Nursing

Using Short-Term Group Psychotherapy as an Evidence-Based Intervention for First-Time Mothers at Risk for Postpartum Depressionppc_350 202..209 Richard A. Pessagno, DNP, RN, APN-C, CGP, and Diane Hunker, PhD, MBA, RN

Richard A. Pessagno, DNP, RN, APN-C, CGP, is Clinical Assistant Professor, Rutgers, The State University of New Jersey, College of Nursing, Newark, New Jersey, USA; and Diane Hunker, PhD, MBA, RN, is Assistant Professor, Chatham University, Pittsburgh, Pennsylvania, USA.

Search terms: First-time mothers, group psychotherapy, postpartum depression, psychiatric nursing

Author contact: Richard.Pessagno@rutgers.edu, with a copy to the Editor: gpearson@uchc.edu

Conflict of Interest Statement There are no financial disclosures to make relative to this manuscript.

First Received March 12, 2012; Final Revision received June 25, 2012; Accepted for publication June 27, 2012.

doi: 10.1111/j.1744-6163.2012.00350.x

PURPOSE: The purposes were to (a) provide an 8-week, short-term, psychotherapy group as a nonpharmacologic, evidence-based intervention for first-time mothers at risk for postpartum depression (PPD) and (b) determine if women’s scores in the Edinburgh Postnatal Depression Scale changed after participation in the intervention. CONCLUSION: The women who participated in the short-term group psycho- therapy intervention experienced a decrease in their Edinburgh Postnatal Depres- sion Scale scores, reducing their risk for PPD. PRACTICE IMPLICATIONS: Group psychotherapy is an effective, evidence-based intervention to reduce the risk for PPD and should remain a current competency of psychiatric advanced practice nurses.

Postpartum depression (PPD) is a serious medical condition that dates back to 400 B.C. (Tovino, 2009). Although it has been noted that nearly 85% of women experience some type of mood change after giving birth (Horowitz & Goodman, 2005), the actual prevalence of PPD is between 10% and 20% (Gjerdingen & Yawn, 2007). While in-hospital postpar- tum screening has helped to increase the recognition of those at risk for developing PPD (Perfetti, Clark, & Fillmore, 2004), fewer than half of those women who are screened and who develop PPD will actually be identified and treated (Gjerdingen & Yawn, 2007; Logsdon, Wisner, & Pinto-Foltz, 2006). As women are discharged from acute care hospitals quickly after giving birth, inpatients often lack readily avail- able access to interventions, even for women identified at risk for PPD.

Pharmacological interventions are a common treatment option for PPD, but many women leave the acute setting, opting not to take medication and having limited resources to access mental health services. Taking medication, specifically psychotropic medication, can raise concerns for many women, especially for first-time mothers (Gjerdingen, 2003). Often, concerns are raised about the use of medications, espe- cially among those breast-feeding mothers, relative to the

potential risk to their infants. Identifying and accessing timely nonpharmacological treatment can be difficult for women who are at risk for PPD or who have PPD. This article describes an evidence-based practice intervention that used short-term group psychotherapy as a nonpharmacologcial intervention with first-time mothers who were identified as being at risk for PPD.

Background

While various factors have been examined in relation to the etiology of PPD, such as hormonal and metabolic changes, lifestyle adjustments, obstetric factors, and changing new roles (Flores & Hendrick, 2002), epidemiological studies have fairly consistently demonstrated that the etiology of PPD is most closely linked to psychosocial factors (Beck, 1996a). PPD has often been associated with women who are from lower socioeconomic backgrounds, who are less educated, and who lack occupational prestige (Séguin, Potvin, St-Denis, & Loiselle, 2001). Yet Anderson (2009) found that PPD is also found in significant numbers among women who are well educated, middle class, and in stable relationships. These findings support the need to adequately screen and provide

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early intervention to all women who give birth, and not only profiled women from disadvantaged backgrounds.

The risk for PPD may be greatest for first-time mothers who hold high expectations regarding childbearing but no personal experience with which to compare their experiences (Epperson, 1999). Because new mothers may not be aware that they are experiencing PPD, they may normalize their feelings. New mothers may fear that others judge their feel- ings as an inappropriate maternal response (Logsdon, Foltz, Scheetz, & Myers, 2010). First-time mothers are less apt to express the need for help during the postpartum period because of the perceived stigma of being depressed, as well as the hesitancy to report depressive symptoms (Thurgood, Avery, & Williamson, 2009). The results can leave first-time mothers feeling even more isolated and unprepared to cope with multiple changes that can negatively impact their health status and parenting effectiveness (Reich, Silbert-Mazzarella, Spence, & Siegel, 2005).

Impact of PPD

The detrimental effects of PPD have gained increasing public awareness, with some extreme cases of PPD in which mothers have harmed their children (Logsdon, Wisner, & Shanahan, 2007). Untreated PPD in first-time mothers, coupled with a lack of maternal experience and fear, can lead to a host of mal- adaptions for both the mother and her baby. These maladap- tions can include issues such as severe social isolation, decreased mother–child bonding, decreased maternal ability to care for the infant, increased incidence of developmental delay in infants, and a reduced rate of identifying infant cues (Reich et al., 2005). Although women who have given birth more than once have also been shown to be at risk for PPD, women with more than one child tend to seek intervention at a higher rate than first-time mothers (Rich-Edwards et al., 2006). The occurrence of PPD has been linked to a host of negative outcomes. Beck (1998) noted that women with PPD can negatively impact infant behaviors and influence child- hood development through the age of 14. A review of eight phenomenological studies on women with PPD suggested that mothers with PPD were often filled with guilt, had feel- ings of loss, and engaged in irrational thinking. These themes were linked to mothers experiencing a sense of detachment from their infants, as well as failure to respond to clues from her children (Beck, 1996b). Current research suggests that there is a negative relationship between the presence of PPD and infant development (Beck, Records, & Rice, 2006).

Treatment of PPD

Treatments for depression and PPD are varied and include psychotherapy, psychoeducation, and support groups, as well as pharmacotherapy. Treatment choices for patients depend

on multiple factors, including availability, cost, convenience, the influence of family and friends, and patient preference (Burlingame, Fuhriman, & Mosier, 2003). The cost- effectiveness of group psychotherapy draws many patients to this treatment option (Burlingame et al., 2003; McRoberts, Burlingame, & Hoag, 1998).

Group psychotherapy has been supported in the literature as being an efficient, cost-effective, nonpharmacologic, evidence-based intervention that can be used for patients exhibiting depressive symptoms. A meta-analysis of 48 research studies examining the effect of group psychotherapy on depression revealed that group psychotherapy was effec- tive in reducing depressive symptoms, further noting that 43 of the studies evidenced that group psychotherapy provided a statistically significant decrease in depressive symptoms for group participants (McDermut, Miller, & Brown, 2001).

Several studies have reported that mothers with PPD responded well to group psychotherapy treatment. Klier, Muzik, Rosenblum, and Lenz (2001) noted in their study (n = 17) that group psychotherapy was an effective intervention that decreased depressive symptoms, with a continued dimin- ishment of PPD symptoms 6 months after treatment. Honey, Bennett, and Morgan (2002), in a study of 45 women scoring 12 or higher on the Edinburgh Postnatal Depression Scale (EPDS), identified that brief group experience reduced depressive symptoms, as evidenced by lower EPDS scores. Other studies on group psychotherapy as a treatment for PPD have reported similar trends (Gruen, 1993; Kurzweil, 2008; Meager & Milgrom, 1996; Ugarriza, 2004).

The benefits of group psychotherapy have been linked to more rapid remission of symptoms, cost-effectiveness, and improved social support. The literature has also demon- strated that group psychotherapy can be an efficacious treat- ment for patients at risk for PPD. Some evidence supports the idea that group psychotherapy may provide longevity of symptom relief for some patients up to 6 months posttreat- ment. The literature cites the importance of screening and early identification of the risk for PPD in first-time mothers and the effectiveness of group psychotherapy as an evidence- based intervention.

Interpersonal psychotherapy (IPT) is an effective, time- limited treatment, which has been shown to be highly effective for depression (Markowitz & Weissman, 2004). Depression is identified as a medical illness that connects an individual’s life events to the individual’s depression (Markowitz & Weissman, 2004). Therapy focuses on helping individuals to create or enhance one’s social relationships while addressing issues such as conflicts and role change. Within the context of a group environment, IPT can provide a setting where individuals with a similar diagnosis can meet to address relationship issues and explore how these issues may be leading to depressive symptoms or other struggles within various relationships.

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For the purposes of this project, IPT was organized by using an unstructured format for group sessions. Group par- ticipants were asked to recognize and notice their affect response, cognitions, and reactions during sessions, and then use those recognitions as a means of relating to others in the groups. Participants were able to use group interactions to address their relationship issues and their role changes. The group was used to help participants improve interpersonal relationships, enhance their ability to empathize, and learn new skills.

Intervention

The purposes of this project were to (a) provide a non- pharmacologic, evidence-based intervention for first-time mothers at risk for PPD and to (b) determine if women’s scores in the EPDS change after participation in the interven- tion. The intervention was an 8-week, short-term psycho- therapy group offered by an advanced practice psychiatric nurse to first-time mothers. The project was approved by the Institutional Review Board for protection of all participants.

Sample. A total of 202 women gave birth on the postpartum unit during the 3-week recruitment period for this project.All 202 women completed the EPDS, and 24 women were then recruited for participation in the project. All 24 women com- pleted EPDS within 3 days after having given birth to their first child and had a score of 11 or higher on the EPDS.A score of 11 or higher triggered a psychiatric evaluation, which was established by hospital policy to determine fitness for dis- charge from the postpartum unit. After completing a psychi- atric screening, eligible women were approached by a postpartum nurse to determine if they were interested in par- ticipating in the group psychotherapy intervention. These eli- gible women then discussed their interest with the advanced practice psychiatric nurse who would be leading the interven- tion groups, and the women were given details about the groups. Sixteen (Table 1) of the 24 women chose to partici- pate in one of two short-term psychotherapy intervention groups.

The age range of participants was between 20 and 38, with a mean age of 28.5 years. More than 68% of the women were between 26 and 30 years old. Thirteen, or 81.25%, of the women were married; two women had a significant other; and one woman was single. The majority of the women were Catholic (62.5%), and all 16 women were Caucasian. More than 92% had at least a high school education, with more than 86% having completed a 4-year college degree. Ten (62%) of the women worked outside their homes in a variety of profes- sional, technical, and service industry roles.

With regard to previous mental health treatment, six par- ticipants (37.5%) had some experience with previous mental health treatment. Four women had participated in counseling

or psychotherapy, and two women had used psychotropic medications previously. None of the participants had previ- ously been hospitalized for psychiatric treatment. None of the women were taking psychotropic medication during the intervention. Six of the participants had been previously diag- nosed with depression.All 16 women had given birth within 1 month before the start of the group intervention, with 5 women giving birth to male children and 11 giving birth to female children.

Women who did not participate decided against participa- tion because of childcare issues, concerns about length of the commitment to the group, and/or lack of interest in partici- pating in a group-related activity. Each participant was randomly assigned to one of the two short-term group psy- chotherapy intervention groups. The remaining women who did not meet the criteria for participation or who decided not to participate in the intervention were referred to other mental health services within the community. Screening for the project took place in May 2010.

Procedure. The short-term group psychotherapy interven- tion was provided to two groups with eight women each for a period of 8 weeks. Each of the 8-week sessions lasted 90 min and started within 1 month of discharge from the hospital.

Table 1. Demographics of Groups

Variables Intervention Group 1 (n = 8)

Intervention Group 2 (n = 8)

Ages 20–25 1 2 26–30 6 4 31–35 1 1 36–38 0 1

Education <12th grade 0 1 High school 2 0 College 5 5 Graduate school 1 2

Marital status Single 1 0 Married 6 7 Partnered 1 1

Work outside home Yes 2 8 No 6 0

Previous psych treatment Yes 4 2 No 4 6

Type of past treatment Psychotherapy 1 1 Medication 1 1 Both medication and therapy 2 0

Previous mental health diagnosis Depressive disorder 4 2

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The groups were provided at no charge to participants, and childcare was provided to women in order make attending the groups easier. A master’s-prepared, advanced practice psychi- atric nurse, who was nationally board certified as a psychiatric nurse practitioner and as a group psychotherapist with more than 20 years of advanced practice psychiatric nursing experi- ence, was the group leader for each of the two intervention groups. This provided for consistency among interviews and among all group sessions. Psychotherapy group 1 was held on Tuesdays, and Psychotherapy Group 2 was held on Wednes- days. Both groups met on the same day of the week for all 8 weeks. Both groups ran for 90 min. The scheduling and timing of intervention provide consistency of scheduling for participants. An interpersonal-focused theoretical model was used to structure the group, which guided the length of the group intervention, as well as the focus for each session. The interpersonal model was selected in order to help participants strengthen their relationships and to enhance their ability to identity and utilize resources to improve their functioning. This focus was structured to provide optimal opportunity in developing skills relative to their new maternal roles as new mothers, coping with depression and stress, honing commu- nication skills with their husbands and partners, and sharing their individual, weekly experiences.

The first session for each group established ground rules for maintaining confidentiality for other group members;partici- pants were told to only talk about their own personal group experiences with nongroup members and to not repeat what other group members disclosed during the sessions. Members also agreed to attend group sessions on time or notify the author group leader about their absences. All members also agreed to attend all group sessions. During the first group session, the participants completed a demographic form.

The subsequent seven sessions had a structured focus, which followed the interpersonal theoretical framework, addressing various relationship issues and helping partici- pants identify resources. Although the recommended length of typical interpersonal psychotherapy orientation is 12 to 15 sessions, the number of sessions for this project was reduced to eight sessions based on group request. The final group session was used to address termination issues, as well as to identify group members who would need and benefit from additional mental health services, as well as refer identified group members who could benefit from additional mental

health services. The EPDS, which had been administered prior to the intervention, was used again during this session.

Setting. The setting for the intervention was a community hospital in New Jersey. In keeping with the hospital policy, all postpartum women needed to be screened for PPD within 72 hr of delivery. This hospital policy adheres to the 2004 New Jersey state mandate that requires all postpartum women be screened for PPD before leaving any healthcare institution.

EPDS Screening Tool. The EPDS was developed in Scotland within several healthcare centers in the cities of Livingston and Edinburgh (Cox, Holden, & Sagovsky, 1987). The tool was initially developed to assist primary care providers in identifying whether women who had recently given birth were suffering from postnatal depression, but now has appli- cations to a variety of clinical settings. For the purpose of this intervention, the first EPDS was completed 3 days postpar- tum and the second EPDS was completed during the last session of the group psychotherapy intervention.

The EPDS is a publicly available PPD screening tool and is used within the hospital to screen for PPD. The EPDS is a 10-question self-report questionnaire that has a maximum score of 30. Scores range from 0 to 30, with scores over 10 indicating adjustment issues to the new baby, and scores over 15 indicating a strong indication of clinical depression. Hos- pital policy states that a score of 11 or higher for women on the EPDS denotes a risk for PPD, and therefore, a psychiatric evaluation is required before the patient can be cleared for discharge. The EPDS has gained wide acceptance regarding the screening and identification of PPD. Therefore, a psychi- atric evaluation is required for all women with scores >11. The EPDS is easily administered and scored, making it an effi- cacious tool for utilization in a variety of postpartum health- care settings. The EPDS has been utilized in more than 20 countries and is noted to have a significant level of sensitivity (86%), as well as specificity (78%), in identifying and indicat- ing symptoms of PPD (Harvey & Pun, 2007).

Results

The mean preintervention score on the EPDS for group 1 (3 days postpartum) was 16.13 (SD = 2.78) and for group 2 was 15.5 (SD = 1.19) (Table 2). These scores reflect the risk for

Table 2. Pre- and Postintervention EPDS Scores

Groups

Preintervention Postintervention

t (df) pM (SD) Range M (SD) Range

1 16.12 (2.74) 11–18 6.38 (1.50) 4–9 21.51 (7) .001 2 15.50 (1.19) 13–17 6.63 (1.99) 6–10 18.50 (7) .001

Note: 8 women/group. EPDS, Edinburgh Postnatal Depression Scale.

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depressive symptoms, in which a maximum potential score of 30 would indicate severe depression and 0 noting no depres- sive symptomology. Scores of 10 or greater are indicative of symptoms presentation, which should warrant further evalu- ation. Following the intervention, the scores decreased sig- nificantly. The mean postintervention score for group 1 was 6.38 (SD = 1.50) and for group 2 was 6.63 (SD = 1.99). These data represent the combined scores of all group members with and without a history of depression. There was a signifi- cant decrease in EPDS scores from preintervention to postint- ervention for both groups 1 and 2 (Table 2), as well as for women with previous depression and women with no previ- ous depression (Table 3), all indicating fewer self-reported symptoms that put women at risk for PPD.

The long-term effects of the group intervention were evaluated at 6 months postintervention for participants from group 1 and group 2 (Table 4), and for women with each group based on previous history of depression and no previ- ous history of depression (Table 5). Both groups demon- strated a significant decrease in scores on the EPDS. These data demonstrate a continued effect of the group interven- tion for participants 6 months beyond the intervention. This

is suggestive that group psychotherapy can have long-term effects to reduce risk for PPD for first-time mothers.

During the initial group sessions, the women bonded quickly and developed a strong alliance with one another. Many of the women stated that they really enjoyed talking with other women who were struggling with similar issues and who were also first-time mothers. Several women stated they felt “safer” talking with other first-time mothers because they did not feel judged. Many of the women stated that they worried about being judged by others when they shared their worries or concerns about being new mothers. The homoge- neity of the group also seemed to be a factor that added to the success of the group.

A common theme noted among the women in both groups was that the women looked forward to attending groups because the group offered a place where the women could be authentic, as well as a place to share “real feelings.” The theme of looking forward to the group could have been one factor that led to all the members attending all the group sessions. None of the women missed any of the sessions, which added to group cohesion, group process, and group stability. These factors could have also added to the effectiveness of the group.

Table 3. EPDS Scores With Prior Depression and Without Prior Depression

Groups

Preintervention Postintervention

t (df) pM (SD) Range M (SD) Range

With previous depression 1a (n = 4) 16.23 (1.50) 15–18 7.00 (2.16) 4–9 14.70 (3) .001 2a (n = 2) 16.00 (1.41) 15–17 6.50 (2.12) 5–8 5.26 (2) .001

No prior depression 1b (n = 4) 16.00 (3.36) 11–18 6.38 (1.50) 4–9 5.43 (6) .001 2b (n = 6) 15.50 (1.36) 13–17 6.67 (1.96) 4–9 8.86 (10) .001

EPDS, Edinburgh Postnatal Depression Scale.

Table 4. All Participants’ EPDS Scores at 8 Weeks and 6 Months Postintervention

Groups

Postintervention 8 weeks Postintervention 6 Months

M (SD) Range M (SD) Range

1 6.38 (1.50) 4–9 6 (1.69) 3–8 2 6.63 (1.99) 6–10 6.12 (1.45) 4–8

Note: 8 women/group. EPDS, Edinburgh Postnatal Depression Scale.

Table 5. EPDS Scores of Participants With Prior Depression and Without Prior Depression at 8 Weeks and 6 Months PostinterventionGroups

Postintervention 8 weeks Postintervention 6 Months

M (SD) Range M (SD) Range

With previous depression 1 (n = 4) 7.50 (1.00) 4–9 6.25 (1.70) 4–8 2 (n = 2) 6.50 (2.12) 5–8 5.50 (2.12) 4–7

No previous depression 1 (n = 4) 6.38 (1.50) 4–9 5.75 (1.89) 3–7 2 (n = 6) 6.67 (1.96) 4–9 6.16 (1.32) 4–8

EPDS, Edinburgh Postnatal Depression Scale.

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It was also noted that some of the women were referred for additional treatment after the intervention concluded. While all of the women showed a decreased risk for PPD postinter- vention, two of the women who had a previous history of depression requested additional psychotherapy support. Both women noted that the group had raised their awareness of the importance of remaining healthy and keeping their depression in remission. Both women believed that partici- pating in additional individual therapy would help them con- tinue to learn healthy ways of coping and adapting to their new roles.

Effectiveness of Intervention

The findings that participants in the group psychotherapy intervention experienced a decrease in their EPDS scores are congruent with the literature noting that participation in group psychotherapy is an effective means of reducing symp- toms associated with depression (Gruen, 1993; Klier et al., 2001; Kurzweil, 2008; Meager & Milgrom, 1996; Ugarriza, 2004). The results demonstrate a gap in clinical services for first-time mothers at risk for PPD and subsequently support an evidence-based, psychiatric nursing intervention to bridge that gap. Providing a group psychotherapy intervention that was connected to an acute care hospital allowed for a more rapid and seamless referral process for women who were identified as being at risk for PPD. Barriers to treatment for women at risk for PPD vary and can include limited numbers of mental health providers skilled in treating PPD issues and long wait times to access treatment. Typically, hospital refer- rals for community-based mental health services for women at risk for PPD have led to long wait times to be seen for treat- ment. There is a lack of qualified mental health professionals who have knowledge and interest in working with the population.

Identifying short-term group therapy as an intervention that could be provided by the psychiatric advanced practice nurse (APN) can bridge a potential gap in clinical services for first-time mothers at risk for PPD, who may otherwise have no other mental health services. Short-term group psycho- therapy can also provide an effective and cost-effective expan- sion of services for women who could potentially develop PPD. The utilization of short-term group psychotherapy has wide application across the healthcare system, as well as to various psychiatric disorders beyond PPD.

Limitations

The main limitation was the use of a nondirective group process style for this intervention. Nondirected group process lends itself to providing members the ability to focus more on relationships and developing empathy. The dynamics with a nondirective psychotherapy group may vary from group to

group. This may provide some account for the differences appreciated in postintervention scores. Additionally, group EPDS scores versus individual EPDS scores were compared for preintervention and postintervention, which could also be noted as a limitation of the project. For the purposes of this project, all scores were aggregated together and compared as a cohort group.

Another limitation of the project was that the group psy- chotherapy intervention was provided at no cost to partici- pants. Additionally, childcare was available to the women as well. It is realized that providing no-cost psychotherapy is not the norm in most cases, and childcare is not always available. Both of these issues may have also influenced the results of the project.

Another limitation to take into account is the interpreta- tion of group scores. While this was an evidence-based prac- tice project that applied current research findings to address a clinical problem and not an original research project, it should be mentioned that change in EPDS scores have both a ceiling and a basement effect, and those members scoring on the higher end of the EPDS can change more dramatically than those members scoring on the lower end of the EPDS. It should be noted that members in group 2 who scored in the bottom range of the EPDS did not change significantly. The scope of the project was limited to implementing an evidence-based intervention based on already produced research evidence, so advanced interpretation of the changing score postintervention results was beyond the scope of this project. Still, a cautionary note must be mentioned relative to the interpretation of postintervention group scores.

Implications for Nursing Practice

For states that mandate screening for PPD, implementing nonpharmacologic interventions such as short-term group psychotherapy across settings is a logical progression of expansion of services for women at risk for PPD. Barriers to treatment for women at risk for PPD vary and can include limited numbers of mental health providers skilled in treating PPD issue and long wait times to access treatment. Develop- ing programs that include such interventions within health- care agencies where pregnant or postpartum mothers seek healthcare services could improve access to mental health care for these women and have a positive impact on both the physical and mental health of mothers and their infants.

Nonpharmacologic interventions, such as short-term group psychotherapy, meet the needs of women who decide against the use of medication. Mental health providers should be exploring alternative interventions that augment choice for patients relative to pharmacologic and nonpharmacologic interventions. The efficacy of group psychotherapy in reduc- ing risk for the development of depressive symptoms may reduce or eliminate the need for subsequent medication use,

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which has significant implications for healthcare spending for both the system as a whole and for individual consumers. Group psychotherapy has also been shown to be cost-effective when compared with the costs of individual psychotherapy (McCrone et al., 2005).

While the cost of this intervention group was free of charge, the cost of group psychotherapy has historically been more cost-effective for consumers when compared with the cost for individual psychotherapy. Group psychotherapy also allows mental health providers the ability to treat several patients at the same time, which can allow the provider to see larger numbers of patients. Many healthcare insurance plans do provide coverage for group psychotherapy, and the short nature of this group psychotherapy intervention provides a discreet number of sessions over a discreet time frame, which might also be an incentive for insurance companies to encourage members to participate. With this type of time- limited intervention, insurance providers would know up front that their insured members would be in treatment for 8 weeks. This type of intervention could be seen as a cost- effective service that provides evidence-based outcomes for this specific patient population, namely women at risk for PDD, which could potentially reduce the need for other mental health services.

It is suggested that having a part-time psychiatric advanced practice position as a member of the women’s health service line could also prove to be cost-effective, as the services pro- vided by the psychiatric APN are potentially reimbursable. Additionally, having a psychiatric APN within a women’s health service line would provide access for patients and allow other healthcare providers, including nurses, easier access to a psychiatric practitioner for consultations.

Within this project, the psychiatric APN’s salary came out of the psychiatric services cost center. The cost to the institu- tion offering the two groups for this project was incorporated into the costs of the psychiatric APN salary. Group psycho- therapy services offered for this project were a new service not previously provided by the psychiatric APN. This project articulated a potentially new revenue source as well.

The outcomes of the intervention also articulated the need for psychiatric APNs to utilize the full spectrum of their edu- cation and clinical training to meet the needs of women at risk for PPD. Psychiatric APNs are uniquely trained to iden- tify and treat both those at risk for PPD and those who may have PPD. Psychiatric APNs can utilize both nonpharmaco- logic interventions, such as short-term group psychotherapy, and pharmacologic interventions management services to treat patients.

In today’s mental health services market, significant focus is paid on the importance of medication management skills of the psychiatric APN, yet the intervention in this project sup- ports the need for continued education and training of advanced practice psychiatric nursing as psychotherapists

with group psychotherapy skills. It is vital that advanced prac- tice psychiatric nurses be able to provide a wide variety of interventions, including psychopharmacologic and nonphar- macological therapies and group psychotherapy.

When advanced practice psychiatric nurses are able to provide both pharmacological and nonpharmacological interventions, there is a potential expansion of psychiatric services, which could improve both the utilization and the access to mental health services by consumers. This expansion also creates potentially greater choice among the types of psy- chiatric services from which consumers can select. Advanced practice psychiatric nurses with training and skill in both pharmacologic and nonpharmacologic psychiatric interven- tions also become uniquely positioned within the mental health system as providers who offer a wide variety of services.

Conclusion

Short-term group psychotherapy as a nonpharmacological psychiatric nursing intervention for first-time mothers who were identified as being at risk for PPD is effective to reduce symptoms associated with depression. Identifying women at risk for developing PPD shortly before discharge from the hospital provided a means for engaging those women who might benefit from a short-term group psychotherapy inter- vention. Implementing short-term psychotherapy group interventions to two groups of eight first-time mothers dem- onstrated lower scores on the EPDS, reflecting a decrease in symptoms presentation and risk for PPD. Lowering the risk for PPD has been associated with a wide variety of improved healthcare outcomes for both new mothers and for their infants. Group psychotherapy should be taught to advance practice psychiatric nursing students and practiced by advance practice psychiatric nurses, in order to improve access to mental health services, improve outcomes, and to potentially impact healthcare spending.

Acknowledgment

The first author was a participant in the 2012 NLN Scholarly Writing Retreat sponsored by the NLN Foundation for Nursing Education.

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Using Short-Term Group Psychotherapy as an Evidence-Based Intervention for First-Time Mothers at Risk for Postpartum Depression

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