Created by: Heather M. Truog, OTD, OTR/L, PYT
capstone project for post-professional doctoral program
University of St. Augustine for Health Sciences
Postpartum depression is a serious mental health diagnosis prevalent in 1 in 7 postpartum women that has an adverse impact on the woman’s quality of life (QOL) and potentially detrimental impact on the health and development of her newborn child.
While there exist adequate screening tools to identify this condition, many women are reluctant to follow through with mental healthcare recommendations.
Shame and fear of stigma are some of the greatest contributing factors for women to suffer in silence with their emotional experience.
Transition to the role of motherhood can be overwhelming for many women, causing them to neglect or abandon other life roles and activities that give their daily lives meaning.
Facilitated engagement in meaningful activities have shown to have a positive impact on QOL and decreased perceptions of depression in women with PPD.
The OT can benefit the client through the promotion of healthy lifestyle, role transition, and engagement in actionable interventions to regain occupational balance and improved perceptions of QOL.
BACKGROUND AND PREVALENCE
While the transition to motherhood is commonly viewed as a positive experience in a woman’s life, it comes with significant physical, psychological and social impact that may require adapting to and overcoming various barriers (Habel, Feeley, Hayton, Bell, & Zelkowitz, 2015). Adjustment to the role of motherhood is a major life change that, for some, may entail unanticipated feelings of stress, anxiety, fear of being a “bad mother”, feelings of inadequacy, and uncertainty as to how to balance one’s life (Habel et al., 2015). The American Psychiatric Association (2019) estimates that one in seven women will experience the more serious diagnosis of postpartum depression (PPD), while up to 70% of all new mothers will experience “baby blues,” a shorter-lasting and less detrimental condition. Hansotte, Payne, and Babich (2017) define PPD “as nonpsychotic depression occurring up to 1 year after childbirth….and is a crippling mood disorder that erodes away at the joy and happiness of new mothers”(p. 2).
What Postpartum Depression Feels Like...
National Coalition for Maternal Mental Health (2016)
Understanding Postpartum Depression...
The Mayo Clinic Minute (2018)
The American Psychiatric Association (2019) clearly emphasizes that “baby blues” and postpartum depression (PPD) are not the same, and the latter has serious implications for the health and wellbeing of both the mother and the child. The American College of Obstetricians and Gynecologists (2018) has acknowledged that the postpartum period as a critical timeframe for both a woman and her infant, and has made continuous recommendations for the optimization of establishing and providing ongoing care as needed to ensure best outcomes in identifying and addressing PPD. However, despite the increased awareness being drawn upon the issue, and the continued efforts being made by leading healthcare professionals to proactively identify and address symptoms that may present as indicators, underutilization of postpartum care and noncompliance with mental health recommendations play a role in undermining effective impact upon the prevalence of this condition.
Feeley and colleagues (2016) articulate that despite valid and reliable screening tools being available to detect the symptoms of PPD, there is a lack of evidence to indicate that the screening process yields effective uptake of the mental health services recommended. They further indicate in their research that few of the women (18-36%) positively identified as depressed accepted and utilized the prescribed mental health services to address their healthcare needs (Feeley, Bell, Hayton, Zelkowitz, & Carrier, 2016). Moreover, of those few who accept a referral for mental health services, less than half followed through with contacting the mental health provider (Feeley et al., 2016). Screening is not enough. Identifying the women who are in need of care is only a first step. Women who do not receive proper postpartum care for their mental health needs will not benefit from the efforts made to screen and identify their circumstances.
PSYCHOSOCIAL AND SOCIOCULTURAL IMPACT
What is keeping women from seeking out care to address their postpartum healthcare needs?
Despite the many efforts to reduce the shame and isolation associated with the diagnosis of various mental health conditions within the United States, the stigma continues to pervade within American culture. Baines and colleagues (2013) indicate that some mothers who have been positively identified as experiencing PPD “are reluctant to seek professional help for fear they will be admitted to a psychiatric unit, get ‘locked up’ or have their baby taken from them.” (p. 780). Women have also reported that they are ashamed to admit to partners and family the feelings they are experiencing, and as a result suffer with their emotions silently – or may be completely unaware that their emotional response to the postpartum experience is beyond the scope of ‘typical’ baby blues (Kim & Dee, 2017).
Other research indicates that there is a general distrust of healthcare providers and the greater healthcare establishment, with women regarding each as threatening or as an inappropriate solution to their needs (Baines, Wittkowski, & Wieck, 2013). Fear and distrust of the medical establishment is particularly prevalent among low socioeconomic demographics and minority populations, who represent an increasingly vulnerable population for the prevalence of PPD. While the American Psychiatric Association has rounded their estimate to one in seven women to experience the condition of PPD, research suggests that women of color may develop an increased rate of PPD at upwards of 38% (Keefe, Brownstein-Evans, & Polomanteer, 2016).
While PPD poses a serious mental health concern for the mother as an individual, there exists an additional critical concern for the developmental and emotional health of the infant. The impact upon infant health is particularly important within the first year postpartum (Barkin & Wisner, 2013). Untreated postpartum depression can result in impaired child development and growth, a hindered ability for the mother to bond and form an attachment to the baby, challenge maternal parent self-efficacy, and negatively impact the marital relationship (Feeley et al., 2016).
The problems that surround the issue of postpartum depression (PPD) are multifaceted as mental health presents as a serious public health concern, while the quality of mother and infant bonding, maturing to mother and child interaction, has a tremendous impact on society (Barkin & Wisner, 2013). Investing in best-practice mental health care for postpartum women is imperative for both the woman and the family she is accountable to. It is paramount that effective treatment and adequate support be provided to mothers with depression following childbirth; however, one of the greatest barriers to executing best care is in first identifying the population in need as many mothers are reluctant to seek care (Baines, Wittkowski, & Wieck, 2013). Despite the growing recognition of the matter and awareness to the need for improved intervention services, studies suggest that the fear of stigma remains the most significant deterrent to the seeking of services (Shivakumar, Brandon, Johnson, & Freeman, 2014).
Working to change the conversation about maternal mental health...
Reproductive Psychiatrist, Alexandra Sacks, discusses the "emotional tug-of-war" that can accompany a woman's transition to motherhood, and how our culture has yet to adequately define or understand what this transition implies.
In this TedTalk, she offers a new term that may help define the process that occurs for many women: matrescence.
LEARN MORE ABOUT THE ROLE OF OCCUPATIONAL THERAPY IN ADDRESSING PPD
PPD'S IMPACT ON THE OCCUPATIONAL PROFILE
The included table (Table 1) describes the ways in which postpartum depression can have the potential for broad impact upon an individual’s occupational profile. The information in Table 1 representing Category and Description of occupation is directly quoted from the Occupational Therapy Practice Framework: Domain and Process [3rd edition] (AOTA, 2014, p. S19-S21), the table is further adapted to include diagnosis-specific interpretation of relevance.
Just as articulated in the previous section relative to endometriosis and the impact upon the occupational profile, each client experiencing postpartum depression will have a unique manifestation of symptom presentation influencing occupational performance and therefore affecting the overall wellbeing and QOL as it is relative to their specific occupational needs. Performance or participation in the identified occupational tasks will be grossly impacted by individual client factors relative to values, beliefs, and spirituality; body functions; and body structures. The impact will likely be further influenced by specific performance skills relative to motor skills and process skills or performance patterns (habits, routines, rituals, and roles) specific to the person and group or population. Overall relevance to occupations should be taken into consideration with respect to contexts (cultural, personal, temporal, virtual) and environments (physical and social).
OT'S ROLE WITHIN THE INTERDISCIPLINARY TEAM
Podvey (2018) strongly advocates for the role of the occupational therapist in maternal mental health as “a good fit,” highlighting several aspects of the intervention process that the OT is uniquely qualified to deliver. Interventions well within the scope and practice of the occupational therapy practitioner outlined within this body of literature include (Podvey, 2018):
Facilitation of coping strategies for common parenting problems and developing realistic expectations
Development of new co-occupations and routines, such as breastfeeding or bathing
Discussing and educating the client on post-natal coping patterns before the birth to aide in better transitions to the parenthood experience
Promote attachment-focused interventions to facilitate mothers’ enjoyment with baby interactions, including age-appropriate play or delivery of infant massage
Empower the mother with education about healthy childhood development to nurture positive engagement, autonomy, and improve emotional wellbeing
MANAGEMENT OF PHYSICAL ISSUES:
Address chronic pain management and physical disorders (e.g., chronic low back pain, urinary incontinence, and pelvic organ prolapse), which affect daily function through remediation, compensation, or environmental modification.
Address the sequelae of physical issues such as accompanying stress, anxiety, depression, diminished sense of wellbeing and ability to care for the baby.
Provide adaptive strategies to address sleep deprivation being common and correlated to exacerbated experiences of physical issues and sequelae in the postpartum period.
Support psychological wellbeing by teaching new skills, assisting with the development of healthy habits and routines, and addressing life balance.
Support development of physical wellbeing through the development of appropriate pre- and/or post-natal exercise programs, addressing potential pelvic health issues, and establishing sleep and breastfeeding schedules and routines.
EDUCATE AND ADVOCATE:
Provide new mothers with empowering information and community resources
Provide access to resources for social supports within the community
Help identify atypical situations (e.g., pelvic floor problems or unmet infant milestones) and to determine the best course of action for next-steps
Refer to needed providers when beyond the scope of the OT domain and process
HOW OCCUPATIONS CAN INFLUENCE PPD
Meaningful activities have been repeatedly cited within the existing body of literature as being a priority for women identified with postpartum depression. Feeley et al. (2016) outlined four primary areas that were expressed by the findings of their qualitative study to be the most important aspects of care in the postpartum period: 1) comprehensive care; 2) support; 3) activities; and 4) professional help. Activities are explicitly valuable to the care of this population. One study indicated that women were most likely to advocate for nontraditional treatment interventions for their symptoms of depression, such as exercise and yoga (Shivakumar et al., 2014). Yoga is shown to have a significant positive impact on PPD in a random controlled trial (Buttner, Brock, O'Hara, & Stuart, 2015). Leisure-time physical activity was additionally found to have a significant impact on participating women with PPD’s perceptions of self-worth, empowerment, and an overall reduction in susceptibility to depressive symptoms (Lloyd, O’Brien, & Riot, 2016).
Engaging in social support related to a church or spiritual organization was highly valued and of positive impact on both women of color (Keefe, Brownstein-Evans, & Rouland Polmanteer, 2016) and Hispanics in rural settings (Kim & Dee, 2017). While one study found that an arts-based program for women with PPD lead to verbalized feelings of improved quality of life, perceptions of self-efficacy and gained satisfaction from informal social support in the 10-week course (Morton & Forsey, 2013). Selix and Goyal (2015) elaborate upon the importance of empowering women with adaptive strategies for returning to the workplace to resume professional occupations, as 80% of women who are employed during their pregnancy return to their professional roles within the first year of the newborn’s life.
Perhaps most importantly, the transition to the maternal role and the ability to engage in the occupation of maternal self-care while balancing the demands of child-rearing is the immediate focus of occupational intervention. This maternal skill set is referred to by Barkin and Wisner (2013) as maternal functioning, further articulating the seven functional domains of maternal self-care as “social support, self-care, psychological well-being, infant care, mother-child interaction, management and adjustment” (pg. 1051). Familiarization with this new occupational domain may require redefining the cumulative occupational profile that is known to the individual previously, prior to the arrival of the infant. An occupational therapist has the unique skills and education to facilitate assessment and intervention strategies that integrate all of the potential benefits relative to occupational intervention.
APPLYING A BIOPSYCHOSOCIAL MODEL
As articulated in the prior section covering Endometriosis & Chronic Pelvic Pain, the occupational therapist has a unique educational background in facilitating both physical modalities of intervention as well as psychosocial aspects of intervention; they are uniquely situated to deliver patient-centered care from a biopsychosocial model. This model allows the therapist to consider the diverse factors of biological, psychological, and sociological influences when creating an intervention plan (Gentry, Snyder, Barstow, & Hamson-Utley, 2018). Each of these dimensions of care has been shown to have a direct impact on the intermediate and final rehabilitation outcomes (Gentry, Snyder, Barstow, & Hamson-Utley, 2018). Gentry and colleagues’ (2018) adapted the Biopsychosocial Model for use in the OT practice addresses the needs of client across the continuum of care, incorporating seven key elements:
Characteristics of the condition (previously termed injury characteristics)
Sociodemographic variables that impact
Psychological variables, and
Social-contextual variables (which reciprocally interact with each other), to impact
The following presentations depict Case Vignette 2 - Nadine, which provides a client-specific scenario utilized to provide context to the completion of the biopsychosocial chart (as outlined in the previous section covering Endometriosis & Chronic Pelvic Pain, Figure 1), elaborated within the secondary presentation on Applying the Biopsychosocial Model as adapted for occupational therapy.
Case Vignette 2 - Nadine
Applying the Adapted Biopsychosocial Model for OT
CONSIDERING OTHER MODELS IN ACTION
As stated in the previous section on Endometriosis and Chronic Pelvic Pain, the Adapted Biopsychosocial Model for OT is only one example of an applicable model of care to address the client presenting with PPD. As this model represents a bridge between the top-down and bottom-up approach, which is largely controversial in the current transition of the occupational therapy paradigm, it was selected to illustrate the interconnectedness of the various components as outlined within the model's flowchart. Many occupationally focused models of care can be applied to the intervention process and may serve to be beneficial when considered in parallel to the existing representation of the Adapted Biopsychosocial Model’s application.
Other options for appropriate models of occupation that can be utilized in the creation of individualized clinical care plans include (Turpin & Iwama, 2011):
Occupational Performance Model (AUSTRALIA) (OPMA)
Occupational Adaptation (OA)
Person—Environment—Occupation—Performance (PEOP) Model
Person—Environment—Occupation (PEO) Model of Occupational Performance
Ecology of Human Performance
Canadian Model of Occupational Performance and Engagement (CMOP-E) as a component of the larger text entitled Enabling Occupation II (EO-II)
Model of Human Occupation (MOHO)
* The included PDF offers an expanded articulation of the use of each model as outlined in previous sections.
Regardless of the model of intervention that is selected by the evaluating therapist to initiate the assessment and intervention process, the most crucial element of the therapist's decision making should be focused upon occupation. In this, that the means by which intervention is delivered is focused upon occupation as an actionable task of daily doing, and that it is meaningful and purposeful to the lived experience and need for desired outcomes within the individual.
COMPLEMENTARY INTERVENTIONS AS ACTIONABLE PURSUITS
The universally recommended standard practice for treating PPD is through a first line intervention of antidepressants and psychotherapy (APA, 2019). However, there is a growing trend within the postpartum population toward an increased preference for integrative or complementary practices to address their recovery needs (McCloskey & Reno, 2019; Nguyen, 2017). Fear of adverse side-effects and negative impact to the baby while breastfeeding contribute to the aversion toward pharmaceutical interventions, while lack of ability to dedicate time to the committed process of psychotherapy contributes to the avoidance and non-compliance with standard recommendations of intervention (McCloskey & Reno, 2019; Nguyen, 2017). Particularly within highly vulnerable populations of low-socioeconomic and ethnic minority groups are these front-line interventions considered unattainable, and more and more are women turning to, even preferring, alternative and complementary methods of treatment (McCloskey & Reno, 2019; Nguyen, 2017).
Chiarmonte, Ring, and Locke (2017) indicate that as many as 75% of women within the general population are utilizing complimentary therapies. The most commonly utilized interventions being mind-body practices and dietary supplements, with use of these therapies being made by self-referral rather than in collaboration with a healthcare professional (Chairmonte, Ring, & Locke, 2017). The authors strongly advocate that physicians and other healthcare professionals should educate themselves on integrative approaches of such practices in order to support patient-centered preferences and approach the needs of women’s health concerns from an integrative perspective.
While complementary and alternative health care practices were once considered distinctly other than traditional models of westernized medicine, there is an ongoing shift within the contemporary health care practices of the United States, Canada, United Kingdom (UK), and Australia toward a more holistic and integrative view of health and medicine (Hilbers & Lewis, 2013). This shifting paradigm within the medical model acknowledges the benefits of complementary and conventional approaches when used in combination to support physical, social, psychological, emotional, and spiritual wellbeing (Hilbers & Lewis, 2013).
DEFINING COMPLEMENTARY AND ALTERNATIVE MEDICINE
The National Center for Complementary and Integrative Health (NCCIH; 2018) elaborates on what the National Institutes of Health (NIH) define “complementary,” “alternative,” and “integrative” as within the evolving paradigm of medicine. While “alternative” and “complementary” are often used interchangeably, they are not synonymous. As healthcare professionals utilizing such methods, it is essential to know how and when to use such terms appropriately when articulating the value and efficacy of services provided.
If a non-mainstream practice is used together with conventional medicine, then it is considered "complementary."
If a non-mainstream practice is used in place of conventional medicine, then it is considered "alternative."
An approach to health care that brings conventional and complementary approaches together in a coordinated way. Integrative healthcare emphasizes a holistic, patient-focused approach to health care and wellness—often including mental, emotional, functional, spiritual, social, and community aspects—and treating the whole person rather than, for example, one organ system.
One of the greatest benefits that emerge from the integrative approach of blending conventional with complementary approaches is that it empowers the client to be a more active participant in their healthcare intervention process rather than mainstream healthcare models allow (Hilbers & Lewis, 2013). Complementary and alternative medicine (CAM) practices allow the patient to seize control of actionable strategies toward their wellness goals. In the perspective of occupational therapy, these actionable pursuits are of primary concern to intervention philosophy and therefore may serve as viable options for intervention strategies when approaching the care of the depressed postpartum women from a holistic perspective.
The benefits of expressive writing have been well studied and documented across multiple patient populations, with research indicating that this easily accessible form of intervention has significant implications for successful impact upon major depressive disorders (Krpan et al., 2013). Looking specifically at the postpartum population, an Italian study of 113 women utilizing expressive writing as a medium for processing and defining their birthing experiences showed significant improvement at follow up 3-months later (Blasio et al., 2015). These writing sessions were conducted while in the hospital at three days postpartum and consisted of two sessions of 10-minute writing, separated by a minimum of four hours (Blasio et al., 2015). Horsche and colleagues (2016) similarly found that expressive writing was both a statistically significant and cost-effective therapeutic approach of addressing maternal posttraumatic stress and depressive symptoms in mothers of very preterm infants.
The profession of occupational therapy has a long-standing and deeply rooted connection to the use of creative arts (e.g., painting, drawing, creative writing, music, and textile arts and crafts) as a treatment medium for improving health and wellbeing across multiple dimensions of mental illness (Perruzza & Kinsella, 2010). Such emphasis has existed on behalf of art as a therapeutic medium that realm of Art Therapy, an integrative health profession, has evolved from influences in the fields of psychology, education, and art (Czamanski-Cohen
& Weihs, 2016).
In a critical review of the literature on art-based practices and their impact on mental health recovery, Van Lith, Schofield and Fenner (2013) found that art-based practices benefited various forms of psychological healing through improvement in self-esteem, self-discovery, empowerment, self-expression, rebuilding of identity, self-validation, motivation, sense of purpose, and focus and cognition (p. 1319). In a study explicitly investigating the postpartum population, Morton and Forsey (2014) found in their pilot study significant evidence in support of a creative arts group based intervention method to improve a sense of wellbeing and quality of life in women diagnosed with postpartum depression and/or anxiety.
Strauss, Cavanaugh, Oliver, and Pettman (2014) define mindfulness as “a state of consciousness that is characterized by the self-regulation of attention towards present-moment experiences coupled with an accepting, non-judgmental stance towards these experiences” (p. 1). In their meta-analysis of randomized controlled trials (RCTs), they found significant benefits upon primary symptom severity in the use of mindfulness-based interventions (MBIs) in the intervention of depressive disorders. These authors outline MBIs as “usually brief interventions… which incorporate mindfulness meditation practice and principles” (Strauss et al., 2014, p. 1). In McCloskey and Reno’s (2019) systematic review of RCTs utilizing complementary methods to address PPD, the authors reference an Iranian study of 410 postpartum women which showed statistical significance in depression scores following only eight sessions of mindfulness training (Sheydaei et al., 2017).
Yoga has become a popularized mind-body practice that has recently been studied with increased interest across a range of professional domains. Kinser, Elswick, and Kornstein (2014) sought to understand the application of yoga as such an intervention for women experiencing major depressive disorder (MDD) in a long-term follow-up study. The findings from this pilot study found significance to suggest that individuals with MDD could benefit from yoga in both a short-term and a long-term time frame (Kinser, Elswick, & Kornstein, 2014). After one-year trends of depression, ruminations, stress, anxiety, and mental-health-related quality of life were sustained even with a minimal degree of yoga practice (Kinser, Elswick, & Kornstein, 2014). The lack of continuity of practice following initial exposure was perhaps one of the most compelling findings of their research, which suggests that yoga intervention has sustained benefit even if in a brief exposure (Kinser, Elswick, & Kornstein, 2014). This carryover is rare for any intervention, particularly for standard care of interventions for depression (e.g., pharmacological or psychotherapeutic approaches) when treatment is discontinued (Kinser, Elswick, & Kornstein, 2014).
As interest in this complementary practice of yoga as an intervention has grown, research efforts have evolved to address the physical and emotional health implications for women in the postpartum period. Buttner, Brock, O’Hara, and Stuart (2015) conducted one of the first RCTs specifically evaluating the impact of yoga on PPD. They found that women in the experimental yoga group improved in measures of depression, anxiety, well-being, and health-related quality of life scores at a significantly faster rate than the control (Buttner, Brock, O’Hara, & Stuart, 2015).
The benefits of physical activity for both physical and mental health have been extensively explored in the research to the current date. Presently, there exists strong advocacy from the U.S. Department of Health and the Centers for Disease Control and Prevention promoting the importance and the value of regular, moderate-intensity physical activity. A Cochrane review completed by Cooney and colleagues (2013) concluded that in the treatment of depressed adults, there were no differences between the implementation of exercise, psychological therapy, and/or pharmacological intervention with antidepressants. Thus, physical activity is a vital intervention to consider for the treatment and prevention of postpartum depression as it transcends many of the known barriers associated with traditional intervention methods (e.g., stigma, cost, side effects) and may be easily accessed across multiple domains (Lewis et al., 2014).
Qualitative studies tell us that women who take up physical activity in the postpartum period feel empowered by their use of physical activity in becoming change-agents of their self-care, growth, and self-reflection (Lloyd, O’Brien, & Riot, 2016). While studies that have focused on the specific treatment of women with PPD, as reported in Lewis and Kennedy’s (2011) systematic review and meta-analysis, have shown overall mixed results with the use of physical activity to treat depression, there may be greater efficacy for the use of such intervention in a preventative capacity. A systematic review and meta-analysis of twenty-one studies, representing 93,676 women, indicated a significant reduction in postpartum depression scores when physical activity was engaged upon during pregnancy (Nakamura et al., 2019).
Nutrition & Diet
Much has been written in the literature on the topic of consuming a healthy diet for the promotion of physical and mental wellbeing. Following a healthy or high-quality diet has been shown to correlate with improved mental health, but to what extent and in what causation of mechanisms has been challenging for researchers to underline (Molendijk et al., 2018). In a systematic review and meta-analysis of diet quality and depression risk, Molendijk and colleagues (2018) sought to better understand the associations of diet and depression. The International Society for Nutritional Psychiatry Research (ISNPR), has stated that “diet and nutrition are central determinants of mental health” and that “nutrition is a crucial factor in the high incidence and prevalence of mental disorders” (Sarris et al., 2015a, p. 271; as quoted by Molendijk et al., 2018, p. 347). Empirical evaluation of these claims was the primary objective of Molendijk and colleagues (2018) research, to which they concluded that such claims are supported in their findings of “a high-quality healthy diet – regardless whether it was a healthy/prudent, Mediterranean, pro-vegetarian, or Tuscan diet – was associated with a lower incidence of depressive symptoms” (p. 350).
McCloskey and Reno (2018) found within their systematic review that dietary supplements such as iron, omega-3 fatty acids, and saffron were all statistically significant in treatment if depression in postpartum women. While Ngyuen (2017) references two studies from Taiwan which focused on herbal teas for sleep improvement, finding that one cup of chamomile tea for two weeks elicited significant
Throughout multiple studies on various intervention strategies, many women with postpartum depression have reported that social support has been an essential component of their recovery process (Buttner et al., 2015; Keefe, Brownstein-Evans, & Polmanteer, 2016; Kim & Dee, 2017; Morton & Forsey, 2014). Gillis and Parish (2019) sought to explicitly explore the benefits of group-based interventions in the treatment of PPD in their research review. In the synthesis of their data, they report finding three primary themes related to the experiences of women in group-based PPD interventions: group environment, sharing, and outcomes (Gillis & Parish, 2019).
The importance of the group environment provided access to the crucial aspects of ‘moms who understand’– anchored in the belief that “only those who have personally experienced PPD can comprehend the emotional anguish” (p. 4) – as well as ‘a place to be accepted’ (Gillis & Parish, 2019). The second theme, ‘sharing of experiences with mood and motherhood’ emerged as a foundation of work to be accomplished in group settings, allowing women to share challenges, knowledge, practical guidance, and wisdom; leading to an achievement of feeling a decreased burden as they progressed toward recovery (Gillis & Parish, 2019). Lastly, in the third theme that was identified, outcomes, outlines ways in which women felt that the groups promoted recovery from depression as a process: ‘validation—its ok to feel this way’; ‘empowered—hope that we won’t always feel this way’; and ‘healed—toward recovery’(Gillis & Parish, 2019).
OCCUPATIONAL THERAPY IN THE PROMOTION OF HEALTH AND WELLNESS
While much of the focus in the occupational therapy profession remains aimed at the assessment and intervention of the individual, a growing trend exists in the practice of occupational therapy toward community-based and population-based interventions of care (Scaffa, Reitz, & Pizzi, 2010). Many aspects of the traditional individual-level OT intervention may include for health promotion activities, but there exists a significant possibility for the profession to broaden the scope of impact by directly influencing public health needs via the family, community, and societal levels (Scaffa, Reitz, & Pizzi, 2010).
In implementing population health strategies with the goal of reducing the incidence of any condition, Scaffa, Reitz and Pizzi (2010) articulate that this is to be achieved through the combination of two primary strategies: early detection and prevention. Additional strategies to impact population health include health services, health promotion, and health protection. The combination of these critical strategies represents the most comprehensive approach to effectively achieving community and population health outcomes. Table 2 elaborates on the definitions of these key terms.
Actions and interventions designed to identify risks, and reduce susceptibility or exposure to health threats prior to disease onset (primary prevention), detect and treat disease in early stages to prevent progress or recurrence (secondary prevention), and alleviate the effects of disease and injury (tertiary prevention).
Interventions typically provided by health-care medical professionals after symptoms are present or diagnosis is evident.
Interventions directed at lifestyle and involve any planned combination of educational, political, regulatory, environmental, and organization supports for actions and conditions of living conducive to the health of individuals, groups, or communities.
Any planned intervention or services designed to provide individuals and communities with resistance to health threats, often by modifying policy or the environment to decrease potentially harmful interactions.
(Scaffa, Reitz, & Pizzi, 2010)
Applying these strategies to positively impact the public health concern of postpartum depression requires the creation of effective community health promotion programs which integrate interventions that span educational, social, and environmental domains (Scaffa, Reitz, & Pizzi, 2010). Scaffa and colleagues (2010) articulate that effective use of occupational therapy models directed at community health outcomes requires careful consideration of intrinsic (person-specific) and extrinsic (environmental specific) factors that impact perceptions of wellbeing and quality of life. The authors reference Baum, Bass-Haugen, and Chrostiansen’s (2005) use of the term situational analysis which is defined as “a process that involves the collection of information and the analysis of factors intrinsic and extrinsic to the individual, the organization or the population to determine the occupational performance issues that will impact the ability to reach client-centered goals” (p. 372; as quoted by Scaffa, Reitz, & Pizzi, 2010, p. 216).
Table 3 represents the authors’ recommended components of a situational analysis for the purpose of designing community-health interventions, and how those apply to the goal of impacting the incidence of postpartum depression (Baum et al., 2005; as quoted by Scaffa, Reitz, & Pizzi, 2010, p. 216).
Situational Analysis Component and the Application to
Postpartum Depression (PPD):
A general description of the population, including health behaviors, disease, injury, and disability incidence and prevalence statistics.
Impacts postpartum women within one year of giving birth
Prevalent in 1:7 women nationally, how does this compare to community prevalence?
Implied adverse mental health outcomes for the childbearing woman
Positive correlates to adverse impact on neonatal/child development
An environmental scan to identify environmental enablers and barriers.
What percentage of the childbearing population has access to healthcare coverage? How is it being utilized?
What percentage of OBGYN or pediatric clinics are actively screening for PPD?
What is their correlated rate of referral for mental health services?
What programs exist in the community to support maternal role transitions?
What community based social programs exist specifically for the postpartum population (e.g., postpartum exercise classes, postpartum yoga, book clubs, support groups, information sharing groups)
Interviews with stakeholders to ascertain community goals related to health and occupation.
Obstetrics and Gynecological clinics
Pediatric Medicine clinics
Community hospitals/birthing centers
… to determine service goals and gaps in provisions of care that elicit positive impact to client populations served.
Measures of health status and intrinsic factors to determine the constraints and capabilities for occupational performance.
Quantitative data extraction to determine frequency and severity scores on PPD screening tools (e.g., the Edinburgh Postnatal Depression Scale [EDPS] and Patient Health Questionaire [PHQ-9]) within the community
Use of survey to generate qualitative data inventory to determine perceptions of occupational impact upon postpartum population within the community
Measures of occupational participation and community engagement.
How are existing programs within the community being accessed and utilized?
What methods of advertising reach the greatest number of potential women in need (e.g., social media platforms, web-based advertising, doctor office pamphlets, direct inquiry to healthcare professionals)?
Collect quantitative/qualitative data regarding perceived needs and interests for occupational resources/outlets or programs that may be implemented.
(adapted from Scaffa, Reitz, & Pizzi, 2010, p. 216)
The desired outcomes of occupational therapy intervention at the community level are congruent with the objectives for outcomes at the individualized level of care. As outlined within the OTPF, the primary objectives of occupational intervention are to achieve health and wellness; prevention of injury, disease, and disability; occupational performance; role competence; adaptation; client satisfaction; and quality of life (AOTA, 2014; Scaffa, Reitz, & Pizzi, 2010). To achieve these outcomes, intervention may potentially include one or more of the following approaches: create, promote, prevent, educate, consult, compensate, adapt, modify, maintain, remediate, restore, and establish (Scaffa, Reitz, & Pizzi, 2010).
Empowering women to break through the barriers of social stigma and the fear of being labeled in a negative capacity during this pivotal time of maternal role acquisition is an imperative priority for all members of the healthcare community. The efforts that have been made to increase awareness of and advocate for change in this patient population are in the early phases, and much work is yet to be done. Increasing receptivity to intervention services requires full-scale interdisciplinary strategy, with emphasis on an integrated approach. Repeated references to the need for client-centered intervention strategies, with culturally sensitive considerations, emerge as themes within the literature review. Assessing and determining the unique needs for individualized care in the scope of the client’s occupational profile may serve as a potentially less stigmatizing and more empowering methodology for initiating effective intervention strategy. While simultaneously targeting program development and community health initiatives at the population level should be considered a primary objective of the occupational therapy profession to elicit positive impacts to overall perceptions of wellbeing and quality of life at both the individual and community levels through increased access to care and the promotion of health and wellness.
FOR AT RISK CONSUMERS
The American Psychological Association’s Consumer Help Center can help you find a local psychologist:
Call 1-800-964-2000, or visit online. You can also view the APA's official brochure on PPD here.
Find local support and help options at Postpartum Support International
Learn more about Postpartum Depression, treatment interventions, and how to get help finding support options at PostpartumDepression.org
United States Department of Agriculture: Nutrition During Pregnancy Resource List
United States Department of Agriculture: Nutrition During Lactation Resource List
Physical Activity Guidelines for Americans [2nd edition] (link to PDF)
The American College of Obstetricians and Gynecologists: Physical Activity and Exercise During Pregnancy and the Postpartum Period (link to PDF)
FOR WOMEN'S HEALTHCARE PROVIDERS
The American College of Obstetricians and Gynecologists: Depression and Postpartum Depression Resource Overview
American College of Obstetritians and Gynecologists. (2018, May). ACOG committee opinion: Optimizing postpartum care. Obstetrics & Gynecology. 131(5)
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48.
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Czamanski-Cohen, J., & Weihs, K. L. (2016). Research Article: The bodymind model: A platform for studying the mechanisms of change induced by art therapy. The Arts in Psychotherapy, 51, 63–71. https://doi-org.prx-usa.lirn.net/10.1016/j.aip.2016.08.006
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