can be additional costs, such as transportation or
child care, to access services (70 - 72). Further details regarding CBT are discussed in Recommendation 2.7.
Arthur E, Seymour A, Dartnall M,  A resource to support the integration of trauma-

Beltgens P, Poole N, Smylie D, North informed principles into practice including
N, Schmidt R. Trauma informed collaboration in care choices. Depression, including
perinatal depression, can be a response to trauma.
practice guide. Vancouver (BC):
British Columbia Centre of Excellence  The guide includes practical suggestions to support
collaborative approaches to care planning and
for Women’s Health; BC Ministry of
RECOMMENDATIONS
guidelines for screening for trauma.
Health, Mental Health and Substance
 Examples of statements that explicitly support
Use Branch; and Vancouver Island
collaboration in care planning include:
Health Authority, Youth and Family
Substance Use Services; 2013. Available ‘I’d like to understand your perspective.’
from: http://bccewh.bc.ca/wp-content/ ‘Let’s look at this together.’
uploads/2012/05/2013_TIP-Guide.pdf ‘Let’s figure out the plan that will work best for you.’
‘What is most important for you that we should start
with?’
‘It is important to have your feedback every step of
the way.’
‘This may or may not work for you. You know
yourself best.’
‘Please let me know at any time if you would like a
break or if something feels uncomfortable for you.
You can choose to pass on any question.’
Use appropriate metaphors: ‘You are the expert or
the driver. I can offer to be your GPS or map to help
guide you to available resources etc.’
Canadian Mental Health Association  A resource examining mental health and equity.
Ontario. Advancing equity in Ontario: Marginalized groups are more likely to experience
understanding key concepts [Internet]. mental illness.
Canadian Mental Health Association  Persons who experience mental health illnesses such
Ontario: [place unknown]; 2014. as perinatal depression can experience additional
inequities which can influence whether their decisions
Available from: http://ontario.cmha.
regarding screening, assessment, and interventions for
ca/wp-content/uploads/2016/07/ perinatal depression.
Advancing-Equity-In-Mental-Health-
 Stigma has resulted in persons with mental illness being
Final1.pdf discriminated or socially isolated. Examples include:
Being denied housing or being harassed by
landlords;
Increased likelihood of being unemployed, not hired
or promoted; and
Experience discrimination in criminal justice or
health care services.
Continued 

 Suggested strategies to promote equity and mental

health include:
Recognize the importance of equitable processes in
mental health policy and planning;
Expand the evidence on equity and mental health
through data collection and knowledge exchange;
Engage those with lived experience in mental illness
RECOMMENDATIONS
in policy, planning and service delivery;

Build healthy communities by recognizing the social
determinants of health; and
Challenge discrimination, exclusion, and stigma by
supporting the human rights and access mechanisms
for people with lived experience of mental illnesses.
BC Reproductive Mental Health  A two-page fact sheet summarizing perinatal

Program. Perinatal depression depression treatment options.
treatment options [Internet].
Vancouver (BC): BC Reproductive
Mental Health Program; date
unknown. Available from: https://
reproductivementalhealth.ca/sites/
default/files/uploads/resources/files/
perinatal_depression_treatment_
options_fact_sheet.pdf
World Health Organization. Social  A paper from the World Health Organization on social
determinants of mental health determinants of mental health.
[Internet]. Geneva (CH). World Health  Comprehensive strategies must be prioritized to
Organization; 2014. Available from: prevent mental illnesses and promote mental health at
http://apps.who.int/iris/bitstream/ the population level across the lifespan. This requires
acting on the social determinants of health – such as
handle/10665/112828/9789241506809_
access to secure housing and food, discrimination,
eng.pdf;jsessionid=7E14520A2E67C6FA or poverty. Such as approach recognizes that mental
0FBBAB1A9E719FCD?sequence=1 illness is triggered by the social, economic, and political
conditions under which persons reside. Systematic
inequalities negatively contribute to mental illnesses.
 Pregnancy and postpartum are times of risk for mental
illness. They are also times when intervention strategies
including prevention can be effective at promoting
mental health and reducing mental illness.
NICE Clinical Guidelines, No. 136.  A chapter from a mental health clinical guideline from
National Collaborating Centre for the United Kingdom focusing on requirements for high-
Mental Health (UK). Service user quality user experience for transfers of care (e.g., from
primary care to a mental health specialist).
experience in adult mental health:
Improving the experience of care  Recommendations for mental health providers
regarding service users' needs during transfers of care
for people using adult NHS mental
or discharge include:
health services. Leicester (UK): British
RECOMMENDATIONS
Recognize that a transfer of care to a mental health
Psychological Society; 2012. Available
service or support can evoke strong reactions or
from: https://www.ncbi.nlm.nih.gov/ emotions.
books/NBK327301/
Provide clear information on all possible support
options available to the person after the transfer of
care.
Involve persons in decisions regarding their care and
respect their preferences.
Provide emotional support, empathy, and respect.
Be aware that transfers of care can raise feelings of
abandonment or supported in a punitive manner.

RECOMMENDATION 2.2:
Implement prevention strategies for perinatal depression to reduce the risk of illness progression.
Level of Evidence for Summary: Ia, Ib, IIb

Quality of Evidence for Summary: High = 5; Moderate = 5; Low = 5
Evidence Summary
RECOMMENDATIONS
Prevention strategies for perinatal depression aim to preserve the well-being of the person and mitigate any
adverse effects of the mood disorder (73 - 74). Implementing prevention or early intervention strategies creates an
opportunity to support the person at risk for, or starting to develop perinatal depression symptoms, and ameliorate or
decrease their risk of illness progression (73 - 74). Prevention strategies in health care can be categorized according to
the target population (71, 75). Those categories are as follows:
 Universal prevention is directed at a whole population (e.g., all pregnant persons) or community samples
irrespective of risk indicators (i.e., none to several). As an approach, universal prevention offers benefits including
reduced stigma, a modest reduction in population prevalence, and more likelihood of being used. This is done
through strategies such as health promotion (71, 74 - 78).
 Selective prevention is aimed at those with risk factors who are identified through self-reporting, screening, or
history taking (71).
 Indicated prevention focuses on persons with early signs and symptoms of a condition, but are not currently in an
illness state (71).
Universal Prevention Interventions for Perinatal Depression

There is limited evidence supporting universal prevention for perinatal depression; interventions targeting a whole
population or community can be costly and study results demonstrate inconsistency in reducing risks (74 - 78). For
example, a nurse-led gender-informed psychoeducational programme for couples focusing on strengthening partner
relationships and coping with unsettled infant behaviours (crying, sleep challenges or difficulties with feeding)
did not demonstrate a difference in screened depression scores post-intervention when compared to controls (75).
Another study found no significant difference in preventing depression symptoms to six months postpartum for
those who received education by nurses on postpartum depression prior to discharge from a childbirth setting when
compared to standard care (77). The study concluded that selective prevention that prioritized those who were at
increased risk (e.g., low socio-economic status or prenatal history of anxiety or depression) may be more effective
than a universal educational intervention.
Nonetheless, there are examples of effective universal prevention strategies such as listening and home visits (76). A
nurse-led structured education prevention intervention for postpartum persons demonstrated significantly lower
depression scores post-intervention when compared to controls (78). In another study implementing universal
prevention, pregnant persons who attended multiple prevention sessions using psychoeducation and psychotherapy
strategies had a significant decrease in depression symptoms, in comparison to the control group, at six weeks
postpartum (63). Participants learned about postpartum depression screening and coping skills, recognizing distress
and seeking help, developing social support, and relaxation techniques.
Selective and Indicated Prevention Interventions for Perinatal Depression
Persons at risk for or starting to develop early signs of perinatal depression may benefit from a variety of prevention
interventions, including psychoeducation and psychotherapies, as discussed below (79 – 82). These can be offered in
multiple and diverse settings by nurses and the interprofessional team (79 - 80).
Psychoeducation
Psychoeducation as a prevention strategy that incorporates health education and informational support has been
demonstrated as an effective prevention strategy (63, 83). For example, postpartum persons with low-income
had fewer depression symptoms at six months following a behavioural psychoeducation intervention provided
in a hospital setting prior to discharge (82). Participants and their partners learned about triggers of depression
symptoms, the benefits of social support and the need to conserve personal resources as a coping strategy. They were
RECOMMENDATIONS
provided written information and a list of resources, in the event of problem developing. In addition, a follow-up
phone call was provided two weeks post-discharge to assess participants' depression symptoms, level of coping and
other needs.
Psychotherapies
Various psychotherapies—including non-directive counselling, CBT, and Interpersonal Therapy (IPT)—were found
to be effective as prevention strategies (71, 81). Non-directive counselling provides empathic listening and reflection.
CBT targets cognitive distortions, negative emotions, and resulting behaviours. IPT focuses on communication and
interactions with others to strengthen relationships (81, 84). These forms of psychotherapy—when delivered by
trained nurses and members of the interprofessional team—can be provided in either individual or group formats
during pregnancy or postpartum (71, 81, 84). For example, a study of pregnant persons on social assistance who
received an IPT-orientated intervention in addition to standard prenatal care demonstrated a significantly lower rate
of depression symptoms at six months postpartum and marginally significant lower levels at 12 months postpartum,
when compared to controls (85). The intervention was structured and provided in small groups over multiple
sessions that included learning IPT-skills such as improving relationships and enhancing social support. In another
study, participants at risk for postpartum depression but had not developed depression symptoms were randomized
to receive either standard nursing care or an intervention of learning cognitive problem-solving skills (81). The results
indicate a reduction for both groups in depression symptoms, as measured by the Beck Depression Inventory pre-
and post-intervention.
The Timing of Prevention Strategies during the Perinatal Period

The optimal timing for prevention interventions is unclear from the evidence (i.e., during pregnancy or during
postpartum) as the findings are conflicting (71, 86). Timing may depend on the type of prevention strategy
implemented and individual response. For example, interventions for postpartum depression prevention were found
to be more effective when conducted following birth, because the interventions when conducted prenatally were felt
to be less relevant to the participants (71). In contrast, other studies noted the efficacy of preventative interventions
that were administered prenatally using strategies that promoted coping techniques, engaged partner support (such
as psychoeducational programs) and included exercise programs (63, 84). An intervention of discharge education
on postpartum depression in a maternity unit that was not found to demonstrate statistical significance concluded
that timing may not have been optimal as persons in the immediate and early postpartum may be distracted by their
recovery from birth, caring for an infant, and seeing visitors (77). Additionally, the study participants may have been
unable to take in and recall the education due to factors such as fatigue or pain. Given these considerations, education
on postpartum depression may be better offered prenatally and addressed briefly in the postpartum unit, with further
follow-up post-discharge.
Selective Prevention Strategies Tailored for Perinatal Depression for Populations Experiencing

Social Inequities
Selective prevention strategies tailored to populations who experience social inequities (identified in the evidence
as those who are socially disadvantaged persons with lower socio-economic status, adolescents with limited social
support, and racialized persons) have shown statistically significant reduction in depression symptoms, when
compared to controls (71, 79, 81 – 83, 87). For example, CBT was found to be effective for Latina postpartum women
with low-income who had significantly lower scores on the Beck Depression Inventory post-intervention (81).
Study participants were taught strategies including mood regulation, self-efficacy skills to enhance confidence, and
parenting skills to promote bonding (81).
Prevention interventions can be modified and culturally adapted for populations who experience social inequities
RECOMMENDATIONS
to promote desired inclusivity and relevance, including through methods such as providing the intervention in the
participants’ first language or adjusting the content to reflect values, beliefs, and culture (81). These modifications
support cultural awareness and recognize the social determinants of mental health. They seek to provide community-
level prevention interventions tailored to persons that recognize and address their health inequities and unique
needs (81).
Notwithstanding the amount of research on prevention strategies for perinatal depression, there are limitations that
reduce the generalizability and strength of the findings (63, 73 – 74, 84). The methodological quality and rigour of
the prevention studies are mixed, with weaker studies being more likely to demonstrate significant findings (79).
Inclusion criteria of study participants varied widely, such as adolescent persons to those over 18 years, depression
symptoms ranging from mild to severe, or persons with high- or low-risk pregnancies (73, 79, 84). Other limitations
include a lack of multi-site trials, small sample sizes, self-reported symptoms of depression, high attrition rates, and
publication bias (63, 73, 84).
Benefits and Harms

CBT, delivered via group format is noted to have added benefits, including expanded social support, increased cost-
effectiveness, and improved accessibility (71).

Prevention strategies that include cultural adaptations are preferred when they fit the needs of the study population
(79). Overall, the integration of tailored approaches to populations can increase rates of study recruitment,
enrollment, attendance, and intervention satisfaction.
Practice Notes
Examples of discussion topics presented in psychoeducation interventions for perinatal depression included:
 Information about sadness, depression, psychosis, and treatment of postpartum depression.
 A review of modifiable risk factors for postpartum depression and ways to reduce these factors.
 The role and significance of available peer or partner support.
 Strategies for stress management and coping.
 Awareness of available local resources.
 Tips for differentiating normal postpartum adjustment and somatic symptoms from postpartum depression (63,
RECOMMENDATIONS
78, 83).
Werner E, Miller M, Osborne LM,  A literature review of 45 trials on psychological (i.e., IPT
Kuzava S, Monk C. Preventing and CBT) and psychosocial (i.e., prenatal and postpartum
postpartum depression: Review and classes and postpartum support) methods of postpartum
depression prevention.
recommendations. Arch Womens
Ment Health. 2015;18(1):41-60.  Many of the interventions were effective that used either
Available from: https://www. an individual or group format. All focused on the person.
ncbi.nlm.nih.gov/pmc/articles/  Emerging evidence suggests focusing on the person/
PMC4308451/ infant dyad may be more effective as infants with poor
sleep behaviour or fussiness are positively associated with
postpartum depression symptoms. Techniques to promote
sleep and reduce fussiness may be an effective prevention
approach.
Dennis C-L. Best evidence for  A slide presentation based on a Cochrane Review on
the detection, prevention, and perinatal depression, including prevention strategies.
treatment of perinatal depression  A beneficial effect of prevention strategies for depression
[Internet]. Toronto (ON): Best Start symptoms was found.
Resource Centre; 2014. Available
from: https://www.beststart.org/
events/2014/bsannualconf14/
webcov/Presentations_
ForParticipants/New/C3_PPD-
BestStart%20February%202014.pdf

RECOMMENDATION 2.3:
Promote self-care strategies for persons at risk for or experiencing perinatal depression
including:
 Time for self (level of evidence = IV).

 Exercise (level of evidence = Ia).
 Relaxation (level of evidence = Ib).
 Sleep (level of evidence = Ia, IV).
RECOMMENDATIONS
Level of Evidence for Summary: Ia, Ib, IV

Quality of Evidence for Summary: High = 2; Moderate = 5; Low = 3
Evidence Summary
The evidence supports the promotion of self-care strategies for all persons at risk for or experiencing perinatal
depression symptoms through an informed decision-making process by nurses and the interprofessional team (88
- 89). Self-care strategies, such as time for self, exercise, relaxation, and sleep reflect a holistic and comprehensive
approach to perinatal depression interventions that are accessible to most persons which promote autonomy
(88). Due to limitations with the findings, nurses and the interprofessional team need to discuss the intervention’s
effectiveness, study limitations, and any potential side-effects or contraindications of the various self-care strategies in
order to support informed decision-making.
Self-care strategies for perinatal depression may be perceived of as beneficial for their ability to be self-administered
in a person’s home and used in privacy as well as safe, with few or no potential adverse effects or risks (88 - 89).
While self-care strategies can be incorporated by any pregnant or postpartum person to optimize health, they can
be especially helpful for those at risk for or experiencing perinatal depression (88 - 89). For these persons, self-care
strategies can be used as a means of independently managing symptoms, promoting personal empowerment, and
supporting improved overall health and well-being (88 - 89). Examples of self-care are varied and must be defined
and selected by the person. It is essential that nurses and the interprofessional team, and the person’s partner, family,
and social network are aware of the need for and benefits of self-care and actively support and encourage regular self-
care practices (90).
Self-Care Strategies
Time for Self
Time for self allows persons the opportunity to engage in self-care activities, such as going for a walk, spending time
with others, having a bath, or going to the gym, as a preventative or therapeutic measure for perinatal depression
(89). It relieves a person temporarily from their daily responsibilities such as caring for their infant and other children
or dependents, housework, cooking or paid work. Time for self recognizes that perinatal depression does not occur
in isolation and that there are associated contributory factors such as available social support, personal relationships,
income, or stressors arising from isolation, chronic sleep deprivation, and infant fussiness (89). Supporting persons
to have time for self requires partners who are willing to share equitably in the practical and emotional care of an
infant. This can contribute to the health of both parents and their offspring (89).
An inverse dose-response relationship between depression symptoms at six months postpartum and the frequency of
time for self was found (89). The study’s results found that ten per cent of participants who had less than once every
two weeks for time for self had depression symptoms, versus less than six per cent who had weekly time for self.
Those who reported never having time for self had the highest prevalence of depression symptoms at 15 per cent.
Although the study on time for self was one of the first to find an association with postpartum depression, there are
important limitations (89). The study sample was mostly persons over the age of 30 years who had university-level
education and established social support. The generalizability of the effectiveness of time for self may not apply to
specific groups of persons who do not share the sample’s characteristics and/or who experience social inequities.
RECOMMENDATIONS
Exercise
Pregnant and postpartum women who engage in exercise appear to benefit from a reduction in depression symptoms
(91 - 92). Studies have shown that physical activities—such as walking, aerobics, aqua-based, stretching, and
instructor-led or home-based programs—are effective in preventing and treating perinatal depression (91 - 92).
The generalizability of the findings on exercise is limited because of studies that included persons who were receiving
concurrent treatments (e.g., pharmacotherapy), making it difficult to draw conclusions about the independent effects
of exercise. Additionally, there were limited studies on prenatal depression and the inclusion criteria for persons with
depression symptoms were inconsistent (91 - 94).
Relaxation
Relaxation techniques have been shown to effectively promote well-being and relieve pain and other stressors (95).
A RCT using a relaxation technique for pregnant persons hospitalized for high-risk pregnancies (e.g., diabetes,
hypertension, or hemorrhage risk) had significantly reduced depression scores (95). These results are considered
important as persons with high-risk pregnancies are at an increased risk of perinatal depression. Participants were
taught the Benson relaxation technique by nurses which included 10 – 20 minutes daily of muscle relaxation,
breathing awareness, and word repetition for five days. The results also indicated decreased feelings of anxiety and
nervousness. Relaxation was found to be a simple, cost-free and non-stigmatizing practice that can be done on a daily
basis with no evidence of harms.
Sleep
Regular sleep cycles are recognized as beneficial for the promotion of overall physical and mental health and disease
prevention (96 - 97). Sleep for persons with a newborn or an infant can be challenging as hours of sleep are frequently
shorter in duration which can be a contributing factor for postpartum depression (96). Sleep can be particularly
challenging for those who have disordered sleep patterns for day and night or ‘fussy’ infants (97). A persistent lack
of sleep, combined with depression symptoms, needs to be identified promptly to avoid developing chronic sleep
problems and worsening symptoms of depression (97).
Study limitations for the body of evidence on self-care strategies include small sample sizes, few randomized trials,
high withdrawal rates, short follow-up timelines, and weak-to-moderate methodological quality (88, 94). Variances
can be found as some studies examined a self-care strategy as a monotherapy, while others used a combination of
other approaches or used self-care strategies as an adjunct to psychological or pharmacological treatments, thus
introducing potential confounders or biases. Furthermore, criteria for participant inclusion in studies varied, ranging

from persons with self-reported symptoms to those who had screened positive using a valid screening tool to those
with a confirmed diagnosis of depression. In the future, there is a need for well-designed large controlled trials to
strengthen the findings on self-care strategies and perinatal depression (88).
Benefits and Harms

Unless medically contraindicated, perinatal persons who engage in regular physical activity have benefits in mood
and an increase in social support, coping, and improved functioning (91 - 94). Thirty minutes of daily exercise is
recommended to support mental health, particularly for depression, although more evidence is needed to support
this guidance (91 - 92).
RECOMMENDATIONS

Among the many care approaches for perinatal depression, there may be a preference among pregnant and
postpartum persons for self-managed approaches (as opposed to pharmacological or psychological interventions)
(88). This may be attributed to personal preference, concerns about the perceived complications or risks from
medication exposure during pregnancy or lactation, or difficulties accessing psychosocial or psychological
treatment(s) (e.g., geographical distance, costs, wait lists, child care, stigma, or available local resources) (88).
Practice Notes
Examples of Self-Care Strategies with Limited Evidence
It is important to support persons with perinatal depression to make informed decisions regarding their choice of
self-care strategies. Within these care planning discussions, nurses and the interprofessional team should be aware
that there is a lack of demonstrated and consistent effect of some self-care strategies or there are significant limitations
that suggest caution when determining generalizability and clinical effectiveness (88, 94, 98 - 102).
Examples of self-care strategies for perinatal depression with limited evidence or inconsistent findings include yoga,
omega-3 fatty acids, iron supplementation, chamomile tea, and newborn skin-to-skin contact (88, 94, 98 - 104). Key
limitations include the following:
 As a self-care approach, yoga can have many benefits including reduced levels of stress, anxiety, pain, and sleep
disturbances (100). Relaxation states can be improved (100). Nonetheless, the optimal frequency of practice for
yoga is not known with the number of sessions per study varying widely, nor its impact as a self-care modality on
postpartum depression (100 - 102). Additionally, the impact of components of yoga (such as mindfulness,
exercises, and relaxation techniques) or specific types of yoga on depression symptoms are not known (102).
 Omega-3 fatty acids, including those found in fish sources (i.e., eicosapentaenoic acid (EPA) and docosahexaenoic
acid (DHA)) have demonstrated inconsistent results in randomized trials with significant and non-significant
changes in mean depression scores, versus placebo. Further studies are needed that feature larger sample sizes,
longer study durations, and consistent dosing to determine the effect (88, 94). In the interim, a healthy balanced
diet emphasizing good nutrition is encouraged in order for individuals to achieve better health (40).
 A randomized placebo-controlled trial examined the effects of iron supplementation for non-anemic postpartum
persons for six weeks, versus placebo, on confirmed depression symptoms (103). Results indicated a significant
decrease in depression symptoms and an improvement in iron stores. However, further studies are needed to
examine other factors that may have influenced outcomes and whether side-effects of iron supplementation causes
any harms to the person or their infant (if breastfeeding).
 A small randomized trial found drinking one cup of chamomile tea consistently for two weeks significantly
reduced short-term depression symptoms and improved sleep deficiencies for postpartum persons (104). However,
the effects were not seen once the participants stopped drinking the tea and further studies are needed. The
researchers conclude that the tea may be useful as a supplementary approach and suggest that the positive effects
of the tea may be due to apigenen, a flavonoid, which has a slight sedative effect to aid sleep and perhaps help with
depression symptoms.
 Skin-to-skin contact with newborns may be an effective strategy for reducing depression symptoms as it can create
a positive feeling of bonding with the infant and enhanced mood (98). The wide variances in mean skin-to-skin
contact time, from two to six hours daily, make it challenging to be able to make any recommendations regarding
the optimal amount of contact time (98 - 99).
RECOMMENDATIONS
To promote time for self, nurses and the interprofessional team can encourage, educate, and support persons to:
 Ensure regular time for self, at a minimum of a weekly basis or more, as available.
 Recognize time for self as a step towards protecting and promoting mental health and well-being and to reducing
 Value time for self as a low-cost and low-intensity prevention strategy.
 Enlist ongoing support from their social network (where applicable) such as friends, neighbours, and paid
childcare to ensure planned and regular time for self.
 Encourage partners to share in the emotional and practical responsibilities of childcare and housekeeping.
 Recognize that persons who face social inequities may face challenges having time for self due to the realities of
their lives (89).
To promote and support regular and healthy sleep patterns, nurses can educate persons who are at risk for or
experiencing perinatal depression symptoms to implement the following:
 Avoid alcohol or caffeine.
 Engage in some physical activity in the late afternoon or early evening.
 Awaken at approximately the same time each morning to establish a daily routine (when possible).
 Get up and move to another room until feeling sleepy if not asleep within 15 minutes.
 Have a light snack or warm milk before going to sleep.
 Encourage short naps during the day to cope with disrupted sleep at night.
 Access the person’s partner, family, social network, or a postpartum doula to allow for times with uninterrupted
sleep (when possible).
 Practice stress reduction and relaxation exercises (e.g., deep breathing, imagery, or progressive muscle relaxation)
(56).

Family Services Ottawa. Resource booklet:  A resource booklet developed for mothers
Postpartum distress, depression and/or who are experiencing postpartum depression
anxious moods [Internet]. Ottawa (ON): or anxiety.
Family Services Ottawa; 2017. Available from:  The booklet includes a section on self-care
http://familyservicesottawa.org/wp-content/ with suggestions on how to reduce stress,
establish support systems, and cope with
uploads/2017/04/PPDinfopackage-2017.pdf
RECOMMENDATIONS
anxiety.
Best Start Resource Centre. Managing depression:  A workbook for a person living with
a self-help skills resource for women living with perinatal depression symptoms that focuses
depression during pregnancy, after delivery on depression management skills and
lifestyle changes.
and beyond [Internet]. Toronto (ON): Best
Start Resource Centre; 2014. Available from:
https://www.beststart.org/resources/ppmd/
DepressionWorkbookFinal_15APR30.pdf
Pacific Post Partum Support Society. Postpartum  A practical guide for purchase for persons
depression & anxiety: a self-help guide for who are experiencing postpartum depression
mothers. 7th ed. Vancouver (BC): Pacific Post and anxiety.
Partum Support Society; 2014.  The ‘little purple book” includes information
on what helps to get through depression and
anxiety and recovery.
Minnesota Department of Health. Maternal well-  A well-being plan for postpartum persons
being plan [Internet]. St. Paul (MN): Minnesota that focuses on sleep, nutrition, social
Department of Health; 2016. Available from: support, and physical activity.
http://www.health.state.mn.us/divs/cfh/topic/  A brief tool for persons to identify their well-
pmad/content/document/pdf/wellbeing-eng.pdf being strategies and signs of depression or
anxiety are included.
Royal College of Psychiatrists. Postnatal  An overview of postpartum depression

depression [Internet]. London (UK): Royal including signs and symptoms and treatment
College of Psychiatrists; 2018. Available from: options.
https://www.rcpsych.ac.uk/healthadvice/  Includes suggestions for self-help.
problemsanddisorders/postnataldepression.aspx
RECOMMENDATION 2.4:
Encourage persons with perinatal depression symptoms to seek support from their partner,
family members, social networks and peers, where appropriate.
Level of Evidence for Summary: Ia, Ib, IV

Quality of Evidence for Summary: High = 1; Moderate = 4
RECOMMENDATIONS
Evidence Summary
Support from Partners, Family Members, and Social Network
Persons with postpartum depression symptoms need and benefit from social support from partners, family members,
and social networks (e.g., friends, community partners, or work colleagues), where appropriate (105). This type of
support can improve a person’s ability to cope with their depression symptoms (105).
Peer Support
Peer support offers encouragement and understanding from individuals who may have had similar experiences with
depression symptoms (106 - 108). This type of relationship is unique, and it differs from a therapeutic relationship
with a nurse or member of the interprofessional team as those professionals are not typically perceived by persons as
having a shared lived experience of postpartum depression (107).
Peer support for perinatal depression may be effectively delivered in-person, via telephone, through online discussion
boards of postpartum groups (106 - 108). Telephone-based peer support increases accessibility and reduces the
stigma that is sometimes encountered with in-person interactions (107). It is difficult, however, to determine the
independent effects of peer support as many of the interventions described in the evidence were multi-modal (e.g.,
peer support and CBT or parent-infant dyad therapy).
Peer Support via Online Discussion Forums

Accessing the Internet or interactive web-based interventions (i.e., technology-enabled care) provides a readily
available mechanism for many postpartum persons to seek and obtain peer support through online discussion
forums (106, 108). Websites with chat rooms for persons with postpartum depression symptoms offer advantages to
users including mitigating barriers to treatment (including cost, travel, stigma, or childcare needs, where applicable)
and providing access to support for a self-determined duration and frequency (108).
Pilot studiesG suggest a feasibility and willingness for persons with perinatal depression symptoms to access and
utilize web-based interventions, although the studies’ findings are limited and inconclusive (106). Other studies have
found that participation in online communities was effective in reducing postpartum depression symptoms (106,
108).
Many online discussion forums for postpartum depression have quality mechanisms to create safe and supportive
online environments for participants that appear to contribute to positive outcomes (106, 108). These include expert

moderators in chat rooms that monitor online discussions and watch for any signs of abusive or inappropriate
postings, access to a live trained coach, and integration of evidence-based approaches. In the absence of these
mechanisms, it is feasible that the outcomes may not be duplicated, and nurses and the interprofessional team should
encourage persons to seek safe and supportive online environments.
Benefits and Harms

An identified benefit of interacting with peers who share similar experiences of perinatal depression includes gaining
knowledge and improved feelings of hopefulness regarding overcoming the depression symptoms (107). However,
it is important to note that a peer who has a history of depression may also render that person less able or available
to provide support due to their own mood disorder (70, 107). Training and support for peers can mitigate some of
RECOMMENDATIONS
these effects.
When a person’s partner, family members, or social network demonstrate a lack of understanding and compassion,
are non-supportive or are abusive, persons with postpartum depression symptoms can experience further isolation
and stigma (70). A lack of support by the person’s partner, family members, or social networks, can be the result of
various causes, including being unsure how to help, normalizing or minimizing depression symptoms in a belief
that depression is not a mental illness that requires that requires treatment or having a lack of empathy and/or
unresolved trauma leading to abusive behaviour. Regardless of the underlying cause(s), the lack of partner, family, or
social network support may cause persons with postpartum depression to rely more on other people, including peer
support (70, 107). In situations where there is no available social support, symptoms of depression may worsen (107).

Face-to-face individual support in a person’s home was valued for being easily accessible and timely. Group support
was preferred for sharing coping strategies and normalizing feelings of depression (105).
Persons reported that they valued the following actions to feel supported: 1) listening to and acknowledging their
feelings, 2) reassurance that their experiences are not unusual, and 3) offering a sense of hope that things can get
better with support and treatment (105).
Practice Notes
Types of partner, family and social network support that persons with postpartum depression symptoms may find
helpful include:
1. Informational (i.e., giving advice and guidance on topics such as postpartum depression symptoms to reduce
feelings of inadequacy, shame or embarrassment).
2. Instrumental (i.e., helping and assisting with practical tasks, such as housework or infant care).
3. Emotional (i.e., providing care, empathy, and compassion through active listening).
4. Affirmational (i.e., acknowledgment and validation of the experience of depression) (105).
Partners to parents [Internet].  An evidence-informed website with strategies on how

Melbourne (AU): Partners to Parents; partners can support each other when becoming parents.
c2016. Available from: http://www.  Includes a focus on perinatal depression and anxiety
partnerstoparents.org/ symptoms and risk factors.
Best Start Resource Centre. Creating  A manual for health and social service providers to help
RECOMMENDATIONS
circles of support for pregnant pregnant and postpartum persons, including those with
women and new parents: A manual perinatal depression, to create a circle of support.
for service providers supporting  A listing of resources of services in Ontario, Canada.
women’s mental health in pregnancy
and postpartum [Internet]. Toronto
(ON): Best Start Resource Centre;
2009. Available from: https://www.
beststart.org/resources/ppmd/pdf/
circles_of_support_manual_fnl.pdf

RECOMMENDATION 2.5:
Provide or facilitate access to psychoeducational interventions to persons at risk for or
experiencing perinatal depression.
Level of Evidence for Summary: Ib

Quality of Evidence for Summary: High =1; Moderate = 2
RECOMMENDATIONS
Evidence Summary
As an intervention, psychoeducation involves nurses and the interprofessional team providing information, support,
health education, and teaching about specific physical or mental health conditions. The goal of psychoeducation is to
engage in a dialogue with the person to promote their improved understanding and awareness of a health condition
and available treatment options, as well as to decrease stressors from a lack of information (83, 109).
Through psychoeducational interventions, pregnant and postpartum persons gain knowledge of depression,
including associated modifiable risk factors (e.g., physical symptoms, low social support, and infant factors), coping
and self-care strategies, risks of untreated depression, and tips for accessing local perinatal depression resources
(83, 109 - 110). Persons learn how family dynamics can change with the arrival of a newborn, steps for building
self-efficacy and help-seeking behaviours, and the role and importance of partner involvement and support (109).
Through psychoeducation, depression symptoms, as measured by valid screening tools such as EPDS, are reduced
post-intervention when compared to controls who received standard care (109).
Using multi-modal approaches, a variety of psychoeducational interventions have been found to be effective in
reducing depression symptoms in pregnancy and postpartum, including:
 Educational session(s) to promote health literacyG (109).
 Self-help workbooks and other written information to support health education and reinforce teachings (110).
 Raised awareness about treatment options and available local resources (109).
Benefits and Harms

Benefits of psychoeducational interventions for persons with perinatal depression include:
 An improved understanding and awareness of perinatal depression and coping strategies (110).
 A higher level of self-efficacy, where a person feels more confident in their ability to care for their infant and
transition to the role of parent (109).
 An increased awareness of resources available from professionals and non-professionals, as well as self-help tools (8).
 An improved ability to develop a nurturing relationship with the infant (109).

A community-based RCT found that participants who received a postpartum psychoeducation intervention within
the first two weeks postpartum had lower scores of depression symptoms at six and 12 weeks postpartum (75).
Participants reported satisfaction with the psychoeducation intervention, which included a home visit, follow-up
telephone calls, and an educational booklet. Study participants felt that psychoeducation should be part of standard
care and that longer follow-up (beyond the first two weeks postpartum), either as home visits or telephone calls
would be beneficial for those who develop postpartum depression later in the first year following childbirth.
A Cochrane Review on postpartum psychoeducation interventions which included a physical assessment component
delivered by nurses at home versus at hospital did not demonstrate improved depression scores by mode of delivery
RECOMMENDATIONS
(111). Nonetheless, home visits were positively associated with individualized approaches, improved access (by
eliminating some barriers such as transportation and childcare), and timely initiation and continuation of care.
Practice Notes
In the context of nursing care, psychoeducational interventions for perinatal depression can be:
 Incorporated into routine clinical care, both verbally and through written materials (109 - 110).
 Delivered briefly and provided in a variety of settings, including prenatal and postpartum groups (109).
 Used to promote help-seeking behaviours, leading to earlier disclosures and potentially improved outcomes (109).
 Offered as a stand-alone intervention or as an adjunct to other interventions (such as psychological and
pharmacological treatments), depending on the results of the comprehensive assessment and the identified needs
and preferences of the person (83).
 Provided to either a pregnant person or to the person and their partner. A controlled trial found that lifestyle-
based education to either the person and/or their partner reduced mean depression symptoms as measured by the
EPDS, in addition to anxiety, during pregnancy (112). Topics reviewed in the intervention included sleep,
nutrition, physical activity, self-concept, and sexuality. The participation of partners was viewed as beneficial as it
provided the pregnant person with psychosocial support.
Corey E, Thapa S. Postpartum depression: an  A PowerPoint presentation summarizing

overview of treatment and prevention. Geneva evidence-based postpartum depression
(CH): World Health Organization; 2011. Available prevention and treatment options.
from: https://www.gfmer.ch/SRH-Course-2011/  Prevention strategies target at-risk
maternal-health/pdf/Postpartum-depression- populations, versus the general postpartum
Corey-2011.pdf population and include psychosocial and
psychological interventions.

RECOMMENDATION 2.6:
Provide or facilitate access to professionally-led psychosocial interventions, including non-
directive counseling, for persons with perinatal depression.
Level of Evidence for Summary: Ia, Ib

Quality of Evidence for Summary: Moderate = 1; Low = 2
RECOMMENDATIONS
Evidence Summary
Non-directive counselling provides support through empathy, active listening, encouragement, collaborative
problem-solving, and developing positive therapeutic relationships where persons are encouraged to find solutions
or approaches that work for them (113 - 114). This type of intervention is suitable for those who do not require care
by a mental health diagnostician (such as a psychologist, psychiatric mental health nurse practitioner, or psychiatrist)
(113). Non-directive counselling can be effectively provided as a type of psychosocial support for postpartum
depression in both individual and group formats, and it can be facilitated by trained nurses or members of the
interprofessional team (115).
Non-directive counselling reduces perinatal depression symptoms, however, the findings are limited (113). Persons
who received non-directive counselling through listening visits during pregnancy by nurses had decreased EPDS
scores in postpartum, compared to those who did not receive the counselling intervention (114). A RCT from
Norway found that persons with elevated depression screening scores who received non-directive counselling
from public health nurses in well-baby clinics had significantly reduced depression screening scores at three and
six months postpartum (113). The number of sessions delivered by public health nurses was designed around the
individualized needs of the person; some participants only received one counselling session but were thought to have
benefited because of awareness of available support.
Benefits and Harms

Further evaluation of supportive counselling by participants is needed to identify if there are any harms that can
develop from this type of social support intervention (113).

To effectively provide non-directive counselling, the nurse must integrate the values of being humane, authentic and
person-centred through self-awareness, self-acceptance, and openness with the person, according to psychologist
Rogers (113).
Practice Notes
When using non-directive counselling, nurses need to ensure that they take the following steps:
 Establish and maintain a therapeutic relationship with the person.
 Focus on the person’s experience and their ability to problem-solve and manage their own situations.
 Ensure a clear understanding of the person’s perspective.
 Be non-judgmental through supportive and empathic listening.
 Treat the person with regard and respect.
 Be open and transparent in all communications.
RECOMMENDATIONS
 Refer to additional supports (such as a mental health diagnostician, i.e., psychiatrist, psychologist, psychiatric-
mental health nurse practitioner) where indicated, in cases of moderate-to-severe depression or worsening
symptoms.
 Refer and facilitate access to an urgent care facility in cases of identified self-harm or suicidal ideation or risk
(113 – 114, 116).
Examples of topics discussed during a non-directive counselling session may include:

 The person’s thoughts and emotions.
 Transitioning to the parental role.
 Changing dynamics in family relationships.
 Problem-solving.
 Encouragement of positive approaches (114).
The Australian College of Mental  A discussion paper on the components of non-

Health Nurses. Non-directive directive counselling including neutrality, autonomous
counselling: what it is [Internet]. decision-making and tailoring sessions to individuals'
circumstances and needs.
Deakin West (AU); c2018. Available
from: http://www.acmhn.org/contact-
the-australian-college-of-mental-
health-nursing
Braddell A. Citizen’s guide to non-  A research-based resource on principles of non-

directive coaching [Internet]. Leicester directive counselling.
(UK): Learning and Work Institute;  The resource is based in concepts of adult learning.
2017. Available from: https://www.
learningandwork.org.uk/wp-content/
uploads/2017/08/LW-Coaching

World Health Organization. Thinking  A manual on the psychosocial management of

healthy: A manual for psychosocial perinatal depression.
management of perinatal depression  Includes tips for good communication strategies
(WHO generic field-trial version including:
1.0). Geneva (CH): World Health  Arrange the meeting time in consultation with the
Organization; 2015. Available from: person.
http://www.who.int/mental_health/  Stress that all communications will remain
RECOMMENDATIONS
maternal-child/thinking_healthy/en/ confidential and that the person has a right to

privacy, unless in urgent situations of identified risk
of harm to the person, infant, or another child.
 Sit at the person’s level speaking in a friendly, non-
judgmental tone.
 Encourage the person to talk openly. Use open-
ended questions to explore feelings.
 Stay positive, even if persons do not show any signs
of change. This will encourage the person to keep
on trying despite their challenges.
Terrazas C, Segre L, Wolfe C. Moving  A RCT examined the effect of listening visits in
beyond depression screening: obstetrician/gynecologist (OB/GYN) clinical settings.
integrated perinatal depression  The results indicated that listening visits were feasible
treatment into OB/GYN practices. and acceptable on-site in an OB/GYN practice setting
Prim Health Care Res Dev. 2018;12:1-9. for persons with mild to moderate perinatal depression
Available from: https://www.ncbi.nlm. as determined by a valid screening tool (e.g., EPDS).
Persons received up to six weekly listening visits lasting
nih.gov/pubmed/29429427
up to 50 minutes by trained social workers, nurses,
or physicians. The health-care providers’ training
included empathetic responding, active listening, and
collaborative problem-solving.
 Offering listening visits in an OB/GYN clinic was
preferred by participants as it overcame barriers to
accessing psychosocial care for perinatal depression
such as mistrust of behavioural health specialists,
stigma and shame of receiving mental health services
and supports, and logistical barriers to care.
RECOMMENDATION 2.7:
Provide or facilitate access to psychotherapies, such as cognitive behavioural therapy or
interpersonal therapy, for perinatal depression.

Quality of Evidence for Summary: Moderate = 8; Low = 5
RECOMMENDATIONS
Evidence Summary
Cognitive Behavioural Therapy (CBT)
CBT is a type of short-term psychotherapy that focuses on the interaction of thoughts, emotions, and behaviours
(115). It has been found to be significantly beneficial as a treatment of perinatal depression in both group and
individual formats (115). Positive effects were seen immediately following the intervention and, to a lesser extent, up
to six months and beyond, as measured by various depression scales, in comparison to standard treatment (115). As
a type of psychotherapy, it can be used effectively as a first-line treatment for persons with mild to moderate perinatal
depression; for those with severe symptoms, psychotherapy can be effective when combined with medications (117).
Providers of CBT include nurses and other members of the interprofessional team, such as psychiatrists,
psychologists, occupational therapists, social workers, and general practitioners (11, 71, 118). CBT can be provided in
a flexible manner in a variety of settings such as acute, primary, and community care services, via telephone, and in
person’s homes (118). It can also be provided in rural areas where access to mental health services and supports may
be limited or where transportation or geography is a barrier (118). No meaningful differences in effectiveness were
found for one type of traditional psychotherapy (i.e., CBT versus IPT) for postpartum depression (11).
In their role of facilitating access to CBT, nurses can educate persons with perinatal depression symptoms about the
key components of this type of psychological intervention which are summarized below. These include types of CBT
techniques, timing, the severity of depression symptoms, individual versus group CBT, therapist-assisted internet
CBT program, and costs.
Types of CBT Techniques

Types of CBT techniques that were found to be effective for perinatal depression symptoms varied and often were
multi-pronged with structured sessions that followed a treatment manual (11). Examples of techniques used in CBT
include psychoeducation as well as the following:
 Cognitive restructuring challenges negative thought patterns of a person’s sense of self, their world, and their
future. These thought patterns act as a filter of experience and can predispose the risk of developing a depression
(11, 115).
 Problem-orientated CBT involves learning skills such as goal setting, managing stress, identifying and replacing
negative thoughts, solving problems, breaking tasks into smaller components, and parenting skills (11). These
skills resulted in higher levels of self-esteem, less stress, and negative thinking. This type of CBT was found to
significantly reduce prenatal depression symptoms, compared to standard care (118).

 Behavioural activation teaches skills to address behaviours such as interpersonal conflict or avoidance as a
coping mechanism that has contributed to depression symptoms. Persons are taught skills to engage in
rewarding activities and reduce avoidance of conflict or difficult situations and increase their social supports (11,
74). Behavioural activation has been found to be as effective as antidepressants for adults with depression
symptoms (74).
 Mindfulness-based CBT is the least studied of CBT-related interventions for perinatal depression (119). It involves
learning skills through verbally-guided sessions to support being present, non-judgmental, accepting of present
moment experiences, and developing an awareness of physical responses (such as breath) to reduce rumination
and negative or self-critical thoughts (119).
RECOMMENDATIONS
Timing
CBT may be used in both pregnancy and postpartum (71). Significantly decreased depression symptoms were
demonstrated when compared to those of control groups, however, CBT may be more effective when initiated in the
postpartum than during pregnancy (71).
The Severity of Depression Symptoms

A RCT found pregnant persons who screened as low to moderate risk for depression who received CBT had
significantly decreased depression symptoms as measured by EPDS, in comparison to controls who received standard
approaches to care (118). The largest improvement in depression symptoms scores was seen with those who were able
to continue to use CBT skills following the conclusion of the intervention time period (118). Similarly, a narrative
review found CBT to be an effective intervention for mild to moderate postpartum depression, but could not confirm
this effect with severe symptoms (116). CBT may also not be effective for pregnant persons who have identified risk
factors for depression but who have not yet developed symptoms (e.g., they have total EPDS scores lower than an
assigned cut-off score of 10, suggesting a low risk for depression) (120).
Individual versus Group CBT

CBT can be offered in either individual or group format. Persons may experience difficulties talking in a group setting
as this format requires participants to openly share their experiences of depression and to apply CBT techniques
(121). Reluctance to participate in group CBT may also be influenced by stigmatization, although this requires
further investigation (116). Group CBT uses fewer resources and offers participants an opportunity to meet others
and build their social network. Nonetheless, the decision of individual versus group CBT needs to be carefully
weighed by each person to determine the best choice (121).
Therapist-assisted Internet CBT Programs

Online CBT programs reported a significant reduction in depression symptoms when the psychotherapy was
augmented with individualized support through weekly email contact or telephone check-ins (122).
Costs
CBT requires time and commitment, and it may have associated financial costs for travel or child care expenses (121).
Many CBT series includes eight to 12 consecutive sessions which may be a challenge for persons to complete due
to competing demands of caring for an infant or another child or other responsibilities. Poor conformity rates (i.e.,
regular and consecutive attendance at the CBT sessions) may negatively impact the benefits of CBT (121).
Study Limitations
Despite the efficacy of CBT for perinatal depression, there are some important limitations that should be considered.
In much of the evidence, the specific components of CBT varied, as only some studies used a structured and
consistent approach detailing each session’s content, participant exercises, and objectives in a manual (121, 123). This
creates potential confounders when attempting to determine which of the components of CBT are most effective
(121, 123). It is unclear whether CBT—particularly in a group format—is suited to all persons, or if it may be a better
approach at certain stages of recovery from depression (121, 123).
Interpersonal Psychotherapy (IPT)

IPT is a type of short-term psychotherapy that focuses on current concerns, such as social functioning, conflicts,
RECOMMENDATIONS
role transitions, grief, and interpersonal deficits (11). IPT has been found to be an effective intervention for
depression in both the non-perinatal and perinatal population, as it examines how a person’s communications
and interactions with others impact their mental health (11, 81). It has been found to be an effective type of
psychotherapy in either individual or group formats both in-person and via telephone to address perinatal
depression symptoms using practical approaches and addressing current personal challenges related to the
transition to parenthood.
Benefits and Harms

Demonstrated benefits of IPT for the treatment of postpartum depression symptoms include the following:
 It is an effective first-line treatment for postpartum depression. Significant improvements have been demonstrated
in reducing symptom severity, improving recovery, and increasing psychosocial adjustment, when comparing
pre-treatment depression scores to those post-treatment, or to controls (81).
 It can be facilitated by a variety of trained health-care providers, including nurses, psychiatrists, psychologists, and
general practitioners (81).
 It has generalizable findings across populations as many rigorous studies use treatment manuals that outline and
detail session objectives and content allowing for comparisons of similar study interventions (123).

Although social support in group settings can be valuable to the person with postpartum depression symptoms, some
persons prefer privacy, individual attention, and confidentiality (70). Group settings can be challenging with regards
to logistics as meeting times may not suit the person’s schedule; in this case, individual sessions may be preferred.
Evidence indicates a preference for psychotherapies, versus medication, due to concerns of risks during pregnancy or
lactation (11).

Practice Notes
An example of content for a brief six-session CBT program facilitated by a social worker and a peer for pregnant
persons included the following (118):
SESSION
NUMBER CONCEPTS DISCUSSED
One  Introduction;
 Symptoms of depression;
RECOMMENDATIONS
 Goal setting; and

 The relationship between thoughts, feelings, and behaviours.
Two  Stress reduction, coping, and relaxation techniques;

 Self-monitoring of distorted and negative thinking; and
 Increasing positive self-talk and affirmations.
Three  Enhance communication skills in the person’s social network;

 Evaluating relationships; and
 Intimate partner violence and safety planning.
Four  Enhancing open communication in the person’s relationships;

 Risk factors for prenatal depression and what can help mitigate these risks;
and
 Signs and symptoms of postpartum depression.
Five  Grief, loss and spirituality; and

 Practice negative thought-stopping techniques and increase positive self-talk
and affirmations.
Six  Signs and symptoms of postpartum depression;

 Evaluation of the six sessions; and
 Goal setting to manage role transition to parenthood.
TRAINING FOR NURSES AND THE INTERPROFESSIONAL TEAM IN CBT
Centre for Addiction and Mental Health. Cognitive  A website outlining the course
behaviour therapy certification program for nurses requirements to complete certification
and other health-care providers [Internet]. Centre in CBT for nurses and other health-
care providers.
for Addiction and Mental Health; c2018. Available
RECOMMENDATIONS
from: https://www.camh.ca/en/education/continuing-
education/continuing-education-programs-and-courses/
cognitive-behavioural-therapy-cbt-certificate-program
Ontario Agency for Health Protection and Promotion  An evidence brief on interventions to
(Public Health Ontario), Mensah G, Singh T. Evidence address perinatal mental health in a
brief: Exploring interventions to address perinatal public health context.
mental health in a public health context. Toronto,  Psychosocial and psychological
ON: Queen’s Printer for Ontario; 2016. Available from: interventions were found to be
https://www.publichealthontario.ca/en/eRepository/ effective in addressing perinatal
Evidence_Brief_Perinatal_Mental_Health_2017.pdf
The BC Reproductive Mental Health Program. Coping  A self-help workbook to learn skills
with depression in pregnancy and following the birth: using CBT-based principles to prevent
A cognitive-behaviour therapy-based self-management or manage perinatal depression
symptoms.
guide for women [Internet]. Vancouver (BC): BC Mental
Health & Addiction Services; 2011. Available from:  The resource also includes information
https://www.beststart.org/events/2014/bsannualconf14/ for health-care providers.
webcov/Presentations_ForParticipants/New/C3_PPD-
BestStart%20February%202014.pdf
World Health Organization. Thinking healthy: A manual  A resource for community health-care
for psychosocial management of perinatal depression providers in primary care settings
(WHO generic field-trial version 1.0). Geneva (CH): who have no prior knowledge or
experience in mental health care.
World Health Organization; 2015. Available from: http://
www.who.int/mental_health/maternal-child/thinking_  The manual outlines evidence-based
healthy/en/ approaches using CBT techniques
and low-intensity psychological
interventions.
 The manual is relevant for perinatal
depression with modules on the
person’s mental health, their
relationship with the baby, and their
relationship with people around them
during pregnancy to eight to ten
months postpartum.

Posmontier B, Neugebauer R, Stuart S, et al. Telephone-  A study involving certified American

administered interpersonal psychotherapy by nurse- nurse-midwives who provided IPT via
midwives for postpartum depression. J Midwifery telephone to postpartum persons with
depression.
Womens Health. 2016;61(4):456-466. Available from:
https://onlinelibrary.wiley.com/doi/pdf/10.1111/  The results indicate a significant
RECOMMENDATIONS
jmwh.12411 reduction in depression scores at

eight and 12 weeks, compared to the
control group.
 IPT delivered via telephone by
certified nurse-midwives was found
to be an effective and acceptable
method of reducing the severity of
World Health Organization and Columbia University.  A manual on group IPT for depression.
Group interpersonal therapy (IPT) for depression (WHO The manual does not include specific
generic field-trial version 1.0). Geneva (CH): World recommendations for perinatal
depression.
Health Organization; 2016. Available from: http://apps.
who.int/iris/bitstream/handle/10665/250219/WHO-MSD-  May be used by facilitators including
MER-16.4-eng.pdf;jsessionid=72F542A8C0F2457C767034 supervised nurses or psychosocial staff
who may not have prior training in
C4ED6220E8?sequence=1
mental health as a tool to support
scaling up services for mental health
in health-care settings.
Dennis CL, Ravitz P, Zupancic J, et al. Telephone-based  A RCT examining telephone-IPT by

interpersonal psychotherapy by trained non-specialist trained non-specialist nurses for the
nurses for the treatment of postpartum depression: A treatment of postpartum depression.
nation-wide randomised controlled trial [unpublished  Participants were socially and
manuscript]. Toronto: University of Toronto; 2018. ethnically diverse living in rural and
remote areas.
 The intervention consisted of 12
weekly sessions or standard care.
 The results indicate that participants
in the IPT group were 4.5 times less
likely to be clinically depressed at
12 weeks post-intervention, versus
controls. It is effective for postpartum
depression.
College of Nurses of Ontario. Psychotherapy and the  Psychotherapy as a controlled act was
controlled act component of psychotherapy [Internet]. proclaimed by Ontario’s provincial
Toronto (ON): College of Nurses of Ontario; 2018. regulatory body on December 30,
2017.
Available from: http://www.cno.org/en/learn-about-
standards-guidelines/educational-tools/ask-practice/  The Regulated Health Professions
RECOMMENDATIONS
answers-to-your-questions-about-psychotherapy/ Act, 1991 (RHPA) defines the
controlled act as “Treating, by
means of psychotherapy technique,
delivered through a therapeutic
relationship, an individual’s serious
disorder of thought, cognition, mood,
emotional regulation, perception or
memory that may seriously impair
the individual’s judgment, insight,
behaviour, communication or social
functioning.”
 The controlled act of psychotherapy
includes the following components:
1. You are treating a client.
2. You are applying a psychotherapy
technique.
3. You have a therapeutic relationship
with the client.
4. The client has a serious disorder
of thought, cognition, mood,
emotional regulation, perception
or memory.
5. This disorder may seriously impair
the client’s judgment, insight,
behaviour, communication or social
functioning.

RECOMMENDATION 2.8:
Support informed decision-making and advocate for access to pharmacological interventions
for perinatal depression, as appropriate.

Quality of Evidence for Summary: High =2; Guidelines: High = 1; Moderate = 1
RECOMMENDATIONS
Evidence Summary
Nurses Supporting Persons Considering Pharmacological Interventions
As part of the interprofessional team providing mental health services for perinatal depression, nurses must be
able to support pregnant and postpartum persons in making informed decisions pertaining to pharmacological
interventions (124). The decision regarding the use, continuation, or discontinuation of medications for perinatal
depression is, therefore, one that must be considered individually by the person and the primary health-care provider
prescribing the medication. It should weigh all the potential risks and benefits related to the person’s history, available
resources, and preferences (40, 56, 124).
Key Pharmacological Nursing Considerations for Perinatal Depression

In collaboration with the interprofessional team, nurses must be cognizant of the use of pharmacological approaches
for perinatal depression, which include the following:
 Pharmacological approaches are generally for those with moderate to severe depression or for those whose
depression has not responded to psychological or other non-pharmacological approaches.
 Episodes of depression can vary and may have spontaneous remissions, but they can still leave a person at risk for
recurrence.
 Safety concerns about the presence or absence of pharmacological treatment may vary across the perinatal period,
and by the individual person.
 Discussions pertaining to pharmacological approaches may differ depending on whether the person is pregnant or
lactating.
 Each person must be made aware of potential side-effects of medications, their interactions with other
medications, and delays in the onset of a response. Until a response from medications becomes effective, additional
support is recommended.
 Medications should be chosen with the lowest known risk.
 Dosages of medications for perinatal depression may need to be adjusted due to the pharmacokinetics and
pharmacodynamics of pregnancy and lactation.
 Discontinuation of medications can increase the risk of worsening symptoms and relapse of illness.
 The understanding of long-term pediatric neurodevelopmental effects is very limited and more evidence in this
area is needed.
 The presence or absence of pharmacological, versus non-pharmacological, treatments for perinatal depression may
impact the interactions and bonding between a person and their infant (40, 56).

Perinatal Depression FINAL Web 0 (001-078) PDF

Uploaded by

Copyright:

Available Formats

Perinatal Depression FINAL Web 0 (001-078) PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Perinatal Depression FINAL Web 0 (001-078) PDF

Uploaded by

Copyright:

Available Formats

Best Practice Guideline

Assessment and Interventions

Greetings from Doris Grinspun,

The Registered Nurses’ Association of Ontario (RNAO) is delighted to present the

Doris Grinspun, RN, MSN, PhD, LLD(Hon), Dr (hc), FAAN, O. ONT

Purpose and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

RNAO Best Practice Guidelines Research and Development Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

RNAO Best Practice Guidelines Expert Panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Algorithm for Perinatal Depression Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Research Gaps and Future Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Implementation Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Guideline Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Process for Update and Review of Best Practice Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Reference List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

BEST PRACTICE GUIDELINES • w w w. R N A O . c a 3

Appendix B: Best Practice Guideline Development Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Appendix C: Process for Systematic Review and Search Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Appendix E: Examples of Perinatal Depression Screening Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Appendix F: Examples of Perinatal Depression Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Appendix G: Considerations for Selecting a Perinatal Depression Screening Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Appendix H: Responding to an Identified Risk of Maternal Suicide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

Appendix I: Edinburgh Postnatal Depression Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

Appendix L: Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Appendix M: Description of the Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

How to Use This Document

BEST PRACTICE GUIDELINES • w w w. R N A O . c a 5

Purpose and Scope

BEST PRACTICE GUIDELINES • w w w. R N A O . c a 7

Use of the Term “Person” in this BPG

RNAO Guidelines and Resources That Align with This Guideline:

 Toolkit: Implementation of Best Practice Guidelines (2012)

Table 1: Levels of Evidence

LEVEL SOURCE OF EVIDENCE

Ia Evidence obtained from meta-analysisG or systematic reviews of randomized controlled

Ib Evidence obtained from at least one randomized controlled trial.

III Synthesis of multiple studies primarily of qualitative researchG.

IV Evidence obtained from well-designed non-experimental observational studies, such as

BEST PRACTICE GUIDELINES • w w w. R N A O . c a 9

Table 2: Quality Rating for Reviews using Critical Appraisal Tools

QUALITY SCORE ON APPRAISAL TOOLS OVERALL QUALITY RATING

A converted score of 62.5–82.3 per cent Moderate

Table 3: Quality Rating for Guidelines using the AGREE II tool

QUALITY SCORE ON THE AGREE II OVERALL QUALITY RATING

A score of 6 or 7 on the overall guideline quality High

A score of 4 or 5 on the overall guideline quality Moderate

A score of less than 4 on the overall guideline quality Low

Research Question #1:

1.0 Recommendation 1.1:

Research Question #2:

2.0 Recommendation 2.1:

BEST PRACTICE GUIDELINES • w w w. R N A O . c a 11

2.0 Recommendation 2.5:

3.0 Recommendation 3.1

Research Question #4:

4.0 Recommendation 4.1

BEST PRACTICE GUIDELINES • w w w. R N A O . c a 13

Registered Nurses’ Association of Ontario (RNAO)

Greeshma Jacob, RN, MScN Laura Legere, RN, MScN

Glynis Gittens, BA (Hons.) Ifrah Ali, BA (Hons)