1. Running head: THE USE OF SCREENING TOOLS 1
The Use of Screening Tools to Identify Risk for Developing Postpartum Depression in
Postpartum Women
Jazmine Randolph, Andrea Ritchie, & Jelena Tomljenovic
Oakland University

2. THE USE OF SCREENING TOOLS 2
The Use of Screening Tools to Identify Risk for Developing Postpartum Depression in
Postpartum Women
Nurses hold a key role in identifying the risk for developing postpartum depression
(PPD) in postpartum women. However, the role of nurses in effectively serving pregnant and
postpartum women with the aim of reducing the prevalence of PPD is not yet fully integrated in
clinical environments. PPD is a significant health issue for postpartum women, affecting
approximately 13% of women and their families (Horowitz, Murphy, Gregory, & Wojcik, 2011).
PPD is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a
major depressive disorder that occurs during pregnancy or within four-weeks of childbirth (Iwata
et al., 2015). According to other medical experts, minor or major depression occurs within 12
months of childbirth may be considered as having PPD (Mitchell, Mittelstaedt, & Schott-Baer,
2006). Therefore, PPD can be thought of as depression that may occur for several months after
childbirth, even up to one year (Iwata et al., 2015). The significance of PPD to the nursing
profession is reflected not only in the fact that it affects roughly 13% of women, but also because
there is significant opportunity for improving nursing practice in the screening and caring for
women with PPD (Horowitz et al., 2011). Therefore, the ability of nurses to effectively screen
for risk factors and signs of depression among women within the first year after childbirth could
have a significant impact on the lives of women affected by PPD and their families. The impact
of PPD on infants is also significant, since it unfavorably impacts the mother's cognitive,
emotional, and communication abilities that lead to the inability to appropriately interact with
their child (Horowitz et al., 2011). Studies show that simple screening techniques when used by
nurses, such as telephone calls and mail surveys, may effectively identify women at risk for PPD,

3. THE USE OF SCREENING TOOLS 3
yet these practices are not standard nursing practice (Iwata et al., 2015). The purpose of this
paper is to write an empirically based literature review related to the use of screening
tools/techniques by nurses caring for pregnant and postpartum women and its effects on the
incidence of PPD.
Review of the Literature
In a study by Mitchell et al. (2006), the purpose of the study was to assess the reliability
of telephone follow-up screening in identifying symptoms associated with PPD in women eight
weeks postpartum. Initially, 126 women provided consent to participate in the study before being
discharged from a Midwestern community hospital. However, after two months, the sample
consisted of 106 women, denoting a response rate of 84%. The study participants had to be at
least 18 years of age or an emancipated minor, able to be reached via telephone for follow up six
to eight weeks after hospital discharge, and English speaking. The study design was descriptive
correlational. Nurses obtained data during the postpartum hospital stay and eight weeks
following discharge. The initial data collection effort used a self-report demographic form
completed by the mother before leaving the hospital. The self-report form asked for the mother’s
age, marital status, employment information, number of prior pregnancies, personal and family
history of depression, and current medications. The mothers were also asked whether or not they
were experiencing an increase in anxiety during the postpartum period prior to hospital
discharge. There are two forms of the PDSS, a short-form consisting of seven-items and a long-
form with 35-items (inclusive of the seven-item short form), that utilized the Likert scale to
measure seven-subscales: sleeping/eating disturbances, anxiety/insecurity, emotional liability,
cognitive impairment, loss of self, guilt/shame, and contemplating harming oneself. Clients then
received follow-up phone calls at eight weeks postpartum; at this time nurses assessed the

4. THE USE OF SCREENING TOOLS 4
mothers for symptoms of PPD using the long-form of PDSS. The full 35-item scale yielded an
overall severity score that fell into one of three categories. A score below 59 was deemed as
being negative for symptoms of PPD and also was considered to be an indicator of normal
postpartum adjustment (Mitchell et al., 2006). Scores of 60 or greater suggest a risk for minor or
major depression, and scores of 80 or greater confirm a high probability of major depressive
symptoms (Mitchell et al., 2006). The results indicated that 77 participants (73%) demonstrated
normal postpartum adjustment with a mean PDSS score of 44.1 (SD=6.5). 18 participants (15%)
had moderate depression with a mean of score of 70.0 (SD=6.2). 11 (9%) of the women screened
positive for severe depressive symptoms with a mean score of 97.1 (SD=14.6). Interestingly,
27% of well-educated and married women were identified as having symptoms of PPD. Overall,
27% of the 106 women studied had scores ranging from 60 to 128, which identified them as
having symptoms of moderate-to-severe depression. Participants who screened positive for
depressive symptomatology on the PDSS were given a referral to a mental health clinician and
urged to notify their current health care provider of the screening results. The study determined a
correlational value of r=.91 (p=<0.1) when comparing the first seven-items of the PDSS to the
remaining 28-items of the long-form (Mitchell et al., 2006). Mitchell et al. (2006) concluded that
telephone screening for symptoms of PPD is reliable mechanism to identify mothers at risk.
Mothers that have received previous treatment or are currently being treated for depression
should be screened for PPD.
In a study by Dindar and Erdogan (2007), the purpose was to evaluate the Turkish
women for the presence of PPD along with potential risk factors for symptoms of PPD. The final
sample consisted of 679 postpartum women in their first postpartum year from nine different
public health centers in Turkey. In total, 622 participants (97.5%) were married, and the

5. THE USE OF SCREENING TOOLS 5
remaining 2.5% were divorced. The mean age of the sample was 26.7 years (SD=5.4) with
maternal ages ranging from 16 to 47 years of age. The study sample was made up of
predominantly unemployed, low-educated mothers, representative of the Turkish population
(Dindar & Erdogan, 2007). The study design used a descriptive random survey method. The
Edinburgh Postpartum Depression Scale (EPDS) is a self-report assessment tool that uses 10-
items to identify symptoms of depression, and then scores individual responses for a possible
score of 0-30. The participants of this study completed all questions in the EPDS in private and
without assistance. A risk factor questionnaire was used during home visits to obtain the
women’s PPD risk histories and detailed socioeconomic background data. The researchers
established an EPDS score of 12 as the cut-off point, detecting a sensitivity score of 0.84 from
screening and psychiatric interviews, along with a specificity of 0.88. Higher scores, those
greater than 12.0, are attributed to higher levels of distress. The results indicated high rates of
depression were identified at two months, eight months, 10 months and then again at 12 months
postpartum. Specifically, 41 or 6% of the women at one month postpartum reported depression
on the EDPS; 309 or 45.5% had depressive symptoms between two and six months; and 329 or
48.5% of women reported depression symptoms at seven to 12 months postpartum. Of the 679
women in the sample, 174 (25.6%) reported high levels of depression (e.g. scores of 12 or
greater on the EPDS). Only 29 of the women (4.5%) reported a score of zero on the EDPS,
whereas 53.3% (n = 362) had EDPS scores > 9. Several variables were identified as being
predictors for future depression: prior psychiatric illness, women who had lost a past baby,
lower-income women, and marital problems. The study identified a statistically significant
relationship (p = < .01) among women who had an unplanned pregnancy, women that used
tobacco while pregnant, or women unsatisfied with their physical appearance, and the scores

6. THE USE OF SCREENING TOOLS 6
obtained from the EPDS assessment. Dindar and Erdogan (2007) concluded that a high
prevalence of PPD was found in Turkish postpartum women, indicating a significant need to
educate these women in both private and public health care environments regarding symptoms of
PPD.
Summary
In Summary, the literature reviewed indicated that nursing use of postpartum depression
screening tools is beneficial in identifying risk for the development of postpartum depression.
The Edinburgh Postpartum Depression Scale and the Postpartum Depression Screening Scale are
two reliable methods to screen for postpartum symptomatology.
Nursing Implications
The nursing implications related to the use of screening tools to identify risk for
developing postpartum depression in postpartum women are numerous. Women are often
hesitant to seek help for postpartum depression for numerous reasons and some may even ignore
and/or deny the signs (Dindar & Erdogan, 2007; Mitchell et al., 2006). The use of PPD screening
tools identifies risk factors for PPD in postpartum women without much effort on the patient’s
part. Nurses need to be advocates for postpartum women at risk for PPD by screening for PPD
and doing a thorough assessment of risk factors associated with PPD. When nurses identify risk
factors associated with PPD or PPD symptoms early, they can assist the women in getting the
appropriate care they need in a timely manner (Segre, O’Hara, Arndt, & Beck, 2010). However
this is not routine nursing care in the intra-partum setting (Mitchell et al., 2006). In order to
effectively screen postpartum women for risk of PPD it is vital to develop all labor and delivery
nurses’/midwives’ skills in identifying PPD in the use of screening tools, such as EPDS and the

7. THE USE OF SCREENING TOOLS 7
PDSS (Dindar & Erdogan, 2007). The option of face-to-face screening, screening via-mail, or
telephone screening makes the screening processes more convenient for the patient (Mitchell et
al., 2006; Serge et al., 2010). Postpartum women who have a history of depression or abuse, or
are experiencing an increase in anxiety or irritability should be screened multiple times during
the first year, as should all postpartum women who are on medication for depression. All
postpartum women with a positive screen for symptoms of PPD should be referred for a
diagnostic interview and should be monitored for worsening of symptoms (Mitchell et al., 2006).
Nurses have the advantage of providing a continuum of care due to frequent contact with
postpartum women, so nursing interventions should include educating the patient about PPD,
providing instructions on what to do if their symptoms get worse, making referrals, and
providing counseling (Segre et al., 2010). More nursing research is needed to explore the use of
PPD screening tools on vulnerable populations in the United States, such as women in prison,
and women of diverse ethnicities and socioeconomic status (Mitchell et al., 2006).
Conclusion
In conclusion, the use of screening tools by registered nurses to identify risk for
developing PPD among postpartum women is effective and allows the patient to be diagnosed
early and receive necessary treatment in a timely manner. While nurses in the intrapartum setting
do not routinely use PPD screening tools, in order to provide evidence-based care to postpartum
women, nurses should receive proper training to develop the skills and knowledge necessary to
use PPD screening tools and accurately identify PPD. As patient advocates it is important that
nurses implement PPD screening into prenatal and postnatal care and provide postpartum women
with education, referrals, and counseling for PPD.

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References
Dindar, I., & Erdogan, S. (2007). Screening of Turkish women for postpartum depression within
the first postpartum year: The risk profile of a community sample. Public Health
Nursing, 42(2), 297-308. doi:10.1111/j.1525-1446.2007.00622.x
Horowitz, J. A., Murphy, C. A., Gregory, K. E., & Wojcik, J. (2011). A community-based
screening initiative to identify mothers at risk for postpartum depression. Journal of
Obstetric, Gynecology & Neonatal Nursing, 40(1), 52-61. doi:10.1111/j.1552-
6909.2010.01199.x
Iwata, H., Mori, E., Tsuchiya, M., Sakajo, A., Maehara, K., Ozawa, H., … Tamakoshi, K.
(2015). Predicting early post-partum depressive symptoms among older primiparous
Japanese mothers. Japan Journal of Nursing Science, 12(4), 297-308. doi:10.111/
jjns.12069
Mitchell, A. M., Mittelstadet, M. E., & Schott-Baer, D. (2006). Postpartum depression: The
reliability of telephone screening. The American Journal of Maternal/Child Nursing,
31(6), 382-387.
Segre, L. S., O’Hara, M. W., Arndt, S., & Beck, C. T. (2010a). Nursing care of postpartum
depression, part 1: Do nurses think they should offer both screening and counseling?.
The American Journal of Maternal/Child Nursing, 35(4), 220-225.
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