The Ministry of Parenting - Promoting Creativity in Parenting



Essex-Tavistock Professional Doctorate in Clinical Psychology

Year 2

Service Related Project: Evaluating the effectiveness of a primary-care based group for women with postnatal depression

Candidate Number: 0922929

Word Count: 4997

Contents

1. Abstract 4

2. Introduction 6

Aims

Overview of Service

3. Method 10

Design

Measures

Data Collection

Referral Process

Inclusion/Exclusion Criteria

Sample

Ethical Consideration

4. Results 13

Dissemination

5. Discussion 16

Main findings

Strengths and limitations

Conclusions and recommendations

Reflexive comment

6. References 21

Appendix 1 33

Appendix 2 34

Appendix 3 35

Appendix 4 36

Appendix 5 43

Appendix 6 46

Appendix 7 47

1. ABSTRACT:

Background and aims:

Although giving birth is generally regarded as a joyous life event, this period of transition consists of a multitude of abrupt changes, and is recognised as a stressful life event. Following childbirth many women struggle with the new demands a new baby brings such as sleep deprivation, loss of order and routine, lack of preparation and social support, and changes in their roles including career decisions, the relationship with their partner and their partner’s possible absence owing to work commitments. These emotional and physical difficulties can lead to depression of varying levels in vulnerable females. Up to 80% of women experience postnatal or maternity blues following delivery, and 10-20% of them go onto develop Postnatal Depression (PND). A community interest company runs a group called ‘Exploring ways to feel better after you have had a baby’ for women who are experiencing PND, however the effectiveness of this group has never been evaluated.

The aim of this project was to evaluate the short-term effectiveness of the group. Research has shown postnatal depression has an effect on the quality of life, self-esteem and anxiety levels of mothers. So to evaluate the group’s effectiveness these variables along with depression were measured before and after the intervention.

Method:

Data was collected at two points using four questionnaires, which were administered pre and post group during the group meeting. The four measures used to measure depression, self-esteem, anxiety and quality of life were the Edinburgh Postnatal Depression Scale; the Hospital Anxiety and Depression Scale; the Rosenberg Self-Esteem Scale; and the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form .

Results:

There was no statistically significant different between the pre and post group self-esteem, quality of life or anxiety scores. However there were statistically significant changes found for the HADS-Depression and EPDS; indicating the PND group was effective in reducing PND symptoms in the short term.

Discussion and dissemination:

The results of the evaluation of the effectiveness of the ‘exploring ways to feel better after you have had a baby’ group have led to the following recommendations:

• Future research to control for variables like social circumstances, social support, divorce and relationship status, and financial difficulties; which are known to contribute to postnatal depression.

• To conduct further evaluations of future groups and compare the outcome data.

• To conduct follow-up measures a month to six weeks after the group ended to evaluate the longer term effectiveness of the intervention.

2. Introduction

Although giving birth is generally regarded as a joyous life event, this period of transition consists of a multitude of abrupt changes, and is recognised as a stressful life event (Curtona, 1983; Terry, 1991; Terry, Mayocchi, & Hynes, 1996). Following childbirth many women struggle with the new demands a new baby brings such as sleep deprivation, loss of order and routine, lack of preparation and social support, and changes in their roles including career decisions, the relationship with their partner and their partner’s possible absence owing to work commitments (Milgrom, Martin & Negri, 2006). In addition to these stresses, a new mother may also experience financial difficulties, relationship problems and break ups, social isolation, an unexpected difficult birth, and post birth complications. These emotional and physical difficulties can lead to depression of varying levels in vulnerable females (Milgrom et al., 2006).

While prevalence rates of PND vary according to different cultures, assessment method, and studied populations (O’Hara & Swain, 1996), between 10- 20% of women will go on to develop postnatal depression [PND] (Appleby, Gregoire, Platz, Prince, & Kumar, 1994; Briddon, 2008; Dennis, Janssen, & Singer, 2004; Elliot, 1989). Postnatal depression is a condition characterised by constant crying, social withdrawal, thoughts about death, difficulty concentrating, loss of interest in everyday life, feeling exhausted all the time, difficulty sleeping (even if baby is), disturbances in appetite, feelings of anxiety, sadness, worthlessness and guilt, feeling inadequate as a mother, and feelings of anxiety that would not normally be bothersome e.g. being alone in the house (Briddon, 2008). PND symptoms are not transitory and can persist in varying degrees for many years (Milgrom et al., 2006); affecting the woman’s psychosocial functioning and the baby’s social, cognitive and behavioural development (Kumar, 1994; Lieberman & Pawl, 1993; McDonough, 1993), as well as the woman’s relationship with her partner (Milgrom et al., 2006). Longitudinal studies of PND indicate it has a negative chronic effect on women’s mental health, the mother-infant relationship, child development and marital relationship (Ballard, Davis, Cullen, Mohan & Dean, 1994; Lovestone & Kumar, 1993; Milgrom & McCloud, 1996; Murray & Cooper, 1997; Murray, Fiori-Cowley, Hooper & Cooper, 1996; Pitt, 1968).

While up to 80% of women experience postnatal or maternity blues following delivery (Miller, Pallant & Negri, 2006), PND is distinguished from that by the severity and increased duration of depressive symptoms. Research on maternal mood highlight the three days following the birth to be an accurate predictor of later PND (Cooper & Murray, 1998; Lane, Morris, Turner & Barry, 1997). Further research into the onset of PND indicates the majority of episodes start in the first three months following the birth (Kumar & Robson, 1984; O’Hara, 1997); and a significant number within the first five weeks after delivery (Cox, Murray & Chapman, 1993). Associated psychosocial risk factors for developing PND include previous history of depression (Milgrom, Martin & Negri, 2006; O’ Hara, Rehm, & Campbell 1982; O’ Hara, Neunaber , & Zekoski, 1984; O’ Hara, Schlechte, Lewis & Varner, 1991; O’ Hara & Swain, 1996), anxiety (Dennerstein, Varnavides & Burrows, 1986; Grossman, Eichler & Winickoff, 1990; Hayworth et al., 1980; Hopkins, Marcus, & Campbell , 1984); previous psychiatric history (Elliott, 1984; Paykel, Emms, Fletcher, & Rassaby, 1980; Watson, Elliott, Rugg & Brough, 1984), stressful life events (O’ Hara & Swaine, 1996), inadequate social support (Brugha et al.,1998), low self-esteem (Cox & Holden, 1994; Righetti-Veltema, Conne-Perreard, Bousquet, & Manzano, 1998); and maternal attitudes (Davids & Holden, 1970; Mills, Finchilescu, & Lea, 1995 ).

While PND is a well researched psychological complication of pregnancy (Elliott, 1989) there are no specific National Institute of Clinical Excellence (NICE) guidelines for women suffering from PND; instead there are NICE guidelines for antenatal and postnatal mental health for women (2010). These guidelines cover care for women with anxiety disorders, depression, and postnatal psychotic disorders (puerperal psychosis). The NICE guidelines make a point of not using the term ‘postnatal depression’ as it emphasises the term is often used inappropriately as a general term to describe any postnatal mental health disorder. Similarly, the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) does not recognise postnatal depression as a separate diagnosis; rather, patients must meet the criteria for a major depressive episode and its onset must be within four weeks postpartum to be recognised as PND. NICE guidelines recommend the following for women who experience depression during pregnancy or during the postnatal period: self-help strategies (guided self-help, computerised cognitive behavioural therapy or exercise), non-directive counselling delivered at home (listening visits), and brief cognitive behavioural therapy or interpersonal psychotherapy.

Over the years there has been much research done on PND, and while there is a wealth of literature highlighting the detrimental effects of PND, most information about the condition remains descriptive, with limited detailed programmes to guide health professionals (Milgrom et al., 2006). Biochemical, behavioural, and cognitive theories of depression have influenced research and treatment of PND over the years (Milgrom et al., 2006), so it is important to consider the theoretical and empirical literature of depression in general to develop effective treatment approaches for PND. Behavioural theory for the treatment of depression indicates increasing pleasant activities, and decreasing unpleasant activities along with social skills, problem-solving, and relaxation training are effective in treating depression (Becker & Heimberg, 1985; Lewinsohn, Antonuccio, Steinmetz, & Teri, 1984; Lewinsohn & Gotlib, 1995; McClean & Hakstain, 1979,1990; Nezu, 1987; Thase, 1995). Cognitive and cognitive behavioural theories of depression emphasise various cognitive techniques (challenging cognitive distortions, cognitive restructuring, self-control procedures) to overcome depression (Glick, 1995; Hollon, Shelton & Davies, 1993; Robinson, Berman & Neimeyer, 1990; Scott, 1996) with better maintenance of treatment gains than pharmacology alone or short-term psychodynamic therapies for depression (Ensenck, 1994; Kovacs, Rush, Beck & Hollon, 1981; Miller, Norman, Keitner, Bishop & Dow, 1989; Scott, 1996; Svartberg & Stiles, 1991). Biochemical theories highlight antidepressant medication, such as selective serotonin reuptake inhibitors (SSRIs) as an effective treatment for depression (Milgrom et al., 2006), especially when combined with cognitive behavioural therapy (Clark, 1990; Kovacs et al., 1981; Prien & Kupfer, 1986; Rehm & Kaslow, 1984), however only if not maintained for longer than six months (Rehm & Kaslow, 1984; Rosenbaum & Merbaum, 1984). Despite the theories and treatment models, the bulk of the evidence shows the combination of psychological with drug approaches does not improve treatment effectiveness for depression (Glick, 1995; Milgrom et al., 2006; Olioff, 1991) ; instead well conducted short and long term Cognitive Behavioural Therapy (Clark, 1990; Lewinsohn et al., 1984; Lewinsohn & Gotlib, 1995) is efficacious.

Information and models for unipolar depression have been adapted for use with PND (Cramer et al., 1990; McDonough, 1993; Stern, 1995 )-as diagnostically it is regarded as a major depressive disorder- with an emphasis on non-biological interventions (Dennis, 2004), especially postpartum. Evidence from controlled trials suggests psychological interventions for PND are effective, namely non-directive counselling, cognitive-behavioural therapy (CBT), psychodynamic therapy, and interpersonal therapy (Appleby, Warner, Whitton, & Faragher, 1997; Holden, Sagovsky, & Cox, 1989; Wickberg & Hwang, 1996); and NICE recommends psychological therapies for ante and postnatal mental illnesses, including depression, as first-line treatment (2007).

As previously mentioned, there are there are strong links between pre and postnatal depression and anxiety. Research shows pathological anxiety is a frequent accompaniment to PND, but is not often addressed in clinical intervention trials (Beck, 2010; Milgrom, Negri, Gemmell, McNeil & Martin, 2005; Robertson, Grace, Wallington, Stewart, 2004). And research shows anxiety and PND are associated with substantial impairment in the quality of life and functioning of women (Pyne, et al., 1997). Giving birth is a stressful life event, and after this stressor the immediate effect of a new family member is a specific stress which lowers self-esteem and leads to the development of a depressive disorder (Cox, Murray, & Chapman, 1993; Kendell, Chalmers, & Platz, 1987). In addition, self-esteem is a reliable contributing factor to the susceptibility to depression in the early postpartum period (Fontaine & Jones, 1998). The evaluated PND group intervention addressed the negative cognitive-behavioural triad depicted in the biopsychosocial model of postnatal depression (Milgrom, Martin and Negri, 2006) (appendix 6). The 11 sessions addressed the following: depression and other emotions (anger, anxiety, sadness); meditational cognitive factors (negative automatic thoughts, poor parenting self-efficacy, my internal dialogue, developing more helpful thinking style, challenging my internal critic); behaviour and coping strategies (lethargy, indecision, social withdrawal, marital conflict, difficulties dealing with an infant, introducing pleasant activities into your life, relaxation on the run, self-esteem and assertiveness). This model draws on the cognitive behavioural theories of depression, and incorporates biological, cultural and social factors, like quality of life, into the model.

Based on the supporting PND literature, research, and the biopsychsocial model of postnatal depression (Milgrom, Martin & Negri, 2006) and the content of the intervention, it was concluded the PND intervention group would be evaluated on the following four outcome variables: depression, anxiety, self-esteem and quality of life.

Aims:

The Ministry of Parenting run a group called ‘Exploring ways to feel better after you have had a baby’ for women who are experiencing postnatal depression. This is the second time this group is being run, however its effectiveness has never been evaluated. So the aim of this service evaluation is to provide data to show if the postnatal depression group run by the Ministry of Parenting is an effective short-term intervention for women with postnatal depression symptoms, in terms of reducing symptoms of depression and anxiety, and increasing self-esteem and quality of life.

Overview of Service:

The Ministry of Parenting is a Community Interest Company and as a not-for-profit organisation is a form of social enterprise. It works with children, parents, professionals and organisations developing creative evidence-based solutions to the challenges faced by families in society today. In partnership with complementary services, The Ministry of Parenting aims to raise self-esteem, confidence, emotional resilience and mental wellbeing amongst parents and children and to promote social integration to enhance and support current good practice, training, evaluation, promotion of healthy living and providing equity of access. The Ministry of Parenting abides by its own professional code of conduct and demonstrates adherence to internal company policies. Both directors came to the organisation from positions in the NHS and whilst not directly working for a specific NHS Trust they are commissioned to deliver services by many of the NHS Trusts in Essex and surrounding counties; and often work in partnership with the Trusts to deliver services. The directors are experienced in consultancy, community development and parental mental health; and deliver courses and training workshops across Essex and the Eastern Region counties. The provision of the postnatal depression group is one such collaboration as The Ministry of Parenting co-facilitated the group with an employee of the Mid Essex Primary Care Trust.

3. METHOD

Design:

This is an evaluation of an intervention group for women with postnatal depression, i.e. a within participant design. Data was collected at two points using four questionnaires, which were administered pre and post group during the group meeting. It was felt this design was appropriate as it was hoped the majority of women would be happy to complete questionnaires as they do not require much time to complete, but interviews would require meeting each woman individually outside of the group, and this method would have place more demands on the depressed mothers.

Measures:

Four measures were used to determine depression, self-esteem, anxiety and quality of life pre and post intervention in a group of women with PND symptoms.

The Edinburgh Postnatal Depression Scale (EPDS), [Cox, Holden, & Sagovsky, 1987] is a ten-item Likert format, valid postpartum depression assessment scale, developed for professionals working in primary health care. Each statement has four possible answers and women underlines the statement most applicable to how she has been feeling during the last 7 days. Items are scored on a 0–3 scale, giving a total range of 0–30. Scores above 9 indicate 'possible depression' while scores above 12 indicate 'probable depression' (Cox et al., 1987). It is recommended when using the EPDS in primary care settings, the cut-off of 12/13 is used instead of 9/10 to prevent over-inclusiveness (Cox & Holden, 2003). The reliability of the 10-item EPDS is 0.88 and the standardised α coefficient 0.87. (Kumar & Riley, 1994). Most women are able to complete the scale in less than five minutes, and it is generally well received by women who have recently given birth. The scale is a screening tool for postnatal depression and does not assess anxiety, phobias or neuroses (Cox & Holden, 2003).

As the EPDS does not assess for anxiety, and given that anxiety is a characteristic of PND (Briddon, 2008), the Hospital Anxiety and Depression Scale [HADS] (Snaith & Zigmond, 1983) was used. The HADS is divided into anxiety and depression subscales (HADS-A and HADS-D). Cronbach’s alpha for HADS-A ranged from .68 to .93 (mean .83), and for HADS-D .67 to .90 (mean .82) (Bjelland et al, 2001). The HADS has a two-week test-retest reliability coefficient of .84 (Marinus et al., 2001). The HADS comprises of 14 statements which measure anxiety (7 statements) and depression (7 statements); and has a four point (0–3) response category so possible scores ranged from 0 to 21 for both anxiety and depression (Snaith, 2003). Scores of 7 and below indicates normal levels of anxiety and depression, while 8-10 suggests mild depression or anxiety, 11-15 moderate, and 16 – 21 severe depression and/or anxiety.

The Rosenberg Self-Esteem Scale (SES) (Rosenberg, 1965) consists of 10 items: five positively worded and five negatively worded phrases; and scores range from 10 to 40, where high scores suggest high self-esteem. Scores of 15-25 indicates normal self-esteem, while scores below 15 indicates low self-esteem. The SES has high reliability, and test-retest correlations range from .82 to .88, and Cronbach's alpha for various samples are in the range of .77 to .88, including antenatal and postnatal depression samples (Leigh & Milgrom, 2008). Like the EPDS, it takes no longer than 10 minutes to complete.

The Quality of Life Enjoyment and Satisfaction Questionnaire Short Form [QLESQ-SF] (Endicott, Nee, Harrison, & Blumenthal, 1993) is a 16-item self-report form, rated on a 5-point scale. A total score is obtained from the first 14 items, computed and reported as a percentage of the maximum score of 70. The two global measures (items 15 and 16) are not included in the total score. The QLESQ- SF has been validated for use in samples of adults with depression and anxiety (Rapaport, Clary, Fayyad, & Endicott, 2005). QLESQ-SF has a Cronbach's alpha value of 0.86 (Stevanovic, 2011), and a test-retest consistency for overall rating of life satisfaction of 0.71 (Rapaport et al., 2005). Any participant who scores within 10% of the mean of the community sample is considered within normal range (Rapaport et al., 2005).

Data collection:

Measures for depression, anxiety, self-esteem and quality of life were taken at the start of the PND group, and again at the end of the group 12 weeks later to evaluate the short-term effectiveness of the programme.

Referral process:

Women were referred to the Ministry of Parenting for the group via their NHS community health visitors. The health visitors completed the EPDS (Cox, Holden, & Sagovsky ,1987) with potential participants, and those who scored 12 or above were referred for the group.

Inclusion/exclusion criteria:

Women who were already under the care of the Community Mental Health Team, who had puerperal psychosis, had given birth prematurely or whose baby has a congenital abnormality, or who had a still birth were not accepted. No limits were placed on the amount of elapsed time from when the woman gave birth to when her PND symptoms developed, or on the duration of her PND symptoms.

Sample:

Eighteen females started the group, and thirteen completed the group thirteen weeks later. All of the females were white British. Marital and relationship status was not obtained from the sample. In the pre-group sample, six females were employed, two were employed but were currently on maternity leave, and ten were unemployed. The age range of participants was 22 to 38 years (M = 30.11; SD = 4.65). Of the 13 females who completed the group, 7 of them had one child, 3 females had two children, 2 females had one child and 1 female had five children. The youngest child was 4 months old and the oldest child was 13 years old. The mean age in months for the children was 33.908 months (2 years 8 month old). This finding reflects the research that if left untreated some women continue to experience depression, classified as being a major depressive disorder according to the DSM-IV criteria, 24 months postpartum (Milgrom & Beatrice, 2003; Pitt, 1968).

(See Appendices 1 and 2 to see information given to the group attendees at the first meeting.)

Ethical consideration:

The women attending the group were informed their completed questionnaires would be stored in an anonymous way, and their date of births formed a unique identification number for each participant. They were informed their data could be removed from the study at any point up until the report was written, and that participation or non-participation would not affect their attendance of the group. At the start of the group the women were given information and contact details should they need to contact people in an emergency (See appendix 2).

Ethical approval to evaluate the intervention was granted by the University of Essex Ethics Committee (Appendix 3).

4. RESULTS

Based on the PND literature, models, and research, four outcome variables (depression, anxiety, self-esteem and quality of life) were chosen to measure the effectiveness of the intervention.

| | |

| |N |Medians |

|QLESQ-SF (Quality of life) |.345 |Medium |

|SES (Self esteem) |.203 |Small |

|EPDS (Edinburgh postnatal |.450 |Medium |

|depression scale) | | |

|HADS-Anxiety |.354 |Medium |

|HADS-Depression |.476 |Medium |

Table 2: Effect Sizes

Based on the medians, the women’s depression scores after the group intervention were lower (EPDS = 13; HADS-D= 5.50), than they were at the start of the group (EPDS= 17.5; HADS- D= 10). The Wilcoxon test (t=2.50 for EPDS; t= 2 for HADS-D) was converted into z-scores of -2.507 (EPDS) and -2.609 (HADS-D), with an associated two-tailed probability of .012 (EPDS) and .009 (HADS-D). So the results show the depression scores have decreased following the intervention, however it cannot be concluded that the intervention caused the reduction in the depression scores as there was no control group and the sample was underpowered. This will be discussed further in the ‘Discussion’ section. The median for Edinburgh Postnatal Depression Scale was 17.5.0 before the intervention and 13.00 post-intervention; and there was a medium effect size (0.45) (Fields, 2009) for the EPDS. The pre intervention median for the HADS depression was 9.00, and the post-treatment median was 3.5, indicating a reduction in depression. The effect size for the HADS Depression was .476, which is a medium effect size (Field, 2009) as shown in table 2 above.

The median scores for quality of life, self-esteem and anxiety before the intervention were 37.00, 14.5, and 14.00. After the intervention they were 55.00 for quality of life, 14.00 for self-esteem and 9.00 for anxiety. However there were no significant difference in quality of life (z = 1.92, p = .055, two-tailed), self-esteem (z = 1.135, p = 0.257, two-tailed), or anxiety (z = 1.944, p = .052, two-tailed) of the women who attended the group.

The effect size for quality of life was 0.345, suggesting there was a medium change (Field, 2009) in the quality of life for the women following the group, even if it was not significant. The median before the intervention for quality of life was 37.00 and after the intervention was 55.00, indicating an increase in quality of life, although it was not significant. There was a small effect size for self-esteem, .203 (Field, 2009); and the median for pre-intervention self-esteem was 14.50 and following the intervention was 15.00, which again indicates there was little change (see table 2), however it was not significant. The effect size for anxiety was .354, which was a medium effect size (Field, 2009). The median for anxiety before the intervention was 14.00 and after the intervention was 10.00, which indicates a small reduction in anxiety (see table 2), but again this was not significant.

(See appendix 5 for Wilcoxon signed rank test SPSS outputs)

DISSEMINATION:

The findings of the evaluation have been fed back to the Ministry of Parenting through a brief report (see appendix 7), and in person.

5. DISCUSSION

This evaluation explored how effective the ‘exploring ways to feel better after you have had a baby’ group was in helping women who were identified as having postnatal depression.

Main findings:

The Wilcoxon signed-rank tests did not show any significant differences in the quality of life, self-esteem or anxiety before and after attending the group; however there was a reduction in the depression scores. However it cannot be concluded that the intervention caused the reduction in the depression scores as there was no control group, and the study was underpowered (This is discussed further in the ‘Discussion’ section of the report).

Strengths and limitations:

Strengths:

Although this is the second time this group is being run by the Ministry of Parenting, it is the first time it is being evaluated and its short-term effectiveness measured. This identified and promoted good practice, ensured better use of resources which potentially increased efficiency; and could lead to service delivery improvements, and improve the quality of the intervention being offered to future users. The information from this evaluation demonstrated how effective the intervention was, and thus ensured its development and continuation, especially when bidding for future funding.

As a result of this evaluation, working relationships between the Ministry of Parenting and the National Health Service (health visitors and GP practices) has been strengthened; and communication and planning future PND groups has been boosted. It has also facilitated communication and liaison between the Ministry of Parenting and other charities working with mothers who are depressed and require parenting support beyond the group, thus providing on-going social support to these vulnerable women.

By completing this evaluation of the PND group the following objectives have been achieved: to deliver demonstrable improvements in client care; to encourage evidence based practice; and to contribute to continual professional development; as recommended by the Clinical Governance Leads Network (CGLN, 2006).

I felt the pre-post evaluation design was a strength as it was able to capture the changes within the women’s depression, anxiety, self-esteem and quality of life before and after the intervention. As these measures were completed during group time it placed less demands on the women who were already feeling overwhelmed by their personal circumstances; and as their infants was not present during the group – they were at the provided crèche facility- the mothers were able to give their time and attention to completing the measures.

And finally, by delivering the intervention in a group rather than individually, the mothers were able to discuss and share their similar experiences, fears, and expectations with one another. This not only promote each mother’s coping abilities during this stressful life event, but also established social networks and support for each mother, and reduced their social isolation, which is a vulnerability factor for maintaining PND. (Brugha et al.,1998; Gordon, Swan & Robertson, 1995; Jones, Watts, & Romain, 1995, May, 1995; Milgrom et al., 2006; Seale, Williams, & Reynolds, 1988). By running the intervention in a group it provided the women with an opportunity to draw social comparisons with other women who were in similar circumstances to themselves, and this allowed a normalising opportunity to take place to ‘normalise’ their experience (Davies & Jasper, 2004).

Limitations:

No clinical information was obtained from the women, i.e. formal diagnosis, medications or previous depression treatments, and this was a limitation as it could have affected the efficacy of the intervention; given that previous episodes of depression is an increased risk factor for PND (Milgrom et al., 2006; O’ Hara et al., 1982; O’ Hara et al., 1984; O’ Hara et al., 1991; O’ Hara & Swain, 1996). Women were referred to the group based on EPDS scores, however the EPSD is a self-report screening tool, which measures depressive symptoms rather than a clinical diagnosis, so a further limit of this evaluation is that none of the women had a formal clinical diagnosis of PND, and so validated clinical measures of depressive symptomatology are lacking from this sample. The sample did appear to reflect some diversity in employment status, although demographics such as socioeconomic status, cultural factors and relationship status were not recorded for any of the participants. This is a limitation of the evaluation, as research indicates these are influencing and precipitating factors for PND (Beck, 2001; Brugha et al., 1998; Leigh & Milgrom, 2008; Milgrom et al., 2006).

A design limitation of this evaluation is not having included a control group. While a control group would have facilitated a more thorough evaluation of the effects of the intervention, it would have changed the nature of this write up from an evaluation to a simple experiment, thus constituting research which would have violated the R & D ethical approval for a service evaluation. In addition, recruiting a control group would have required applying for NHS ethical approval, and the time constraints for this to take place would have extended beyond the SRP submission date. As there was no data collected from a control group, no inferences could be made from the results of this evaluation on PND, or what would have happened to these women if they had not attended the group.

This evaluation only took measures at pre and post group, so only the immediate short-term effects of the group intervention were measured. As no follow-up measures were taken in the weeks after the intervention had finished it is unknown how sustainable the identified changes were in the long-term.

Given the small sample size, any results from this intervention must be interpreted with caution, as the sample was under powered. The sample size was based on the number of referrals received from health visitors rather than from power calculations insuring the correct number of participants attended to make the results clinically significant.

Conclusions and recommendations:

The evaluation of the Ministry of Parenting’s ‘Exploring ways to feel better after you have had a baby’ group indicates it was effective in reducing the short-term depression symptomlogy in the evaluated group, so the main aim of this service related project (SRP) was achieved.

In future evaluations, variables like social circumstances and support, relationship status and divorce, and financial difficulties, need to be accounted for as many of the women who attended the group spoke about having some or all of these problems in their lives, and this could maintain their PND symptoms. The Biopsychsocial model of depression (Milgrom, Martin & Negri, 2006), shows how social withdrawal and marital conflict contributes to the maintenance of the negative cognitive-behavioural triad in PND. In addition consideration should be given to the education status of the women as lower education attainment predisposes women to PND (Marcus, Flynn, Blow & Barry, 2003); and clinical information like previous depressive episodes and current medication should be obtained.

The effect of facilitators’ expertise and the therapeutic alliance was not evaluated on treatment outcomes in this evaluation, and this should be considered, as the quality of the therapeutic alliance is as important as the type of treatment in predicting positive therapeutic outcomes ( Safran & Muran, 1995). The facilitators were warm, empathetic, compassionate, non-judgemental, gave support outside of the group during the 12 weeks the programme ran, and offered a sympathetic ear when women needed to talk; so the affect of these should be accounted for.

Given there were moderate effect sizes for quality of life and anxiety, future studies should consider having enough participants so the study is appropriately powered to explore whether the near level of significance values for quality of life (p = .055), and anxiety (p= .052) is potentially a trend in the treatment programme for PND.

A further recommendation is to conduct follow-up measures a few months after the group has ended to evaluate the longer term effectiveness of the intervention, as the current evaluation only measure the short-term effects of the intervention. While this was attempted with the evaluated sample at the group reunion at the end of September 2011, the women felt they wanted to spend their reunion time talking to one another rather than completing forms, and so I respected their request.

As with any research, there were participants who dropped out of the study. Five participants did not complete the group and it would have been informative to know the reasons why they left the group, so this could be taken into account when planning future groups. This was not felt like it was a limitation to the current evaluation, as the sample was already under powered before the five women dropped out.

Reflexive comments:

In conducting this SRP I gained practical experience on preparing, researching and conducting a clinical evaluation of a service, and I feel these skills will be transferable when I do my thesis. I have not done a service evaluation before, so I lacked the knowledge of when and how to do things, e.g. when and how to apply for ethical approval, what outcome measures to use, and how best to address a group of depressed women to encourage their participation in the evaluation. I often felt I did not have the skills or the know-how to fall back on to smooth out the research/evaluation process.

Waiting for ethical approval to be granted for my SRP was at times frustrating, and left me feeling very powerless, especially as the group was originally due to begin in April 2011; and despite submitting my ethical application in February 2011, I had not heard back from the University by the time the group was due to begin. I was lucky when the start date for the group was pushed back unexpectedly to July 2011 as this gave me additional waiting time to hear back from the ethics board. With hindsight this was a valuable experience for when I do future research, as I now know to allow plenty of time for ethical approval as it can be a lengthy process.

As I was evaluating a group for a charity, I found I sometimes experienced tensions between meeting my academic needs from this project as a trainee clinical psychologist, and the needs of the service. In addition, it was a challenge to balance the various deadlines and demands of the service, the group starting/ending, being on clinical placement in a different service while the group was running, University Ethic Board and academic submission date for this SRP. This not only developed my communication skills, and ability to manage my time to meet the various demands and deadlines, but also challenged my ability to manage my stress and anxiety whilst remaining courteous and professional.

I thoroughly enjoyed working with the facilitator from Ministry of Parenting, and found she not only provided me with valuable reading whenever we met, but was always generous with her knowledge, time, and expertise when it came to PND and planning my evaluation. As a result of working with her I feel my job was made a lot easier, and collecting sufficient data went better than expected. I have come away feeling valued as a person, for the work I have done for the charity, and supported and accommodated by the charity.

References

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed – text revision. Washington, DC: American Psychiatric Association.

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Appendix 1:

Exploring Ways to Feel Better After You Have Had a Baby.

PROGRAMME

May 27th Introduction

June 3rd Feeling Better in Mind, Body and Spirit

June 10th Importance of Exercise

June 17th Mood and Food

June 24th No Group

July 1st Sleep, Rest and Relaxation

July 8th Building Relationships

July 15th Being Assertive (& managing finances)

July 22nd De-stressing your life.

July 29th Thinking about Thinking

August 5th Sources of Help

August 12th Feeling Better, Moving On

September 30th Reunion.

Appendix 2:

Information given to Mothers attending the group

Exploring Ways to Feel Better After You Have Had a Baby.

Welcome to this 10 week course which will explore moods and feelings in the months after having a baby and ideas for activities and interventions that can help you to feel better.

Course runs every Friday 9h30am – 12 midday in Maldon Town Hall from May 27th – August 12th

Creche is provided by The Artful Splodgers mobile crèche service.

Course facilitators :

Cathy Lowenhoff

Rachel Dorado

If you need to contact someone about the course, please ring or text Rachael Dorado on her mobile - 07961 785311.

You may want to access help from other sources as well as attending this course. For example, you may wish to discuss how you feel with your health visitor or G.P or you may want to be referred to someone whom you can talk things through with on a one-to-one basis. If you do not know who to talk to about the best sources of help, please feel free to discuss your needs with one of the course facilitators.

Remember that it is good to talk so if you have a partner, friend or close relative that you can talk to about the way that you feel, they may also be able to think of ways to help you to feel better.

Netmums also have a chatroom where you can talk to other Mums and to health professionals about the way that you feel. ()

Please do look after yourself ; if things get really bad, contact your G.P or go to the Accident and Emergency Department of your local hospital.

Appendix 3:

Ethical Approval

[pic]

Appendix 4:

SPSS Outputs

Kolmogorove-Smirnov Test results

|Tests of Normality |

| |Kolmogorov-Smirnova |Shapiro-Wilk |

| |

|*. This is a lower bound of the true significance. |

Appendix 4:

P-Plots for pre and post group Quality of Life

[pic]

[pic]

Appendix 4:

P-Plots for pre and post group Self-esteem.

[pic]

[pic]

Appendix 4:

P-Plots for pre and post EPDS

[pic]

[pic]

Appendix 4:

P-Plots for pre and post group HADS- Depression

[pic]

[pic]

Appendix 4:

P-Plots for pre and post group HADS- Anxiety

[pic]

[pic]

|Statistics |

| |

Appendix 5:

Wilcoxon Signed Rank Test SPSS Outputs

Quality of life, self-esteem, Hospital Anxiety and Depression scale, and Edinburgh postnatal depression scale: Wilcoxon Signed-rank test

|Descriptive Statistics |

| |

| |N |Mean Rank |Sum of Ranks |

|QOL-Po_Per - QOL-Pre-Perc |Negative Ranks |3a |6.00 |18.00 |

| |Positive Ranks |10b |7.30 |73.00 |

| |Ties |0c | | |

| |Total |13 | | |

|Post-SES - Pre-SES |Negative Ranks |7d |5.50 |38.50 |

| |Positive Ranks |3e |5.50 |16.50 |

| |Ties |3f | | |

| |Total |13 | | |

|Post-EPDS - Pre-EPDS |Negative Ranks |9g |6.78 |61.00 |

| |Positive Ranks |2h |2.50 |5.00 |

| |Ties |2i | | |

| |Total |13 | | |

|Post-HADSA - Pre-HADSA |Negative Ranks |7j |6.64 |46.50 |

| |Positive Ranks |3k |2.83 |8.50 |

| |Ties |2l | | |

| |Total |12 | | |

|Post-HADSD - PRE-HADSD |Negative Ranks |9m |5.89 |53.00 |

| |Positive Ranks |1n |2.00 |2.00 |

| |Ties |2o | | |

| |Total |12 | | |

|a. QOL-Po_Per < QOL-Pre-Perc |

|b. QOL-Po_Per > QOL-Pre-Perc |

|c. QOL-Po_Per = QOL-Pre-Perc |

|d. Post-SES < Pre-SES |

|e. Post-SES > Pre-SES |

|f. Post-SES = Pre-SES |

|g. Post-EPDS < Pre-EPDS |

|h. Post-EPDS > Pre-EPDS |

|i. Post-EPDS = Pre-EPDS |

|j. Post-HADSA < Pre-HADSA |

|k. Post-HADSA > Pre-HADSA |

|l. Post-HADSA = Pre-HADSA |

|m. Post-HADSD < PRE-HADSD |

|n. Post-HADSD > PRE-HADSD |

|o. Post-HADSD = PRE-HADSD |

|Test Statisticsc |

| |

|b. Based on positive ranks. |

|c. Wilcoxon Signed Ranks Test |

Appendix 6:

Biopsychosocial

Model of Postnatal

Depression.

(Milgrom et al., 1999)

Exacerbating/maintaining factors are expanded below:

Negative

Cognitive-Behavioural

Triad

Appendix 7:

Service Evaluation Feedback to the Ministry of Parenting

Summary of evaluation:

The ‘exploring ways to feel better after you have had a baby’ group was run from May 2011 to August 2011, to help women who were identified as having postnatal depression symptoms. The launch of this group provided a postnatal depression service for women who did not meet the eligibility criteria for Adult Mental Health, but who required non-biological intervention for their symptoms.

The aim of this project was to evaluate the effectiveness of the ‘exploring ways to feel better after you have had a baby’ group. Research has shown postnatal depression has an effect on the quality of life, self-esteem and anxiety levels (Cox & Holden, 1994; Dennerstein, Varnavides & Burrows, 1986; Grossman, Eichler & Winickoff, 1990; Pyne et al., 1997; Righetti-Veltema, Conne-Perreard, Bousquet, & Manzano, 1998). So to evaluate the effectiveness of the group, these variables along with depression were measured before and after the group intervention.

Aim of the evaluation:

The aim of this intervention evaluation is to provide data to show ifthe group run by the Ministry of Parenting is an effective treatment for women with postnatal depression, in terms of:

• Symptoms of depression

• Self-Esteem

• Symptoms of anxiety

• Quality of life

Methodology:

Data was collected at two points using four questionnaires, which were administered pre and post group during the group meeting. The four measures used to measure depression, self-esteem, anxiety and quality of life were the Edinburgh Postnatal Depression Scale (EPDS), [Cox, Holden, & Sagovsky ,1987]; the Hospital Anxiety and Depression Scale [HADS] (Snaith & Zigmond, 1983); the Rosenberg Self-Esteem Scale (SES) (Rosenberg, 1965); and the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form [QLESQ-SF] (Endicott, Nee, Harrison, & Bluemthal, 1993).

Findings:

The depression symptoms of the women improved significantly following the group on both the Edinburgh postnatal depression scale and Hospital anxiety and depression scale. While effect sizes showed medium positive changes in quality of life and anxiety levels in the women, the changes were not significant. A small and non-significant change occurred following the group in the women’s self-esteem.

Recommendations:

The results of the evaluation of the effectiveness of the ‘exploring ways to feel better after you have had a baby’ group have led to the following recommendations:

• Future research to control for variables like social circumstances, social support, divorce and relationship status, previous depressive episodes, and financial difficulties; which are known to contribute to postnatal depression.

• To conduct further evaluations of future groups and compare the outcome data.

• To conduct follow-up measures a month to six weeks after the group ended to evaluate the longer term effectiveness of the intervention.

References:

Cox, J.L., & Holden, J.M. (Eds) (1994). Perinatal psychiatry: Use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell.

Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, Vol. 150, 782-786.

Dennerstein, L., Varnavides, K., & Burrows, G. (1986). Postpartum depression: A review of recent literature. Australian Family Physician, 15, 1470 – 1472.

Endicott, J., Nee, J., Harrison, W., & Bluemthal, R. (1993). Quality of Life Enjoyment and Satisfaction Questionnaire : A new measure. Psychopharmacology Bulletin, 29: 321 – 326.

Grossman, F.K. Eichler, L.S. & Winickoff, S.A. (1990). Pregnancy, birth and parenthood. San Francisco: Jossey-Bass.

Pyne, J.M., Patterson, T.L., Kaplan, R.M., Ho, S., Gillin, J.C., Golsham, S., & Grant, I. (1997). Preliminary longitudinal assessment of quality of life in patients with major depression. Psychopharmacological Bulletin, 33, 23 – 29.

Righetti-Veltema, M., Conne-Perreard, E., Bousquet, A.& Manzano, J. (1998). Risk factors and predictive signs of postpartum depression. Journal of Affective Disorders, 49, 167-80.

Rosenberg, M. ( 1989). Society and the Adolescent Self-Image.  Revised edition. Middletown, CT: Wesleyan University Press.

Snaith, R.P., & Zigmond, A.S. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67: 361 – 370.

-----------------------

Cultural

Factors

Vulnerability Factors

Precipitating Factors

including biological factors

Depression and other emotions

Anxiety

Anger

Sadness

Postnatal Depression

Mediational Cognitive Factors

Negative automatic thoughts

Poor parenting self-efficacy

Behaviour/Coping Strategies

Lethargy Indecision

Social withdrawal Marital Conflict

Difficulty dealing with infant

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